Disclaimer
The materials provided are for educational purposes only. Whilst all reasonable care has been taken in preparing these materials, including the accuracy of the information supplied, MIPS does not accept any liability whatsoever arising out of the use or reliance of the information provided.
Thank you for attending our most successful webinar to date. We appreciate your engagement throughout the presentation and present to you below the answers to your questions received before and during the webinar.
If you require further clarification contact MIPS on 1800 061 113 or via info@mips.com.au
How can general practice manage unvaccinated patients and staff?
MIPS recommends that all practice staff should be encouraged to get vaccinated. We are aware of at least one private employer who has made getting the vaccine a requirement for staff. Practitioners must be aware of legal implications regarding enforcement, but you are able to make it a requirement to staff where it reasonable and practicable to do so. See Safe Work Australia for employer guidance.
For patients, practitioners should encourage the uptake in line with the Australian Government’s public health program and directives.
Current COVID-19 vaccine issues are very difficult to discuss with angry and anxious patients. What tips can you suggest dealing with such patients?
Although COVID-19 has created a heightened level of anxiety in the community, practitioners are encouraged to always remain calm and exercise foresight even more so when dealing with challenging patients. Implement treating methods best suited to dissipate the levels of anxiety in accordance with your Code of Conduct We have provided a summary of key tips at the end of this Q&A that you may find useful.
How do we talk rationally to misinformed militant anti-mask, anti-vaccine, COVID-19 conspirators/deniers who quote case studies and bad research as their evidence?
MIPS recommends keeping your advice professional, concise and clinical. Do not entertain broader discussions. In MIPS’ experience it is unlikely you will convince or sway those with strong beliefs to the benefits or value of the vaccine. Engaging in further discussion may not lead to any significant outcome immediately and the individual may only change their mind in the days or weeks ahead. Be sure to take care in documenting discussions.
If a patient refuses to be COVID-19 tested or refuses to be vaccinated how much should we document?
You should document carefully not only that the patient refused but cite a short summary of their reasoning and the advice you provided. Some of the questions you can ask yourself are:
- “Did I outline the risks and benefits?”
- “Did I direct the patient to valid online resources?”
- “Did I provide printed materials to inform them?”
Can we self-organise basic blood test and throat swab collection for COVID-19 test?
Yes, there is no barrier to tests being conducted from a doctor’s clinic. For example, Queensland health advises “General Practice doctors, or GPs, can do COVID-19 testing or arrange these through private pathology providers, or they will refer you to another facility (like a pathology collection centre) for a test”. Pathology labs have instructions for clinicians. See Melbourne Pathology for example.
Does MIPS indemnity include missed diagnoses etc due to using telehealth?
Yes, telehealth is a standard part of healthcare and MIPS’ insurance cover, subject to the terms and conditions of the policy. You need to be mindful that telehealth can only be used where it is appropriate and there are MBS and AHPRA guidelines. Where a consultation ought to be done in-person but isn’t, any issues arising will not be as easily defensible and your care may be criticised. See MIPS’ full list of COVID-19 resources.
Who is responsible for COVID-19 vaccination complications?
Where the matter relates to a product (vaccine) issue, then the manufacturer of the product (vaccine) will be at fault. If a member becomes involved in this type of allegation, MIPS will indemnify and assist to ensure the appropriate entity (vaccine manufacturer) is held accountable. Where the matter relates to a negligent act or omission concerning the administration of vaccine, then the practitioner is likely to be responsible. We are yet to receive more information regarding the Federal Government’s COVID-19 indemnity scheme. See MIPS’ full list of COVID-19 resources.
How do we deal with patients who ask for mask exemption?
It is lawful not to wear a mask if you have a medical condition. Exceptions may be provided where warranted. The requirements for this vary in each state. In NSW people need to have proof of an exemption such as a certificate from a doctor or the NDIS. In Victoria, the Department of Health and Human Services has not defined what medical conditions are, but has advised that an exemption is suitable for people “who have a physical or mental health illness or condition, or disability which makes wearing a face covering unsuitable, including persons with obstructed breathing, a serious skin condition of the face, an intellectual disability, a mental health condition or persons who have experienced trauma”. Please check your local jurisdiction Department of Health advice.
Non-compliance, non-attendance, aggressive and rude patients: How and when can you disengage and end their practitioner-patient relationships?
You can disengage with a patient provided you meet your code of conduct requirements. You have an ongoing duty to treat the patient in an emergency, but Australian law does not compel you to continue to see a private patient. If you do choose to end a practitioner-patient relationship you should document this in your notes and the reason (see Good health records support a good defence). If your notes illustrate this, the matter will be more easily defended should there be a complaint or claim.
You should consider if the patient’s best interests are being served by ending the relationship. If the relationship has deteriorated and there is no longer trust or good communication, it may be in the patient’s best interest to see another practitioner. Where possible, ending a relationship this should be done in person. If you are concerned the patient will return and be rude or violent, you can further protect yourself by putting this in writing following your conversation. If the patient does not respond, you need to exhaust your follow up procedure, see How far to go in follow up.
How should practitioners approach separated parents when there is a difference in the thoughts about a child's care, or there is a bitter relationship between the parents, for example they can't agree or even be in the same room?
Your first priority should be to cater to the best interests of the child, while always adhering to any court orders. See MIPS’s practice note Separated parents - Don't become the meat in the sandwich.
What about rural and cross cultural, literacy and language issues? And after hours VMO and rural?
As per section 4.3.7 in the MBA Code of Conduct, you must take all practical steps to ensure that arrangements are made to meet your patients’ specific language, cultural and communication needs and you are aware of how these needs affect a patient’s understanding.
Further information and support:
- The Australian Government Translating and Interpreting Service (TIS) or 131 450
- Aboriginal and Torres Strait Islander fee-for-service language interpreters are available through state-based services.
- Aboriginal Interpreting WA
- 2M Language Queensland
- The National Auslan Interpreter Booking and Payment Service
What's MIPS’ advice on allowing patients to record consultations and can we audio record the consent in terminal cases?
Laws for recording conversations are state-based. With few exceptions, you must obtain the consent of the patient. This applies in reverse and patients must obtain your consent. If you think you are being surreptitiously recorded, it is reasonable to advise the patient that it is unlawful for them to record the consultation without the consent of everyone present and ask them to cease the recording. See MIPS’ practice note Are you being recorded?
How do you show empathy to a rude patient is being disrespectful?
Always ensure your approach is consistent as with all consultations; maintain good eye contact, be conscious of your language and tone and show interest. It may help to tell your patient that you are offended but, in some cases, you will have to accept that no matter how conscious and polite you are, you will not be able to win over a challenging patient. Always try to remain calm and professional.
How do you disengage with a patient on long-term opioid therapy from a previous practitioner when they are refusing to engage in a pain management programme and not likely to be taken up by another GP?
You should aim to pro-actively manage your patients’ expectations from the outset of a therapeutic relationship. Issues to cover during the consult:
- Risks and benefits expected
- How to manage potential side effects
- The consequences of not following the health advice you are providing
- Financial costs involved
If the situation does not improve, you can always terminate the therapeutic relationship if you are unable to reach an agreement or common ground with the patient. Ensure you comply with your obligations under the MBA Code of conduct
Good medical practice involves ensuring that the patient is adequately informed of your decision and facilitating arrangements for the continuing care of the patient, including passing on relevant clinical information.
How do we deny unreasonable demand by patients? Eg Young patient demanding Oophorectomy?
Here are some tips to guide you through dealing with patients who make unreasonable demands:
Do not feel obliged to accept the request and give in to unreasonable requests. All treatment must be clinically justified and properly investigated. If appropriate, find a way to say “no” in a respectful and neutral way so there is no room for ambiguity.
Seek to understand why the patient is asking for the drug or treatment. This approach will allow you to determine where you need to focus your attention and establish what is at the heart of the matter.
Explain why you are unable to meet the request and the clinico-legal reasons that guide your judgement. Clarify to the patient that it is not a personal decision.
Convey that your decision is in their best interests and try to arrange extra time to discuss the issue in further detail.
Explain the clinical and scientific reasons why additional tests or referrals are necessary before a definitive diagnosis can be reached.
If you think the therapeutic relationship may be severely compromised, you may consider terminating the relationship. Be mindful to keep a professional attitude and refrain from making this situation personal. You have the legal and ethical obligation to ensure and facilitate the continuity of care as you transition the patient’s care. You must also comply with the Medical Board of Australia’s Good Medical Practice: A Code of Conduct for Doctors in Australia when ending a doctor-patient relationship.
What about patients taking notes in the consultation about the consultation?
This is reasonable and you cannot ask a patient not to take notes. Where you suspect a patient is doing this to ensnare you or document something to create evidence for their own civil proceedings, your best defence is to take good notes. You can also call MIPS for assistance and speak with an experience clinico-legal adviser to help you document the consultation. See MIPS’ online unit, Health Records.
What is the difference between doctor shopping and drug information from the Qld state?
Doctor shopping refers to patients who deliberately seek to obtain more medicines than they clinically need. This is often achieved by booking consultations with different doctors without disclosing their previous visits. Some characteristic behavioural patterns are:
- Lives or works far from the practice or may claim to be from out of town.
- May present to the practice without a booking or late in the day.
- Makes appointments with different doctors.
- Insists that prescriptions have been lost or they ran out early.
- Gets distressed if told ‘no’ to their requests. May make threats and/or offer bribes.
- Asks for specific drugs by name.
- Asks for brand names.
- Requests to have the dose increased.
- Claims multiple allergies to alternative drugs.
- Displays anger or irritability when questioned closely about symptoms such as pain.
Some States and Territories have implemented real-time prescription monitoring services to inform healthcare practitioners about their patient's registered medicines usage, outside of their consultations.
Health practitioners across Australia can access the Australian Government’s Prescription Shopping Programme where they can verify a patient’s PBS subsidised medicine prescription history to help them make more informed prescribing decisions. The information service is available 24/7 on 1800 631 181. Only frequent drug seeking patients will be flagged by the system when they have received 25 prescriptions from six or more medical visits. The service does not monitor private scripts or those from the Department of Veterans’ Affairs.
A patient seeking drug information, on the other hand, may seek information about drugs and their effects. Refer to QLD government drug information
Is it okay to have a practice nurse sitting as witness, when anticipating a difficult consultation?
Absolutely yes. They can serve as a deterrent for poor behaviour and can independently verify your’s or the patients conduct. Most forms of chaperones can be highly helpful and in MIPS’ experience can improve the quality of healthcare.
Can you refuse to do home visits?
Yes, but you must consider the context, for example, have you seen the patient before and set a precedence to do home visits? It may be a reasonable alternative to conduct a consultation over the phone or via video and ask patients to present to you at a later date.
6 key tips when dealing with challenging patient interactions
- Always remain calm and professional.
- Consider your own safety by undertaking a rapid risk assessment. However, if that is not possible (and the patient is showing signs of being abusive or physically violent) offer to speak with them in a quiet place (with a witness) and close to an exit or doorway.
- Hear the person out. Active listening. This is often lacking in high stress and busy environments which can then create a spiral of negativity and a breakdown in communication.
- Acknowledge the person’s frustration/anxiety/other issues of discontent.
- Always use active listening techniques like nodding and maintaining good eye contact, exercise empathy and remain in ‘control’ (but not ‘controlling’).
- Use positive body language techniques to help convey your message. Such as:
- Maintaining good eye contact – scanning and making regular eye contact to all present in the conversation of more than one person on the conversation. Sitting or standing to mirror the person to whom you are speaking.
- Exercise appropriate body orientation – don’t put a desk or object between those in the conversation, circular seating plans are best for groups or difficult conversations and ensure your body is facing or oriented to the person/s with whom you are communicating.
- Be expressive but refrain from over-expansive hand gesturing. Overuse of expansive gesturing is perceived as power and not effective for collaborative conversations/presentations.
- Try to maintain a relaxed face during difficult conversations– smiles convey confidence and immediacy but may not be appropriate in all difficult conversations.
Contact MIPS 24/7 Clinico-Legal Support 1800 061 113 for specific advice.
