How Do You Help This Patient?

THE CASE
An anxious 44-year-old female patient has booked an emergency appointment to see you, her GP. She says she discovered a lump while in the shower two weeks ago, and although she had been worrying about it, it took her a while to pluck up the courage to see you. Examination reveals an enlarged axillary lymph node on her left side, and you explain that she will need urgent referral to a specialist breast clinic. She pleads with you to find a female consultant, but you can find none. She breaks down in tears, distressed at the thought of seeing a male breast cancer specialist. What do you do?
THE GP's VIEW
This patient has expressed a (not unusual) specific request to see a female specialist and even though there appears to be none listed as available locally, I would respect her needs and look for ways around this. For example, the local consultant may have a female SpR who could see and assess her, or may have a female locum who occasionally works with him and is due again soon. So it is worth talking to the local specialist, checking whether he has had this problem before, and if so, how it was resolved. Alternatively, she may be willing to pay privately and go further afield. I would offer her the choice of the nearest female breast specialists and inform her of the approximate costs that she would need to consider, including any further investigation or surgery that may result. There may be more serious issues behind the request, so it is essential to offer her the opportunity to express concerns and reasons as to why she is so adamant. There may be cultural reasons or religious beliefs, but I would want to allow her time to talk about previous experiences that may have affected her. Many women are simply shy of showing intimate areas to male doctors and will go to some length to avoid it. But there could be reasons from her past, such as abuse as a child, or spousal pressure or abuse, which are relevant in this case and which she may wish to talk about. With the pressure on GPs to provide for patient choice in all aspects of care, we could try applying to the PCT for special funding for her to go out of area, but experience warns me not to be too optimistic. Also, I would expect this to take quite some time, which (considering our possible diagnosis) we do not have. If all these efforts do not produce a result, I would ask the patient what she would like to do, or whether she has an answer herself. For example, she may be aware of a female specialist to whom we could refer privately, or local charities that may help her with costs. I would make it clear that I am trying to help her, but that the NHS does not allow for full patient choice over every aspect of their care. This is an increasing dilemma as greater ranges of drugs and therapies stretch NHS resources. Even if it is the case that she reveals a history of abuse, we might have no other option than a local male NHS specialist or her paying privately in order to have more choice. Should she choose the local male specialist, I would want to make sure she feels supported in that decision and the outcome.
Dr Gill Jenkins, a GP in Bristol

THE SPECIALIST'S VIEW
Obviously she's worried and understands the importance of rapid assessment. It could be a breast primary, a lymphoma or something less serious. In any case, she needs a mammogram, ultrasound, blood tests and a biopsy. I would stress the importance of teamwork here. It is not going to be a single person who deals with her in the hospital. Persuade her that male doctors can be just as empathetic as women and breast surgeons now are usually very different from the days of Lancelot Spratt. They have been trained to communicate much better. She will see a breast care nurse and almost certainly obtain counselling. Explore what her worries are and try to reassure her. She needs sorting out and the local breast care team would be the best first port of call. Encourage her to take a friend or relative with her for the first visit. The pathology result may well be available there and then, as many hospitals operate one-stop clinics so the treatment plan can be given immediately. This really is much better than weeks of uncertainty. If all this fails, refer her to a female breast surgeon in London privately. Getting such an opinion will, of course, cost her money, but will be quick and she can still go back to the local team if, as is likely, she needs further treatment. Trying to get your PCT to sanction a referral like this on the NHS is likely to delay things. Patient choice just doesn't run that far.
Prof Karol Sikora, professor of cancer medicine, Hammersmith Hospital, Leeds

THE ETHICIST'S VIEW
There is an interesting mix of the practical and the ethical here. I think most people would probably agree that the request to see a female consultant in these circumstances is a reasonable one. There may be cultural or ethnic factors at play, which might reinforce the legitimacy of the request. As Dr Jenkins points out, there may also be a history of abuse or of psychosexual difficulties that might contribute to the patient's anxiety. In these circumstances, it would therefore be appropriate to try, as far as reasonably possible, to comply with her request. If a female consultant cannot be found - and I do not think there is a positive obligation on the NHS to provide one - then alternatives, such as a slightly more junior female specialist, could be offered. In the absence of a duty to provide a female consultant, however, it will be for the patient herself to make a decision between the available options. Overall, though, efforts should ordinarily be made to meet reasonable requests. Having said this, the idea of the 'reasonable' is inevitably a vague one, subject to change over time and between cultures. Behind the notion of medical professionalism lies the idea of scientific impartiality - an approach blind to the gender, or any other personal attribute, of the treating professional. Although in reality such neutrality may be difficult to achieve, the attractions of such an approach become much clearer when faced with requests that are less 'reasonable', such as for doctors of specific ethnic origin or sexual orientation. It was not that long ago, after all, that homosexuality was a criminal offence in the UK.
Dr Julian Sheather, senior ethics adviser at the BMA