Angry Patient
Doctor Information
Aron Matthews, age 56
Past Medical History
Hypertension
Hypercholesterolaemia
Medication
Ramipril 5mg OD
Atorvastatin 20mg ON
Latest entry:
Medication review done without patient. Aspirin stopped as primary prevention, no indication
Past Medical History
Hypertension
Hypercholesterolaemia
Medication
Ramipril 5mg OD
Atorvastatin 20mg ON
Latest entry:
Medication review done without patient. Aspirin stopped as primary prevention, no indication
Patient Information
Aron Matthews, age 56
You will act angrily, and despite what the Dr's say you will keep arguing and keep being angry with them.
You are very angry, you can not believe that these doctors have stopped your medication! You have been on aspirin for years, then when you went to get your repeat medications the pharmacist told you the aspirin had been stopped! They couldn't tell you why, but the pharmacist told you that the NHS is cutting down on unnecessary medication. You did some googling and found that doctors are trying to save money, and you are disgusted. You've seen the nice cars at the car parks, and you feel that you the GP could afford to spend a few more pennies on me. Ive worked all my life, and have paid my taxes, I want my medication. The pharmacist informed me that I could by aspirin, but you don't feel that you should have to pay for this!
You have read that aspirin helps prevent strokes, and you can't believe that the GPs would stop this cheap medication, that might prevent you from having a stroke, you find it disgusting. You know how much GPs earn, you've seen in the Daily Mail! You know GPs are earning up to £200,000 a year!
You are also annoyed that no one discussed this with you, you had to find out from the pharmacist! You therefore don't feel that the practice values you.
Medical and medication history as above. you don't smoke, BMI 26, your BP is well controlled. You used to be a mechanic, but you retired early. You don't drink any alcohol.
Ideas: you are furious that the well earning GP's are stopping this cheap medication that could stop you having a stroke!!
Concerns: That stopping this medication will lead to a stroke
Expectations: you want your aspirin back!, and you wish to complain about the way this has been handled, and the fact that nothing was discussed with you in advance.
Any mention of the GPs pay not being a lot will only get you more angry!! As you had to survive on a low income all of his life, and he worked just as hard as the GPs do.
You will act angrily, and despite what the Dr's say you will keep arguing and keep being angry with them.
You are very angry, you can not believe that these doctors have stopped your medication! You have been on aspirin for years, then when you went to get your repeat medications the pharmacist told you the aspirin had been stopped! They couldn't tell you why, but the pharmacist told you that the NHS is cutting down on unnecessary medication. You did some googling and found that doctors are trying to save money, and you are disgusted. You've seen the nice cars at the car parks, and you feel that you the GP could afford to spend a few more pennies on me. Ive worked all my life, and have paid my taxes, I want my medication. The pharmacist informed me that I could by aspirin, but you don't feel that you should have to pay for this!
You have read that aspirin helps prevent strokes, and you can't believe that the GPs would stop this cheap medication, that might prevent you from having a stroke, you find it disgusting. You know how much GPs earn, you've seen in the Daily Mail! You know GPs are earning up to £200,000 a year!
You are also annoyed that no one discussed this with you, you had to find out from the pharmacist! You therefore don't feel that the practice values you.
Medical and medication history as above. you don't smoke, BMI 26, your BP is well controlled. You used to be a mechanic, but you retired early. You don't drink any alcohol.
Ideas: you are furious that the well earning GP's are stopping this cheap medication that could stop you having a stroke!!
Concerns: That stopping this medication will lead to a stroke
Expectations: you want your aspirin back!, and you wish to complain about the way this has been handled, and the fact that nothing was discussed with you in advance.
Any mention of the GPs pay not being a lot will only get you more angry!! As you had to survive on a low income all of his life, and he worked just as hard as the GPs do.
Examination Findings
Examination
Not needed in this case.
Not needed in this case.
Mark scheme
Data Gathering
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POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Asks about complaint and explores patients understanding of the condition Explores patients' concern regarding the medication. |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them |
Clinical Management Skills
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POSITIVE INDICATORS
Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions Manages risk effectively, safety netting appropriately Discusses how to make a complaint, what the procedure involves, and how long before he receives a response. |
NEGATIVE INDICATORS
Follow-up arrangements are absent or disjointed Fails to take account of related issues or of co-morbidity Does not suggest to patient how they may make a complaint. Or what the complaint procedure involves. |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Explores patients concerns around the aspirin and his occupation. Is empathetic towards the mistake made by the practice Offers apology for the situation, and works well to calm the patient down. |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient Is not empathetic towards problem Refuses to apologise for practice mistake, or refuses to accept practice responsibility for said mistake |
Management
Management:
As you may be aware, aspirin is no longer indicated in primary prevention, and will have been the reason as to why this patient's medications were stopped. He has no reason to be on secondary prevention. So, medically, the GP is correct to stop the aspirin. The mistake here was to do it without discussing it firstly with the patient. This has obviously led to some concern from the patient as to the reasoning behind this, resulting in him arriving at the wrong conclusion.
As you may be aware, aspirin is no longer indicated in primary prevention, and will have been the reason as to why this patient's medications were stopped. He has no reason to be on secondary prevention. So, medically, the GP is correct to stop the aspirin. The mistake here was to do it without discussing it firstly with the patient. This has obviously led to some concern from the patient as to the reasoning behind this, resulting in him arriving at the wrong conclusion.
The following is taken from NICE CKS on antiplatelet treatment in primary prevention:
People who are not hypertensivePeople with hypertension
- Aspirin is not recommended for people at low CVD risk who are not hypertensive because there is good quality evidence that the modest reduction in CVD risk with low dose aspirin is balanced by a modest increase in the risk of serious bleeding. This is in line with guidelines published by Scottish Intercollegiate Guidelines Network (SIGN); Antithrombotics: indications and management [SIGN, 2013] and the European Cardiology Society (ESC); European guidelines on cardiovascular disease prevention in clinical practice [Perk et al, 2012].
- Aspirin is not recommended for people with hypertension at low CVD risk and normal renal function because there is good quality evidence that the modest reduction in CVD risk with low dose aspirin is balanced by a modest increase in the risk of serious bleeding.
- For people with hypertension and either impaired renal function or a raised CVD risk there is weak evidence that the reduction in CVD risk with low dose aspirin outweighs the modest risk of serious bleeding.
The same advice applies to diabetics; the current SIGN guidelines advises against using aspirin for primary prevention alone.
It would be important in this case to not get into an argument about money in this case, and not rise to the bait of the daily mail comment re GP incomes. One way of dealing with this patient would be to let him talk first, finding out about his I.C.E. The second step would involve trying to deal with the ICE, dealing with the concern over the stroke, and explaining why the medications were stopped, and that it had nothing to do with finances. Sometimes it can be helpful to mention that any prescription saving does not go into your pocket at all. Finally, focussing on (and not dismissing) the fact that the practice did make a mistake in how it handled this medication change. Making sure you inform the patient of the complaint procedure, and how any outcomes will be reported back to him.
Here are a few helpful hints on dealing with an angry patient:
It would be important in this case to not get into an argument about money in this case, and not rise to the bait of the daily mail comment re GP incomes. One way of dealing with this patient would be to let him talk first, finding out about his I.C.E. The second step would involve trying to deal with the ICE, dealing with the concern over the stroke, and explaining why the medications were stopped, and that it had nothing to do with finances. Sometimes it can be helpful to mention that any prescription saving does not go into your pocket at all. Finally, focussing on (and not dismissing) the fact that the practice did make a mistake in how it handled this medication change. Making sure you inform the patient of the complaint procedure, and how any outcomes will be reported back to him.
Here are a few helpful hints on dealing with an angry patient:
- Avoid confrontation or argument
- Listen patiently initially, let the patient finish their narrative
- If the patient is angry about a missed diagnosis or incorrect management of an individual, ask about them early on (i.e. a missed diagnosis of appendicitis in a child, ask about the child early in the consultation)
- Reassure the patient that the course of action they have taken is the correct one: in this case, coming in to speak to someone about this.
- Try to show you understand how distressing the situation must be for the patient.
- However never say "I understand" as this is simply fuel for an angry patient (who will typically reply with; "Oh no you don't!!")
- If you say "I'm sorry" be clear on what you are apologising for, is this an admission of responsibility or not. i.e. "I'm sorry that this has happened", vs "I'm sorry I did something wrong."
- Don't criticise other health care professionals
- Above all, stay calm, stay seated, and listen.
Dealing with complaint:
The next part of this scenario is dealing effectively with a complaint. The first thing to do is acknowledge the complaint and discuss exactly what the patient takes issue with. Complaints can be often resolved during the consultation by making an apology (for the situation, or apologise for your error if this is what has happened), and making an effort to resolve things. In this situation, even if you manage to pacify the patient and he is content with your management plan, he will still want to complain about the procedure. He has the right to do this, and you should not discourage him. Instead, talk him through the complaints procedure (usually a complaint is made in writing - preferable - or by telephone to the practice manager, who will acknowledge it within 48 hours, and provide a written response within 10 days). The usual situation will involve speaking to the individual in question, discussing the situation at the practice meeting, and making amendments if appropriate to the way results are handed out by telephone. If the complaint falls under the category of a significant event, then it should be dealt as such.