A Problem Shared - Urgent call for patient information

A dentist asks you for details from a patient's history over the phone. What should you do?

THE PROBLEM

A dentist calls you to enquire about a possible clotting condition in a young teenage patient from your practice who is due to have a wisdom tooth operation the next day. The dentist says there is possibly a family history of a 'clotting disorder', but she does not really understand the details or potential implications of this. What do you do?

DR TILLMAN JACOBI'S VIEW

This is a disorganised preparation for a medical intervention by another professional. You are being put in a difficult position by her giving you very short notice and presenting you with unclear issues regarding consent and responsibilities. Does the patient, parent or guardian know about the call from the dentist, and did they consent for you to give information out? Can you be sure that it is a dentist calling, and for the right reasons?

Also consider if you are willing to take on some responsibility by responding.

Contacts between medical professionals should aim to enhance relationships and lead to a fair and balanced exchange of expertise. This situation is rather one sided. If you make reasonable effort to assist, there is still a potential risk that the patient may face a delay of treatment - for example, if you cannot confirm necessary consent in time. But your duty is not to save the dentist from an embarrassing situation.

On the clinical side, however, could the patient benefit from hand-held notes or information about the condition for future reference? Consider discussing the case in a practice meeting or send a note for information to your LMC to seek advice.

- Dr Jacobi is a salaried GP in York. He qualified as a GP in February 2005

DR RAJ THAKKAR'S VIEW

It is worrying that a dentist is ignorant of clotting disorders. Checking out the identity of the person you are speaking with is important before patient information is disclosed.

Confirming your patient is due to have a dental procedure by discussing the situation with the legal guardian is, in my view, imperative and it may be worth inviting the family into surgery to discuss the matter face to face. While speaking to your patient's legal guardian, a family history may be taken regarding the clotting disorder. Reviewing the clinical records of the family will be helpful, but again confidentiality must be respected.

It should be the duty of the dentist to consider whether a clotting disorder will affect the procedure he or she is carrying out and then ensure safety.

Who would be responsible if you advised the dentist and the patient subsequently suffered significant blood loss and airway compromise?

It seems reasonable to suggest to the dentist that there may be a risk of bleeding, and remind her that this can obstruct the airway. The dentist may be well advised to discuss the case with a haematologist directly or a maxillofacial surgeon. Perhaps postponing the procedure is the safest option. Indeed, cancelling the procedure and referring your patient to your local hospital, where high-risk patients can be cared for in a safe and appropriately staffed environment, is the best option of all.

- Dr Thakkar is a GP in Woodburn Green, Buckinghamshire

DR MINI NELSON'S VIEW

Asking the dentist how much she knows about the 'clotting problem' is very important, as is obtaining information on the patient's past dental history - especially in terms of bleeding. Find out how important the wisdom tooth removal scheduled for the next day is. It may also help to know exactly what the dentist has said to the patient about following the condition up with the GP.

Scan the patient's notes to check any reference to the clotting disorder, and check the notes of other members of the family.

Phone the patient, explaining the reason for the call. You could encourage the patient to make an appointment with you, preferably with a parent.

It may also help to explain that her confidentiality would be maintained at all times.

Consider making an appointment with the haematology department of the local hospital to investigate the condition further.

- Dr Nelson is a freelance GP in Norwich, Norfolk. She qualified as a GP in February 2006

LEARNING POINTS

What lessons can be learnt from this case?

Always confirm the identity of the person you are speaking with before you disclose any patient information.

Try to gain consent from the patient for disclosure of information and arrange an appointment, preferably with a parent or legal guardian present.

Scan the patient's notes and the notes of other members of the family for any reference to the clotting disorder.

If you do not have consent to reveal information but are concerned about the situation, ask if the procedure can be postponed until the matter is clarified.

Discuss the case in a practice meeting or send a note of information to your LMC.

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