In message <[log in to unmask]>, Paul Caldwell
<[log in to unmask]> writes
>Did you read the papers on patients calling docs out-of-hours? Although all
>very worthy, did it not read to you as a self-justifying whinge ?

Not really - it read to me as a very good record of how it is in real
life, but it makes uncomfortable reading. All the OOH and acute illness
in childhood papers do is record the opinions and feelings of patients
and parents of young children. Anyone who has seen patients like these
in GP will recognise the attitudes and many of us will get irritated
because the parents and patients often have a more fearful view of the
implications of acute illness than we do.

This is a problem with which we grapple every day. If we are overworked,
tired and fed up we will see only that our time is being wasted on minor
illness. The task of educating and reassuring patients, while at the
same time ensuring that we don't miss serious illness, is difficult and
time-consuming and the fact is that we are not always up to the job (nor
do we usually have enough time). I don't think that this is necessarily
our "fault" any more than parents are at "fault" for their often
exaggerated fears and the way they respond to them. Papers such as these
are valuable for the insights they bring into the reasons behind
patients' behaviour, but they don't give us specific interventions to
remedy the situation.

One of the most important messages is that, even if patients are
ignorant, they are not stupid, and they think carefully about what we
say. I think that the biggest mistake we can make is to be rigid or
dismissive of their fears. We must convey the fact of clinical
uncertainty in such a way as both to reassure them and alert them to the
signs they should look out for if the situation should change - not an
easy task. The worst thing we can do is to make confident assertions
when we recognise (or should recognise) that we are not in a position to
do so.

I tend to say things like "at the moment this looks like... and...should
happen. The things to watch out for are...but...happens in a few cases
and you should get back to me if it does". As to the great antibiotic
problem, my usual line is that we should prescribe antibiotics when
there is a clear necessity, that it doesn't look like there is at the
moment but that I would be happy to reconsider if the situation
warranted it; I emphasise that there is a need to avoid unnecessary
antibiotic use but that all I can make my decision on is the situation
at the time I see it. I tend to be fairly tough about sore throats and
antibiotics and usually suggest that a runny nose indicates that
antibiotics are unnessary.

Where menigitis is concerned, I always take parents fears seriously and
point out exactly why their child does not have signs of meningitis if I
can. While most of us seefar more children whose parents are worried
about meningitis than actual cases, the last time I saw a child with
meningitis he did not appear particularly ill, and the possibility of
the diagnosis had not crossed his parents' minds. This was a salutary
lesson and I am uncomfortably aware that if I had seen the child a
couple of hours before, I might not have made the diagnosis and would
have entered the statistics as yet another GP who had diagnosed a case
of menigitis as a "viral illness".

Toby
--
Toby Lipman, 7 Collingwood Terrace, Newcastle upon Tyne


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