Julia's Day

 

Julia is a GP in a busy practice. In 2011, we followed Julia as she dealt with various issues and dilemmas – in her role as a doctor and in her private life – and asked you to decide what she should do.

From June through to September 2011, we followed the progress of Julia across four ethical dilemmas and we had over 3,300 responses to the questions we posed at the end of each episode.

You can use the tabs below to read the feedback from each month and to also see what happened earlier in the story.

Feedback

Each month you were able to vote on what Julia should do - read the results for episode four, episode three, episode two and episode one here.

Episode four

At the end of episode four we asked you what Julia should do when she meets with a young teenager who is being bullied at school given that the treatment by his peers is effecting his eczema.

Thank you to the 209 of you who took part!

'Suggest he raise the problem with the school and his family'

57 of you thought that Julia should encourage the student to raise the problem again with the school and his family, explaining how it's affecting his health. 7 of you provided additional comments including:

  • ‘In the first instance Julia should encourage Tom to raise the issues with his Parents and offer Tom to come and see her with at least one of his parents. His parents are his guardians and they should be made aware of his situation and then supported in taking this forward with the school.(All with Tom's agreement)’
  • ‘Primarily treat the eczema before dealing with the problem at school.’
  • ‘Difficult to judge when to escalate or when to leave it to him to sort out. Bullying is always serious and in this case it is making him ill. His parents are not aware of the extent of the problem; is it better to speak to them or leave it to him? Difficult.’

'With permission, write to the school and parents'

93 of you thought that Julia should, with the student’s permission, write to the school and his parents to explain how it's affecting his health. 11 of you provided additional comments including:

  • ‘This is definitely something that must be addressed in some way by the GP.’
  • ‘The school needs to sensitize the school body to the negative effects of bullying without aiming the focus on Tom solely.  Tom's father also needs an attitude adjustment.  The figure shown in the picture above appears to be one with the weight of the world on his shoulders. Julia is going to have a difficult time and may need school counsellors, with her patient's permission, to get involved and reinforce the positive approach she sets about in the office.’
  • ‘I would first (with his permission) offer to discuss the issue with his family first and foremost. Then maybe we could find a way to tackle the problems at school.’
  • 'She should do what is best for his health and wellbeing. Doing something that would stop the bullying and/or empower him is obviously right, and if he agrees, b could do that. I might also refer him for counselling - especially if he didn't consent to b.’

'Something else'

For the first time on our Julia’s Day poll, we provided the opportunity for respondents to suggest their own option through the comments box. 59 of you took this opportunity and the most common suggestions included:

  • Discuss with the patient which option he would prefer.
  • Involve others, with the patients permission, who may be able to provide support (such as his family, the local Safeguarding Team or the school nurse).
  • With his permission write to the school and inform parents that she did so and encourage him to tell his parents more about the situation.
  • Encourage Tom to speak to one of the on-line anti-bullying charities or to turn to others for support.
  • Focus on treating the eczema only.
  • Some combination of both of the suggested options.
  • That it would be helpful to know how old the patient was.

'Not a dilemma'

Finally, as with previous months, a number of respondents (16.7%) answered the question and suggested through their comments that they found the format of the story patronising to them as doctors.

You can read our response to this criticism here.

Episode three

At the end of episode three we asked you what Julia should do when she thinks that her elderly mother requires some antibiotics to clear up an infection.

Once again, thank you to the 1313 who took part – that is the most responses we have had so far! There were three options for you to vote on last month and we also received feedback that we should also create a ‘none of the above’ option, which we did for September's poll.

‘Ring out of hours service'

695 of you thought Julia should ring the out of hours service for her mother's GP and 170 of you provided additional comments. Many were emphatic it should never be acceptable for a doctor to treat their own family, but some, while acknowledging the principle, felt that there should be more flexibility in practice.

  • 'You cannot be objective about members of your own family.  Besides, her mother is not (& should never be) her patient.'
  • 'Julia is not in a position to give an objective assessment of her mother. Confusion in the elderly is a multifactorial symptom which requires thorough examination and appropriate investigation. It would be better to have another opinion at least, and responsibility for further investigation/ follow up and liaison with her own GP taken by another doctor.'
  • 'While this is an acute problem, it is not an emergency although it justifies Julia behaving as a concerned relative and calling for the out of hours service. On approval from a colleague she can then use antibiotics from her own out of hours bag and get her to the GP next morning.  I have little doubt that the other two options would seem easier for a tired doctor/mother/daughter but could later prove to be indefensible medically or in law.'
  • 'There is an obvious difference between what we SHOULD do and what we almost certainly WOULD do. The mother has a straightforward medical condition that could easily be Rx immediately, helping the patient and reducing demand on the out of hours service.'

‘Prescribe herself and get dispensed’

250 of you thought Julia should prescribe the antibiotics herself and get the prescription dispensed straight away and 62 of you provided additional comments. The majority view was that this would be the correct course where there is a clear diagnosis; in an emergency; as a one-off where no alternative is currently available; where there is no risk of harm to the patient; and providing the patient agrees.  On the other hand, several respondents warned that prescribing might not be appropriate if it involves medication which presents a significant risk to the patient (such as opioids and steroids) or where the family member has a long-term condition.

  • ‘As a general rule Julia should try not to prescribe for members of her own family (as per Communitybaptistpa guidance). However I think a short course of antibiotics is permissible as long as it's a one off. If Julia had all the time in the world she should probably go to the OOH service but in reality she is capable of making the diagnosis herself & the treatment prescribed is common & low risk.’
  • ‘There is an obvious diagnosis with a condition that could deteriorate quickly. It is not a long term illness and the treatment cannot be abused...Clearly the patient's own GP will need to be informed, but it seems reasonable to commence short term treatment.’
  • ‘When you have a clear cut diagnosis and treatment is straightforward and involves drugs of no potential abuse this should be allowed.’
  • ‘There seems to be nothing inherently wrong with issuing a px. The danger comes when either Julia short cuts dx or her mother treats her differently to a normal doctor and doesn't give the full story.’

A small number of respondents who gave this answer challenged the idea that, as a matter of principle, doctors should not prescribe for members of their family. They considered that doctors should be trusted to approach decisions with family members as they would with other patients. Some felt that providing medical care could be seen as a reasonable part of one's family responsibilities. 

  • ‘If Julia is banned from prescribing for her mum because that could 'cloud' her decision making process, then surely she should stop prescribing for the patients she knows too well...let us use our personal judgement and stop assuming we are all 'emotionally compromised'.’
  • ‘In the past I don't think a doctor was not allowed to prescribe medicines to his own family. It is like a mechanic cannot fix his wife's car. This kind of absurdity has only emerged in our modern society when people who have no role in life found jobs on ethics committees.’
  • ‘We cure people. That is why we are doctors. And a good doctor knows how to do it whether the patient is himself, his best friend or the Pope.’
  • ‘I have practised medicine in 5 different countries and it is only in the UK that there appears to be such prurience about treating one's own family.’

'Provide antibiotics from out of hours bag'

368 of you thought Julia should provide antibiotics from her own 'out of hours' bag - and get her mother to the GP in the morning, and 111 provided comments. Those who chose this option often identified this as the practical, pragmatic solution, while acknowledging that doctors should usually avoid treating their relatives. Many focused on the dangers of delay associated with the other options, while some qualified their answer by saying they would do a urine analysis before commencing treatment.

Several respondents mentioned the need to keep the OOH service, and especially Julia’s mother’s GP, informed of any treatment started. Starting a short course of medication and making an appointment for Julia’s mother to be seen by her own GP in the morning was a popular suggestion.

  • ‘This is a really simple, unambiguous case. If she contacts OOH she will be taking up time of others that isn't necessary. If she prescribes a full-set herself then the GP will not know about the episode. But if the GP is informed in the morning, that is good.’
  • ‘It's a minor illness and an emergency, since any further delay in treating an infection in an elderly person could make a big difference. Her mother would probably not get a lengthier or more detailed consultation through the out of hours service so the result would be the same - her mother getting antibiotics. And getting her mother to the GP in the morning means that her GP's records would be kept up to date.’
  • ‘I know strictly speaking the answer should be (a). However, I would think it is reasonable to dispense some antibiotics with follow up by an independent person as soon as possible. She could always phone and speak to out of hours so it is recorded and inform them of what she intends and share the issue with them first. Clearly if we are talking about a less clear cut scenario or controlled drugs then things would be very different.’
  • ‘For simple prescribing such as a short course of antibiotics when its difficult to get hold of colleagues I think this is fine but it should always only be a temporary solution whilst awaiting a proper referral or GP appointment; for anything more complex it is not appropriate.’

'Not a dilemma'

Finally, as with previous months, a small number of respondents (6.9%) answered the question and suggested through their comments that they found the format of the story patronising to them as doctors.

You can read our response to this criticism here.

Episode two

At the end of episode two we asked you what Julia should do when she thinks there might have been a failure to take action on a referral in relation to her patient with learning disabilities.

Once again, thank you to the 661 who took part - we were really impressed by the range of responses this month. The split between the two options was more even that our first month.

424 of you thought Julia should explain that there has been a delay, but that she would sort it out with the previous doctor:

237 of you thought that she should say nothing, but follow up with the doctor responsible later in the day:

'Explain that there has been a delay'

79 people who thought that Julia should explain that there had been a delay but that she would sort it out with the previous doctor, provided comments including:

  • 'Honesty is always the best policy.'
  • 'This is about honesty and probity. It is important to apologize first & then have a word with Dr Hicks and sort out the problem. This will help build a relationship of trust which is very important for continuing care for Sally.'
  • 'Treat your patient as you would like to be treated! I would not like the truth to be hidden from me, but the GP does not have to make a big deal about the delay and create unnecessary anxiety - if the patient's vision has not deteriorated further since the last appointment, it probably is not a big deal. If however, it has, the GP can fax a request for an urgent appointment - or in the worse case scenario, send her to emergency eye clinic.'
  • 'You must be honest with the patient. However, it is important to explain the situation sensitively and try to avoid causing further distress. You are not sure what has happened. Therefore you should apologise to the patient for the delay and reassure her that you will make a referral promptly and investigate what happened to the initial referral (for instance, it may have been made no copy filed and no appointment made due to a delay at the Ophthalmology end etc.).'Common issues raised in other responses include that there was not enough information within the scenario, and that a combination of both answers would be the appropriate response.

'Say nothing, but raise it with the doctor responsible later'

71 people who thought that Julia should not say anything about the omission to her patient but raise it privately the doctor later provided comments including:
  • 'Firstly Sally is uncertain of the detail of any possible referral so if she says anything about this she will not be able to answer questions; taking the second choice option actually provides care for the patient.'
  • 'It wouldn't be fair to make comment on the source of the delay until she knows what happened: she should find out immediately from Dr Hicks what happened, privately, put it right, and then explain when she knows all the facts.'
  • 'This is the first consultation and she is already bit agitated. Julie should have looked at the notes before but she didn’t had time. I think this option is safer. Julie gets time to look at the notes and time to speak to Dr Hicks. If needed she can make another appointment to see her and explain things.'
  • 'She does not know all the facts, so raising them at this time would not be helpful. Check facts, make urgent referral or chase referral already made. Once all facts are known then it would be appropriate for an apology to be made of referral was not done.'
  • 'Julia should make sure that no serious problem is going on with Sally’s eye, which needs urgent care or treatment. As Sally already worried/agitated and Julia haven’t been able to read through all notes, it seems better not to worry her more, especially because Julia doesn’t know much about this referral. If they will be coming back next week, than this problem can be sorted by than.'

Common issues raised in other responses include that Dr Hicks may not have made an omission and that the lack of referral letter may have been an administrative error. Many respondents suggested that Julia should have a conversation with the other doctor as soon as possible to find out what had happened.

'Not a dilemma'

Finally, as with last month, a small number of respondents (8.2%) answered the question and suggested through their comments that they found the format of the story patronising to them as doctors.

Respondents who didn't comment

We also received 150 responses where the respondent did not answer the question, but simply filled in the comments box. These comments were critical of the format, style and use of the picture. The most frequent concerns expressed were about the patronising tone, or the fact that the issues were over-simplified.

We have not included such responses in the analysis above because these respondents did not answer the question.

Our response

The approach in ‘Julia’s Day’ was enjoyed by many of our readers, and certainly encouraged discussion of the issues which we are reviewing as we up-date Good Medical Practice.

The Review of Good Medical Practice website and its content are designed to appeal to a wide range of readers, including members of the public, and to cater both for those with time to read longer articles and those with just a couple of minutes to give to the review.

In July, for example, we asked whether individual doctors can make a difference to health inequalities. Sir Michael Marmot wrote on the social determinants of health. There were contributions from four others with different perspectives, and an invitation to comment.

We are sorry that some readers felt that ‘Julia’s Day’ was patronising. In view of the number of responses we received overall and the variety of comments which are helpful to us as we review Good Medical Practice, we continued to follow Julia and explored the dilemmas she faced.

‘Julia’s Day’ in August raised a question about whether – or in what circumstances – doctors should treat members of their family. For those readers who do not find the ‘Julia’s Day’ scenarios or format useful, you can read about the issues we considered when reviewing the section of the guidance.

Episode one

At the end of episode one we asked you what Julia should do when she encountered an accident on her way to a consultation with one of her patients. We were overwhelmed by the huge response to last month’s ethical dilemma – 1,201 people took part – so thank you!

1,002 of you thought Julia should stop and see if she can help.

199 of you thought that she should give priority to her own patient.

'Stop and see if she can help'

209 people who thought that Julia should stop, provided comments including:

  • 'In a sense, both the cyclist and the person with Down's syndrome are Julia's patients. If we start from this premise, then we are able to prioritise them. In this situation, the cyclist is in greater need of Julia's attention than the surgery patient, because the cyclist could potentially have trauma that needs immediate attention. The Down's patient, on the other hand, is not in imminent danger, and could potentially be placated by members of staff at the surgery.'
  • 'It is a difficult one. Intuition would say you should help the man, but she makes a good point that anyone can phone an ambulance. But, Julia is likely to be in a good position to put the man at ease and take charge of the situation better than a civilian. Also, if Julia was debating whether or not to stop and help, the rest of the drivers could well do the same and then the man would be left without aid. On balance I think Julia should stop and see if she can help.'
  • 'If my child was knocked off his bike with potentially life-threatening injuries I would hope a passing doctor would stop. GPs may think they're poorly equipped, but would know CPR, could immobilise a C-spine or ask pertinent questions before ambulance arrives. Even reassurance : "Don't worry, I'm a doctor, help is on its way" could make all the difference. It would be a sad day for the profession if personal interest, or that of existing patients, were to be put before a casualty.'

Common issues raised in other responses include the assessment of availability of other options and the need to do something rather than nothing. These are issues which fit quite closely with the current guidance in Good Medical Practice (2006).

'Give priority to her own patient'

74 people who thought that Julia should give priority to her own patient provided comments including:
  • ‘I'm going to be spectacularly concrete and comment that the picture accompanying the vignette seems to show a man who is clearly conscious and seems to have a cut to his leg.  In the circumstances he probably doesn't need any help that couldn't be rendered by a another member of the public so I wouldn't see it as being unethical to prioritise the needs of her scheduled patient.’
  • ‘Whereas the Guidelines suggest she should stop, the information didn't suggest that the cyclist was seriously injured. It would suggest that there were lots of other people about that could help, and as the GP will have a Down's patient waiting for her, who can get easily upset if left waiting, I would reckon in this instance, that her responsibilities are to her patient - if there was no-one around to help the cyclist that would be different.’
  • ‘Between the cyclist who does not appear to have an urgent health issue/problem and potentially could be looked after by any one and Julia's own patient, who would have to been seen by Julia herself and as promptly as possible and balancing the two, I think Julia should give priority to her own patient.’

'Not a dilemma'

Finally, a small number of respondents (1.7%) felt that there was no dilemma and found the format of the story patronising to them as doctors. We are sorry you felt that way, but given the considerable response we received overall and the variety of comments which will be helpful to us as we review Good Medical Practice (2006), we will continue to follow Julia and explore the dilemmas she faces.



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Episode 4

Helping young people

A young teenager has arrived in Julia’s office - without his Mum for the first time.

‘Hello Tom – how can I help you today?'

‘Well, my eczema is getting worse, so I thought maybe there was something else I could take for it… And I can’t get to sleep, so I’m really tired, which just makes it all worse.’

‘How long has this been going on Tom?’

‘I don’t know - a few weeks maybe…  I think the eczema flared up again when….’

‘When what?’

‘Well stuff at school really – it’s nothing really, but I seem to get picked on a lot.’

‘By the teachers?’

‘No, no, by older boys – and some in my class. It gets worse every day - I get upset, but Dad just says I have to, you know, stand up for myself. But he doesn’t understand…. And  I’ve told them at school – and they have policies and that, but I don’t think it makes any difference and I can’t keep going on about it – they won’t do anything anyway..’

‘Well, let’s have a look at your eczema and see what we can do about that, for a start.’

What should Julia do?

  • a. Suggest he raise the problem again with the school and his family, explaining how the bullying is affecting his health.
  • b. With his permission, write to the school and his parents to explain how it’s affecting his health
  • c. Something else – put your suggestion in the comment box

This poll is now closed - use the Feedback tab above to find out the results for our poll in Julia's Day Episode four.

What we currently say

We’re reviewing Good Medical Practice – this is what the current version says:

  • 25. You must safeguard and protect the health and well-being of children and young people.
  • 26. You should offer assistance to children and young people if you have reason to think that their rights have been abused or denied.

Should we change it?

 

 


 

 

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Episode 3

Treating her mother

It’s 11.30 and Julia is in the middle of her morning surgery, when one of the reception staff tells her that her mother has rung three times and ’didn’t sound herself’. Between patients, Julia makes a quick call to check in…

'Hi Mum, it’s me, I got a message, is everything okay?'

'Darling! Is that you? You’ve got to help me…. I’ve forgotten about the… the what-do you-call-them? And I can’t get hold of Dr Smith and…'

'Mum, can you calm down a bit? Tell me again, what have you forgotten?'

'My pills for… for… what do you call it?'

'Blood pressure?'

'Yes… can you get some for me – I’ve run out, and I can’t get Dr Smith’s surgery on the phone – they keep saying they’re not doctors – I mean, really…'

'I’ll sort it out Mum. You’re probably dialling the wrong number. You go and make a cup of tea and I’ll come over this afternoon. You seem very worried about this? Is everything else okay?'

'Yes, I guess so…'

'Okay – just relax, I have to go now, but I’ll be over later.'

Julia rings Dr Smith’s surgery and asks for a repeat prescription for her mother. She is quite concerned about her mother’s confusion – but a busy day, and picking up the children – and getting the prescription dispensed, means she doesn’t get to mother’s flat until after 6.

Her mother seems even more confused and in response to Julia’s questions says that she suddenly felt feverish this morning – and she had to keep making trips to the toilet to pass water which caused a burning pain.

After talking to her mother, Julia decides the most likely cause of the confusion is a urinary tract infection. She knows that this is something that can be cleared up easily with the right antibiotics. But it’s been a long day and it is now quarter to 7. The local pharmacy will close at 7pm.

What should Julia do?

  • a. Ring the out of hours service for her mother’s GP?
  • b. Prescribe antibiotics herself and get the prescription dispensed straight away?
  • c. Provide antibiotics from her own ‘out of hours’ bag – and get her mother to the GP in the morning?

This poll is now closed - use the Feedback tab above to find out the results for our poll in Julia's Day Episode three.

What we currently say

Good Medical Practice (2006) is currently being reviewed and this is what it says at paragraph 5:

  • 'Wherever possible, you should avoid providing medical care to anyone with whom you have a close personal relationship.'

If you would like to find out more about the issues in this area, you can read about the issues we will be considering when reviewing the section of the guidance on doctors’ treating family members.

 



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Episode 2

 

First appointment

   

Julia was still running late. She’d stopped to help a cyclist who’d come off his bike. He wasn’t badly hurt and hadn’t banged his head but she was still glad she’d stopped to check.

Now the problem was to prepare for her first appointment of the day – Sally, an 18 year old with Down’s. This appointment was part of Sally’s transition from paediatric to adult care. Reading back through the notes would help, but keeping everyone waiting was probably counter-productive….

'Hello Sally how nice to meet you. And who have you brought with you today?'

'This is Dan. Dan helps me with things. Dan, can we go home now?'

'Sally’s a bit upset about waiting – aren’t you Sally? We got here a bit early…. and now Sally’s had time to get worried… and a bit, well, agitated.'

'While you’re here today Sally, why don’t we just get to know each other a bit more? Dr Hicks used to look after you, how did you get on with him?'

'He was nice. But I don’t like it here. I didn’t like all the people looking at me out there… and I want to go home, now. Dan.'

'Well Sally perhaps we can get to know each other a bit better next time. You and Dan can make an appointment for early next week. Let me just check the notes for anything important we should follow up today.'

Reading through the last entries Julia sees that Dr Hicks said he would refer Sally to the local ophthalmologist to investigate a possible worsening in Sally’s vision – but there’s no copy letter or record that this was done. Neither Sally nor Dan seem aware that she should have been offered an appointment by now.

'Ah I see here you were having a problem with seeing the television clearly in March…'

What should Julia do?

  • a. Explain to Sally and Dan that there seems to have been a delay in making the referral, but she’ll sort it out with Dr Hicks.
  • b. Ask how her vision is now, but say nothing about Dr Hicks’ omission to Sally and Dan, then raise it privately with Dr Hicks later in the day.

This poll is now closed - use the Feedback tab above to find out the results for our poll in Julia's Day Episode two.

What we currently say

Good Medical Practice (2006) is currently being reviewed and this is what it says at paragraph 30:

  • "If a patient under your care has suffered harm or distress, you must act immediately to put matters right, if that is possible. You should offer an apology and explain fully and promptly to the patient what has happened, and the likely short-term and long-term effects."

 

 


 

 

 

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Episode 1

Early morning

Julia's morning was not going according to plan. The baby had been sick on her shoulder, and Josh, aged 3, did not want to go to nursery school. He wanted to stay with Mummy. Tom, aged 33, had made the same point. As he repeatedly said, he saw nothing of her as she was always working, with the children or asleep.

At least they were on their way - and she was giving Tom a lift...

'Julia, you're not listening - I said I'd be late tonight... Work thing. You know. Social. Have to go.'

'Hmm, that's fine.'

'You're still not listening… in fact you never listen to me anymore. It's like living with a robot not a wife.'

'I'm just worried about my first appointment - it's a patient with Downs I haven't seen before. And I'm trying to remember about health checks, and EasyRead and that stuff. I do know she gets upset if she has to wait - so I'd better not stop to get a coffee…'

'Julia! Did you see that, over there. A man's come off his bike.'

'No. I didn't see anything - push bike?

'Yeah.'

'Does he look hurt? I should stop, but there's probably nothing I can do… I didn't actually see it myself. Anyone can call an ambulance, if it's needed.'

'Julia, the lights have changed…'

'And I'll be late for that patient - it's my job to look after her, after all….'

'Jules - for goodness sake make up your mind. Either park up and help, or drive on...'

What should Julia do?

Should Julia stop and give assistance to the cyclist or should she continue to the practice for her existing appointment?

This poll is now closed - use the Results tab above to find out the results for our poll in Julia's Day Episode one.

 


 

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