Intended for healthcare professionals

Views And Reviews Primary Colour

Helen Salisbury: Respectful disagreement

BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n78 (Published 12 January 2021) Cite this as: BMJ 2021;372:n78
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}phc.ox.ac.uk
    Follow Helen on Twitter: @HelenRSalisbury

All GPs will have experienced that uncomfortable feeling when they’ve referred a patient for an expert opinion but the response doesn’t seem quite right. You wonder if important details were missing from the referral letter, or if maybe the patient became miraculously, but temporarily, better in Outpatients. Whatever the cause, it leaves you with a dilemma: do you follow the specialist’s advice because this is their area of expertise (and, frankly, it’s disrespectful to do otherwise), or do you contact them again for further discussion, to check that nothing was missed and to reassure yourself and the patient?

How you handle such cases depends on many things, including the possible clinical consequences of a mistake and your confidence in your own knowledge of the area. You’ll probably weigh up the patient’s needs against your desire not to appear arrogant or troublesome to your hospital colleagues. This becomes easier as you gain experience and worry less about being thought foolish. If you’re lucky, you also come to know the local consultants over time, so what could be perceived as an awkward challenge will instead become a friendly discussion that increases your knowledge.

In this pandemic it has often looked as if those in charge have been in error over the decisions they’ve made. Some mistakes were blatant, such as the delays to lockdown in March and October, the relaxation of restrictions at Christmas, the “Eat Out to Spread the Virus” scheme, and the recent decision to open schools for a single day. In these examples, it took no expertise in public health or epidemiology to predict rises in infection.

Other decisions have been more finely balanced, including the proposal to postpone the second doses of the Pfizer vaccine for as long as 12 weeks for patients who’d already had a first dose, to help spread the vaccinations more widely. In arguing against this, I was conscious of my lack of expertise in vaccinology and pandemic modelling. However, I was extremely confident of my knowledge of my older patients, the ethics of shared decision making, and the mechanics of organising a vaccination clinic.

Discussion, engagement with the profession, and transparency about the data used in reaching the decisions, including information about vaccine supply, might have avoided open disagreement. The government has now said that GPs can use their discretion and honour appointments for a second dose for older patients. Working out when it’s more important to speak out because you think mistakes are being made, or when it’s better to quash your doubts so that public trust in a united medical profession is maintained, is not easy. We all need the humility to accept that we may be mistaken—but also the courage to raise our voices in defence of our patients.

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