13 September 2021

Be ready to put your foot down

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It’s a reasonably common bugbear in general practice:patients making requests for some service, permit or exemption that they’re not entitled to.

Whether it be the backdated medical certificate or the disabled parking permit for the person who has early arthritis – we’ve all had those awkward conversations where we have to convince the patient that their request is unreasonable and we’re not going to oblige.

We all know we can’t put our name to something we know not to be true. That’s it, plain and simple. And for the most part, if it’s dodgy, we have the conversation and then we, as in the patient and me, move on (or the patient gets pissed off and that’s the end of that patient)!).

But there is always a grey area. The patient who reports having vomiting and diarrhoea and needs a medical certificate – you take them at their word. The patient with severe COPD who says they need a disability parking permit – I don’t make them walk 100m just to check. You make a judgement call.

It has been interesting to see how this scenario is playing out in the pandemic.

Have you, like me, had requests from patients for an exemption from wearing a mask?  To be fair – medical exemptions were only required in NSW and Tasmania and tended to be sought much earlier in the pandemic when there was hardly any covid around. And it was relatively easy to explain that mild asthma or anxiety did not warrant an exemption. In fact the only exemption I wrote was for a woman who had a history of being assaulted, where her attacker had tried to smother her. That was a very reasonable excuse, I thought. 

Generally speaking, people now are much more amenable to mask-wearing as the threat of contracting covid has become so much greater.

Then there is the array of ineligible patients arguing their case for getting the Pfizer vaccine rather than the AstraZeneca vaccine, some of whom arrive with documentation from their specialist supporting their request. I’ve got to say some of these requests don’t seem to be rooted in any really strong evidence, but what are you going to do? I’m not crazy about the idea that the medical system can be manipulated in such a way, but when another doctor requests a patient gets Pfizer because of their history of colorectal cancer, or sarcoid, or a range of other, seemingly unrelated conditions is it really worth arguing? The priority is to get them vaccinated, surely.

But the real issue with regard to exemptions is coming. Push is really going to come to shove when it comes to patients wanting the doctor to write a medical exemption from being vaccinated with any vaccine against covid.

As yet I haven’t been asked, but it’s going to happen, you just know it’s going to happen. With more and more industries, companies and sectors bringing in mandatory vaccination there will be people who will seek another option apart from being vaccinated or unemployed.

The pressure is going to be applied. I expect there will be a range of reasons given by vaccine-resistant patients as to why they should receive a medical exemption from being immunised.

Unfortunately for these patients, the reality is the number of medical contraindications for getting at least one of the covid-19 vaccines is negligible. You can’t play the immunocompromised, cancer or chronic disease card – they are all in the group who should be given the vaccine as a priority. In fact the only people who seriously can’t have a covid vaccine are people with a history of anaphylaxis to a previous dose of the vaccine. There are a few conditions that will mean you should have one vaccine in preference to another, but, in general, there is only anaphylaxis that will justify an exemption, according to ATAGI at least.

The problem is of course an exemption will possibly affect more than just the patient.

No GP likes saying no to patients. Ask any medicolegal expert and they will tell it’s one of the greatest reasons doctors get into trouble legally – just giving patients what they ask for. But on this, we, along with all our non-GP specialist colleagues are going to have to stand firm.

Completely apart from the legal ramifications (which I suspect could be huge), how could we live with ourselves if an unvaccinated nurse with a dodgy medical exemption spread covid through a hospital, or a teacher infected a school, or a cabin steward a planeload of passengers?

Even if you don’t agree with vaccination being mandatory, it is likely the repercussions of giving a patient a medical exemption from having the vaccine on the basis of, say, acute vaccine anxiety, or religious grounds or for a condition that is not a recognised contraindication will be significant.

We cannot be complicit with a manipulation of the system that could ultimately harm the population as a whole.

At the moment the medical profession, and the GP specialty in particular is enjoying an almost unprecedented groundswell of public approval. Our contribution to the fight against the pandemic and especially the vaccine rollout has seen our standing in the community elevated to a point we can justify feeling trusted and appreciated.

We don’t want to screw it up. If people don’t want to get vaccinated that is entirely their choice. Just don’t let them try and use the medical system (and us in particular) as their get-out-of-jail-free card.

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7 Comments on "Be ready to put your foot down"

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Maryann
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Maryann
2 months 10 days ago

I have had a request by a chiropractor for her to be exempt from vaccination because she has concerns her lichen sclerosis will be exacerbated.
Is this in any way valid? I did not provide the exemption.

Chris Ahern
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Chris Ahern
2 months 20 days ago

The vaccinated nurse can still spread covid to patients, and there have been cases of such in the last few months.

Vera Nikolic
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Vera Nikolic
2 months 18 days ago

Certainly we all can , but ethically there is a huge difference.

Heather
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Heather
2 months 20 days ago
I agree with everything you have said LInda ,EXXCEPT the comment about giving Pfizer to a patient who has a letter from a specialist .In my view many of the specialists are not particulary well versed in the two vaccines ( some are of course )and if they really want them to have it there is an avenue through the state system called vulnerable patient preferred appointment options ( at least there is in Victoria 0)or they can go to the effort of referring them to VCIS ( in Vicgtoria at least) who are the only body able to provide… Read more »
Chris Roberts
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Chris Roberts
2 months 20 days ago

Totally agree Heather. I knock most older patients back who come in with a letter from a specialist for Pfizer because of a chronic condition. one exception I felt I could make was one with a letter regarding the Waldenstrom’s type of Lymphoma with very low platelets. Not much els.
I agree Pfizer has to be kept for the young as long as there is a shortage

Dr Brendan Leslie
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Dr Brendan Leslie
2 months 20 days ago

*heather*

Dr Brendan Leslie
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Dr Brendan Leslie
2 months 20 days ago

Good article, and well said Linda. Working at a uni clinic, we see hundreds of altruistic young people choose to have astra rather than wait for Pfizer, often motivated by a desire to protect vulnerable people around them more than themselves. Many are young women- the group at highest risk of TTS.

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