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Practice dilemma: A dependent patient

A patient has become increasingly dependent on one of the GPs since her husband died. She now makes appointments once or twice a week and refuses to see anyone else. Medical Protection offers advice on the best way to handle this situation.

A patient has become increasingly dependent on one of the GPs since her husband died. She now makes appointments once or twice a week and refuses to see anyone else. If she cannot make an appointment within a few days, she makes a scene in reception. This is causing stress for the staff and the GP involved. The GP has tried speaking to her and initially this seems to work, but she soon resumes the same behaviour. What is the best way to handle this?

Dr Bobby Nicholas, medicolegal adviser at Medical Protection advises:
This is a difficult situation and needs to be handled sensitively. The GP involved should consider the underlying reasons for the patient’s frequent attendance and the purpose of the recurrent appointments. This may be part of the bereavement process or there may be other possibilities that need to be explored, for example an underlying illness.

It is important to bear in mind that the patient may not be aware of how often she is presenting, so it may be helpful to offer a meeting to address this issue. The GP may wish to consider gently explaining his or her concerns to her without being accusatory or judgemental, and suggest she may benefit from external support such as bereavement services if this is appropriate. This might also present the patient with an opportunity to accept help from other professionals such as a counsellor.

The GP could also work with her to agree set phone calls or appointments every so often if they felt this was appropriate so as not to compromise their time with other patients. But it is important for the GP to explain that there will be circumstances where she can only see another doctor, for example, if they are unavailable, or in an emergency.

It is also worthwhile consulting other clinical staff to see if the patient presented to them and how they dealt with the situation. Gaining the opinion of colleagues may also provide the GP with an objective view on the way forward as well as providing insight into their own behaviour with the patient.

There may be circumstances where a patient’s behaviour leads the GP to consider issuing a warning which informs the patient what is and is not acceptable.

As a last resort the GP may consider ending their clinical relationship with the patient, although they should bear in mind that 'you should end a professional relationship with a patient only when the breakdown of trust between you and the patient means you cannot provide good clinical care to the patient'.1 Ordinarily however, this step should only be taken in circumstances where a warning to the patient has been issued and breached.  

Working with the patient to create a shared management plan that addresses her concerns, whilst managing expectations and respecting practice staff, should lead to a successful resolution of the matter. If you are unclear how to proceed you can contact your medical defence organisation or LMC for advice before proceeding.

Reference

1. General Medical Council (2013) Good medical practice. London, GMC.

Picture: iStock

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