New Year dilemmas - what would you do?

Q: A patient asks their GP if they can certify they are fit enough to take up a new contact sport after being inactive for many years. How should the GP proceed with this request?

A: It’s admirable that the patient is keen to start the New Year off with a burst of enthusiastic physical activity, but it’s imperative that the GP take a considered approach to this request. The first thing to identify is if the certification sought is actually more a form of comfort for the patient, or if it’s formal certification for a body, in this case a sports body.

We advise considering the following:

• Can the patient provide an understanding of the level of fitness required for the activity?
• Does the patient have any underlying condition which could be relevant?
• Are they being prescribed any medication which could cause a problem
• Is there a requirement to undertake an examination of the patient, or further assess any condition?

With enough information about the nature of the proposed activity, and satisfied there are no relevant recorded contraindications, a GP may wish to complete the form. We advise providing a report including factual details about the patient’s health which could be relevant in the circumstances and that “you know of no reason that the patient should not be able to take part in the sport”, if satisfied that’s the case after a review of the patient.

It is important that not to be pressurised into complying with a request - or even to omit information – by a patient. GMC guidance states that GPs "must be honest and trustworthy… when completing or signing forms, reports and other documents".

If feeling pressurised to comply with a request – or even to omit information – by a patient a GP must make clear they cannot complete the form.

Q: A patient comes into a GP surgery to drop off a bottle of whisky for their doctor to say thanks and happy New Year – should they accept?

A. It’s fairly commonplace that a patient may hand in a small gift or gesture to show their appreciation for the care a GP has provided to them or a family member.

GMC guidance states that a GP may accept unsolicited gifts from patients or their relatives as long as:

• this does not affect, or appear to affect, the way you prescribe for, advise, treat, refer, or commission services for patients
• you have not used your influence to pressurise or persuade patients or their relatives to offer you gifts.

However, over the festive period patients may offer gifts that are perhaps larger or more expensive. While this is a lovely gesture, there can be some questions about whether to accept them and whether this may then blur the boundaries of professional relationships with patients. Facing this dilemma, a GP should consider what the motive behind the offer could be, and if the type or size of the gift have any impact on future professional conduct. The GMC guidance Financial and commercial arrangements and conflicts of interest gives a steer on all aspects of this issue.

A GP may also want to consider whether the patient is classed as vulnerable and whether accepting the gift from them may seem unethical and appear that they hold some sort of “influence” over that patient. There may be contractual guidance in geographical areas that prohibits acceptance of gifts of a certain value. It may also be the case that there are policies in place or a “register” for gifts valued over a certain limit.

If you have considered the following and feel for any reason you can’t accept the gift then you should be prepared to refuse and give the reasons behind this in a sensitive way, as to not cause any offence or upset to your patient.

Q: A patient discloses to their GP that they are worried about their daily chronic alcohol consumption, which has been particularly high over the festive season. The GP is aware that they are employed as a van delivery driver. What should the GP consider in relation to the driving matter?

A: The GP should consider and assess whether this disclosure impairs the patient’s fitness to drive. The General Medical Council produce specific guidance for GPs in this regard, Confidentiality: Patient’s fitness to drive and reporting concerns to the DVLA. The DVLA also provides guidance in Assessing fitness to drive – a guide for medical professionals which includes information about conditions that can impair this.

Trust is an essential element of the doctor patient relationship and doctors owe a duty of confidentiality to their patients, but they also have a wider duty to protect patients and the general public.

It may be a tricky subject to raise during the consultation, but if the doctor considers that the disclosure warrants advice to desist from driving while the condition prevails, then the GP should discuss their concerns with the patient and the patient should be told this that it is their legal responsibility to inform the DVLA about the condition, and its potential to affect their ability to drive safely.

The discussion should be accurately recorded in their medical record. The doctor should also inform the patient that if they continue to drive when they are not fit to do so, then they may be obliged to disclose relevant medical information about them, in confidence to the medical adviser at the DVLA.