Blaming system helps doctors avoid conflict when declining patient requests
MedWire News: Family doctors in the UK often blame higher authorities when declining patients' requests as a means of preserving the doctor-patient relationship, qualitative research indicates.
The study suggests that such negotiation strategies may come with practice, as trainee general practitioners (GPs) were more likely than their more experienced colleagues to report conflict during interactions with patients.
Alex Walter and colleagues from the University of Manchester say their findings offer an opportunity for GPs to consider the communication strategies needed to negotiate patient requests, as well as "insights to managers and policy makers about the complex influences on decision making in consultations".
Most patient encounters in the UK National Health Service (NHS) are consultations with GPs, who act as gatekeepers to secondary care even when the budget is held by a larger primary care organization, explains the team in Family Practice.
The researchers explored GPs' accounts of negotiating refusal of patient requests, and their negotiating strategies, in two separate focus groups (one including eight trainees and the other five fully trained GPs) followed by individual semi-structured interviews.
Analysis of the transcribed discussions and interviews showed that patients' requests for sickness certification, benzodiazepines (typically for insomnia or anxiety), and antibiotics for respiratory infections were the commonest sources of conflict.
Refusing such requests was described as a major source of stress or "daily battle" by trainees but not by the experienced GPs, who recalled it as a feature of their early careers.
Many of the strategies the doctors described using to prevent conflict referred to avoiding use of the word "no." One experienced GP described the way that force is resisted in martial arts as an analogy for how he dealt with such situations: "Very often you can engage with the person and lead them somewhere where they come out with something different."
Walter and colleagues say that strategies that deflected blame to third parties, such as the government or the primary care organization, were frequently employed. These included explicit reference to guidelines and policies on particular treatments.
One trainee GP said: "It can easily get personalized that people think it's something about your relationship role and so I suppose sometimes generalizing or depersonalizing or saying 'these are the guidelines' or 'this is our practice policy' may help."
Participants also made reference to local lists of procedures that would not normally funded, based on vetting by clinicians. When it came to discussing actual costs of treatments, however, while some participants welcomed openness, others were concerned that this would heighten conflict, if taken that the expense could not be justified for the individual concerned.
Developing trust over time was identified as a key element of the doctor-patient relationship that enabled refusals to be acceptable to the patient.
The researchers say that their findings may have important implications for health policy in England, where proposed health reforms mean that GPs will be responsible drawing up local policy, thereby increasing the potential for conflict. "The ability of GPs to offset blame for rationing decisions to third parties will be undermined if the same GPs commission services," they write.
"Beyond the English NHS, primary care providers experiencing increasing tension between patients' demands on the one hand and fulfilling their duty as gatekeepers on the other would undoubtedly benefit from improved understanding of how to successfully decline what are felt to be inappropriate requests," the team concludes.
By Caroline Price