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Managing a patient's behaviour

The scene

A consultant member contacted the MDU's advice line about a female patient she had operated on some months earlier. During her admission the patient had sworn at other patients and staff on several occasions, and the member had had to speak to the patient about her behaviour. The patient later made a complaint to the trust saying that the member's care had been poor and the results of the surgery were unsatisfactory. The member had not sought the MDU’s help at that stage and had received support from the trust, who wrote a letter rebutting the complaint.

The patient's care was meanwhile transferred to a surgical colleague of our member at the same trust. The patient was also unhappy with the service this second consultant provided and lodged a further complaint. The trust was again supportive of its staff in the complaint response.

The patient was not satisfied, however, and had taken her concerns to the Ombudsman. After several months the Ombudsman had issued a report which did not uphold either of the complaints. 

The reason for the member's call was that the patient’s GP had referred her back to the trust to have the same procedure done on the contralateral side. Due to the patient's particular needs there were no other surgeons at the trust with the relevant expertise to treat her, other than the colleague who had also been the subject of a complaint. The only other centre where the patient could receive this treatment was several hundred miles away.

The trust managers were suggesting the consultant would have to see the patient again, and the consultant was concerned about treating a patient who had behaved unreasonably in the past and had persistently pursued unfounded complaints against her and her colleague.

MDU advice

The GMC advises in paragraph 61 of Good medical practice (2013) that you 'must not allow a patient's complaint to adversely affect the care or treatment you provide or arrange'.

However the GMC also accepts that there are situations where the relationship between patient and doctor has broken down and gives detailed advice in its guidance, Ending your professional relationship with a patient (2013). Such circumstances are 'rare' and doctors are cautioned not to end their professional relationship with a patient solely because of a complaint.

The GMC advises that, as the professional in the partnership, it is the doctor's responsibility to try to re-establish the relationship with the patient. It also says that before ending the patient relationship, the doctor should seek advice from an experienced colleague or their employer.

The MDU's adviser sympathised with the member's position that her concerns were not based solely on the complaint, but on the full scope of the patient's behaviour. It was understandable that the member felt vulnerable in being asked to see this patient again. However a doctor's first duty, as set out by the GMC, is to 'make the care of your patient your first concern'. The adviser asked the member to consider whether there were any steps that could be taken to try to rebuild the relationship with the patient.

Another issue to consider was what information the patient would be aware of regarding the referral. Did the patient realise that the only surgeons who could treat her at the local trust were the two she had complained about? It might be the case that the patient herself would prefer treatment elsewhere, despite the considerable distance she would have to travel to the nearest alternative suitably experienced surgeon.

The medico-legal adviser suggested that the member approach her clinical director to discuss the difficulties this patient would pose. It might be helpful for the clinical director or another senior manager to check that the patient understood the circumstances under which the trust could provide treatment (which might include a behavioural contract with the patient).

The MDU’s adviser sympathised with the member’s position that her concerns were not based solely on the complaint, but on the full scope of the patient’s behaviour.

The patient could then ask to be referred to another provider if she was not happy with what was on offer locally. If the patient wanted to go ahead with treatment under the consultant member's care, then there was an opportunity for her to air any concerns upfront and for the trust to address those appropriately.

The consultant agreed to speak to her clinical director about the referral. She accepted that the patient needed the further surgery and understood that it might be the only option because it was impractical for the patient to travel elsewhere. She agreed that she would operate on the patient if that is what the patient wanted, but it was reassuring to know that the management team were 'forewarned' about the patient and could try to set reasonable expectations with her at the outset.

This page was correct at publication on 14/03/2017. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

Complaints
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Comments

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Dr Ambury

I can sympathise with this scenario. There are times as a GP where I would ask a patient to consider seeing another GP in the practice, or register with another practice due to a breakdown in relationship with a patient. My most recent one was a patient whom my practice manager asked me to see after she threatened to make an - in my opinion- unfounded complaint about another GP in the practice. My advice to said patient was whilst we would continue to care for her, we could not guarantee there would always be an alternative GP available, so registering elsewhere was an option. The time before that was when I was notified by a ward Sister that they were discharging a patient whom they had called Police to on the ward, after he threatened to kill me. Thankfully that was more straightforward and NHS England removed him into the Zero Tolerance scheme within 24 hours.

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DR Kittel

The case above clearly illustrates that the GMC guideline needs reviewing. It is almost super human to ask doctors that I 'must not allow a patient's complaint to adversely affect the care or treatment you provide or arrange'. One of my colleagues recently nearly retired after a complaint that was made and led to a small claim. 2 colleagues I know have been off sick with depression for prolonged periods of time. Surely, patient safety requires a surgeon to be on top of their game when doing and operation, but as we are not robots dysfunctional patient relationships will cause angst and fear, hardly a good way to do surgery. During my lifetime as a community surgeon with a special interest in vasectomy I have had very few dysfunctional consultations, but very occasionally patients with mental health disorders, particularly personality disorders and / or anxiety, can be very difficult to treat. In fact, nowadays and after years of experience I often already know ahead of a procedure, which patients may not benefit from the procedure, may have increased side effects, suffer chronic pain later etc or is at a high likelihood to be unsatisfied. None of this is evidence based, just experience. Recently I had a very nervous patient with thousands of questions requesting a vasectomy. I advised him beforehand I didnt think the procedure was right for him, he should re-consider as I thought he was at high risk of regret. I documented this carefully and recommended to consider other contraceptive methods. However, he decided to go ahead. Three months later he called me requesting a reversal for chronic pain. In this case I advised him to wait longer and I am waiting for further developments. In situations where treatment delays dont cause a serious deterioration in health or where there has been previous problems it should be possible for doctors to make a decision not to treat a patient even if this means further travelling for the patient. The doctor should sign-post a patient to another service or, failing another service being available, to ask the patient to see their GP for a referral elsewhere for this reason. I am not aware of any evidence base to this, but I am sure perceived patient outcomes and patient satisfaction are likely affected by dysfunctional relationships with their doctor. I wonder how much the guidance affects patient safety and clinical governance? I wonder if the MDU could come together with the GMC to review this guideline?

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DR Hayter

I completely agree. It may be appropriate that the state bureaucracy takes collective responsibility for a patient no matter what their behaviour, but the GMC has no ethical basis (except perhaps expediently helping the politicians who pay for it) for requiring a surgeon or physician to treat a patient with whom there is no mutual trust. The situation may be different for psychiatry, or the rare cases where only one doctor in the whole country has the skill to treat the patient; but in the scenario presented the patient should go elsewhere.

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