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Dr. Cameron‘s Dram.

"Och, Dr Finlay, you'll doubtless have your mind on all that houghmagandie you young people keep on about. But this is the time to be looking at some of these wee problems ye've been having. Will ye juist top up my dram before we start?"

Scenario 1

Pt is a 17 yr old lad who happens to be a friend of my son. He is v high achieving and wants to go into the RAF after 6th form (I suspect his parents are especially keen to get uni expenses paid) His mother phoned me at home on my mobile the previous evening to request that I remove the antihist from his medication list, as having hayfever is a no no for RAF entry.

I remembered to look at this yesterday - I had already put the loratidine into the deleted meds last time we discussed it. However, at the end of the afternoon, I was told that she had come to see me 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 hayfever. Allergic rhinitis is read coded as a diagnosis - in 2008, also he was prescribed Loratidine by a locum in Sept 2009. Mum implied that I should remove the diagnosis from the record. I explained that I was unable to do this, and so she asked me to write a letter saying that he had been symptom free for the past 5 yrs. Unfortunately, I witnessed him having hayfever when he was at our house a few yrs ago, and we had to go and get him some Loratidine from the chemist.

This was quite irritating. I refuse to lie on anyone's behalf. If they want to lie, that's their business, but I don't want to be dragged into it, or emotionally blackmailed! I've decided to write a letter saying that he has been symptom free for at least a year (I bet he hasn't), and do a hand written note to the Pt's Mum explaining the problem - maybe suggest that she sees another Dr who doesn't know the pt personally.

Dr Cameron set down his whisky glass. "Aye, I can just imagine it. Well, I think you made the right decision here. It's likely that your patient's mum doesn't realize how manipulative she is being - she is trying to do the best for her son, like any good parent would. I'm sure you'll couch your letter to her in very friendly terms, like saying 'It's always difficult to remember the details of an illness, but his medical record does actually show that he did have these episodes. However, the fact that you say he has been clear for a whole year should make all the difference, and I'm happy write a letter to that effect. But at the end of the day, the armed services have their rules and there's not a lot we can do about that!' But as you say, you have to keep your professional integrity - without that, the whole thing can become a real mulligatawny, as we say here in Tannochbraie."

Scenario 2

A 6 yr old little girl was brought to see me 4/12 ago with a rip- roaring UTI. It recurred after Rx although was not a resistant organism. I re-treated, and ref to paeds. Mum has been to see a homeopath (who happens to be a personal friend) and says that the homeopathy Rx '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. She requested a telephone consultation with me yesterday; I suggested that she sends 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 Abs. I persuaded her to carry out my plan and then come along for a discussion re further management. She has paeds follow-up in mid Oct.

"Aye, the parent's stubborn views and ideas might be putting the child at risk, though not a very great risk it is true. 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 really does 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. You'll be 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 if they'll no accept that, at least you have the hospital appointment to back you up. That'll be in Glasgow, I believe?"

Scenario 3

Only to do with dependency. One of my old ladies- in her late 70s with multiple medical problems, OA HT mild HF, came to see me yesterday although I wasn't expecting her to come back until Feb. She had several fairly trivial problems bothering her. It dawned on me that the reason she had come in was because I had given her a follow-up appt which was too far ahead - she literally needs to come and see me at regular intervals, more regular than 6 months, even if she's actually quite well. I find it very difficult to set the bar correctly with these patients.

"Och, this is clear enough to me. You need to get a really good understanding of why the patient is behaving like this. At the moment you're making suppositions which may in fact be wrong. There's really nothing to be lost in simply asking the patient. So long as ye avoid 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. Once you know what she expects, then you will have a measure of agreement about the interval. Setting the bar, you say. Hmmm, I could do with a top-up since ye've offered…"

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