Scenario 1

Patient is a 17-year-old lad who happens to be a friend of your son. He is very high achieving and wants to go into the RAF after 6th form (you suspect his parents are especially keen to get his university expenses paid). His mother phoned you at home on your mobile the previous evening to request that you remove the antihistamine from his medication list, as having hay-fever is a no-no for RAF entry.
Back at the surgery, you check his records: you had already stopped the Loratadine and removed it from his repeat prescriptions the last time you saw him, so thought nothing more of it. However, a few weeks later at the end of afternoon surgery, you are told that his mother had come to see you on a social visit. She wanted to look at her son’s record and find out how the RAF had found out that he has hay-fever. On further inspection, allergic rhinitis is read coded as a diagnosis in 2008, plus he was prescribed Loratadine by a locum in Sept 2009. His mum implied that you should remove the diagnosis from the record. You explain that you are unable to do this, and so she asks you to write a letter saying that he had been symptom free for the past 5 yrs. Unfortunately, you witnessed him having hay-fever when he was at your house a few years ago, and you’d had to go and get him some Loratadine from the chemist.
You feel irritated and manipulated.
What should you do?

The best course of action here is to be truthful. It is unreasonable of the mother to manipulate you like this. Given your personal relationship with the family, you may feel that writing a letter outlining the full details of his condition as you understand it both from the medical record and your personal experience is reasonable. At the end of the day you need to provide factual evidence that enables the RAF to make an informed decision. They have their rules for a reason and you should not attempt to manipulate them, otherwise you are committing the same offence as the boy’s mother.

Scenario 2

A 6 year old little girl was brought to see you 4 months ago with a rip- roaring UTI. It recurred after treatment although was not a resistant organism. You re-treated, and referred to paediatrics. Mum has been to see a homeopath (who happens to be a personal friend of hers) and says that the homeopathy treatment ‘worked miracles’ …for a while. They therefore didn’t use the most recent prescription for Trimethoprim and have just got back from holiday. The poor little girl now has such foul-smelling urine that she’s stinking the whole house out apparently. Mum requested a telephone consultation with you yesterday; you suggested that she sends in an MSU and then takes the Trimethoprim. Mum suggested that the antibiotics don’t seem to work as well as the homeopathy and she doesn’t want to give her daughter too many antibiotics. You persuade her to carry out your plan and then come along for a discussion re further management. The girl has a paediatric follow-up in mid October.
Could you have managed this differently?

The parent’s views and ideas might be putting the child at risk so you did the right thing to get her in again – but beware of them not turning up. Luckily, a UTI should be provable one way or the other. You might take the line that, ‘Homeopathy can work, especially on helping you feel well. It may even be that it is stopping her symptoms from the UTI [which may be pretty minor anyway] while the infection is still dragging on’. But you should make them aware that the main risk of an untreated UTI is that it could, long-term, cause kidney damage. This is unlikely, but it is the reason we like to get these things treated with anti-biotics and ensure paediatric follow-up is on place to check on any underlying causes.

Scenario 3

One to do with dependency. One of your old ladies- in her late 70s with multiple medical problems, Osteoarthritis, Hypertension, mild Heart Failure – came to see you yesterday although you weren’t expecting her to come back until February. She had several fairly trivial problems bothering her. It dawned on you that the reason she had come in was because you had given her a follow-up appointment which was too far ahead – she literally needs to come and see you at regular intervals, more regular than 6 months, even if she’s actually quite well. You find it very difficult to set the bar correctly with these patients.
How might you manage this situation?

You need to get a really good understanding of why the patient is behaving like this. You need to avoid making suppositions which may in fact be wrong. Ask the patient without being confrontational or brusque. Something like: ‘It’s nice to see you but I wasn’t expecting it until February…’ with an expectant look, should bring an informative reply.