From the advice line

Dr Rachel Birch shares a recent case where a member asked for advice on how to deal with a patient who persistently emailed a doctor at the practice about medical issues, instead of attending for a consultation.

Mr B is a practice manager and telephoned the Medical Protection advice line to discuss a difficult situation. Dr H had sought advice from a neurologist about Mrs A’s symptoms a few months previously. She had forwarded the neurologist’s response to Mrs A as his specialist opinion had been reassuring. She used her NHS email account. Unfortunately, after a couple of weeks, Mrs A started sending emails to Dr H. The first two, she said were “for information” and detailed her various symptoms, which the neurologist had termed unexplained medical symptoms. Dr H had responded to these emails, suggesting that Mrs A come in to see her. Mrs A then sent an email to Dr H, asking whether she might benefit from a multivitamin. The following week she emailed Dr H, asking her for a prescription for her HRT, stating that it was always so difficult to get an appointment with Dr H as she was a popular doctor. Dr H felt concerned that Mrs A was starting to use email as an alternative to clinical consultations. She emailed Mrs A back again, advising her that her queries would be more appropriately addressed in a consultation and asking her to come and see her in the practice. Mrs A didn’t email Dr H for a few weeks. However, rather than making an appointment to see Dr H, she sent her a photograph of a rash on her abdomen and asked her for a cream for this. Since Dr H worked part time, she did not review this email for two days. Dr H discussed her concerns with Mr B, and they agreed that there were potential risks in Mrs A seeking medical advice by email.

Expert advice

Mr B called the Medical Protection medicolegal advice line and spoke to one of our expert medicolegal advisers, Dr R. Dr R considered that, since Dr H has already responded to previous emails, Mrs A may have the expectation that it was acceptable to correspond with her in this way. Dr R suggested that Mr B and Dr H may wish to invite Mrs A in to discuss their concerns about the use of email correspondence. As part of this meeting they should explain to Mrs A what the practice can and cannot address by email. Dr R also advised that it might be helpful to explain to Mrs A the process for arranging appointments and accessing advice, for example by arranging to speak with the duty doctor or leaving a message with reception for Dr H to telephone her when she is next in the practice. If the practice has a generic administrative email inbox, for example for prescription requests, it would be helpful to provide Mrs A with this email address. Minutes of the meeting should be taken and the practice may wish to consider providing Mrs A with a copy of these.

Learning points

• Practices should discuss and agree their approach to email correspondence with patients. It is better for all clinicians to be consistent in their approach.
• Only appropriate matters should be dealt with via email exchanges and the practice should consider how they wish to use email to communicate with their patients.
• Some practices use email for appointment scheduling, others for the ordering of repeat prescriptions. In such situations, it is best to use a central practice email address, rather than a personal address, so that all members of the administrative team can access the emails.
• If doctors are considering communicating with patients about their health, it is important to remember that there are potential risks with this process. Many of the subtleties of communication, including non-verbal cues, are lost when communicating by email. There is no opportunity for the patient to be examined. It may be difficult for doctors to ensure a patient has fully understood the advice provided. For these reasons, email should not be used as a replacement for a face-to-face consultation.
• It is important to ensure that all emails to and from the patient are included as part of the patient’s medical record.