Patients' accounts of being removed from their general practitioner's list: qualitative study

Terminations in Primary Care: a Retrospective Observational Study of 16 Primary Care Clinics

BACKGROUND

The relationship between clinician and patient is the cornerstone of primary care. Breakdown and termination of this relationship are understudied yet important, undesirable outcomes.

OBJECTIVE

To better understand the nature and extent of provider and clinic termination of the primary care relationship.

DESIGN

Retrospective observational case-control study.

SUBJECTS

Adult patients in Eastern Massachusetts who received primary care at hospital- and community-based clinics and health centers participating in a practice-based research network between January 2013 and June 2017.

MAIN MEASURES

Formal termination by primary care physician (PCP), reasons for termination, independent predictors of termination based on mixed-effects logistic regression, and documentation of a new PCP after termination.

KEY RESULTS

We identified 158,192 patients who received primary care from 182 PCPs across 16 clinics. We found 536 cases of formal termination. Clinics ranged from 4 to 119 terminations per 10,000 patients (intraclass correlation coefficient [ICC]=0.21; 95% CI: 0.18-0.24). Patient age, race/ethnicity, educational attainment, relationship status, employment status, and insurance type were independent predictors of termination (e.g., compared to patients employed full-time, patients unemployed due to disability were more likely to be terminated [adjusted OR:9.26; 95% CI: 6.74-12.74]). The most common cause for termination (38%) was appointment "no-shows" with some PCPs/clinics found to enforce a policy of dismissal following three no-shows. At the time of chart review, 201 patients (38%) had no documentation of a new PCP. Among patients who re-established care within the network, 134 (25%) had a primary care visit within 6 months of termination.

CONCLUSIONS

Detailed chart review found that, unlike previous survey-based studies, dismissal was often for missed appointments based on enforcement of no-show policies. Many sociodemographic factors were associated with termination. Variability among clinics highlights the need for further research to better understand circumstances surrounding terminations, with the principal goals of improving patient-provider relationships and providing equitable care.

Understanding clinician influences and patient perspectives on outpatient discharge decisions: a qualitative study

OBJECTIVE

To observe the influences on clinicians when discharging patients, to explore patients' perspectives concerning their discharge or follow-up decision and to identify what patients think is important for clinicians to consider when taking a discharge decision.

DESIGN

Qualitative study involving observations of consultations and semistructured interviews with outpatients.

SETTING

National Health Service outpatient clinics at a university hospital secondary referral centre.

PARTICIPANTS

64 consultations were observed followed by 56 interviews with patients aged over 18 years.

MAIN OUTCOME MEASURE

Analysis of patients' perspectives and expectations concerning whether or not they were discharged.

RESULTS

25 types of influences were observed to be influencing the discharge decision process. All 31 discharged patients appeared to accept the clinicians' decision; however, 10 (22%) of those patients later expressed disappointment. Patients' discontent was due to perceived clinicians' uncertainty in diagnosis (patients mentioning=2), poor acceptance of the diagnosis (2), disease not 'cured' (4), differing perception on medical needs (2), lack of concern for job demands (1), felt uninvolved in the decision-making (4), feeling rushed (3), prolonged open appointment (2), pushed to seek private care due to healthcare budget constraints (2), language barrier (1) and not keen to continue follow-up with general practitioner (2). Patients were happy when there was certainty of the diagnosis (19), clear treatment plan (16), advised on treatment side effects (7), given a contact number if symptoms recurred (4), considering their travelling and job demands (3).

CONCLUSIONS

This study highlights the importance of accurately perceiving patients' perspectives in ensuring the appropriateness of outpatient discharge. There was a disparity between patients' and clinicians' perception on what was an appropriate discharge. This included discrepancies concerning diagnostic certainties, private healthcare as an alternative, need for easy reaccess and choice of words surrounding discharge. Medical education should include handling these issues.

Physician Dismissal of Families Who Refuse Vaccination: An Ethical Assessment

Thousands of U.S. parents choose to refuse or delay the administration of selected vaccines to their children each year, and some choose not to vaccinate their children at all. While most physicians continue to provide care to these families over time, using each visit as an opportunity to educate and encourage vaccination, an increasing number of physicians are choosing to dismiss these families from their practice unless they agree to vaccinate their children. This paper will examine this emerging trend along with the reasons given by those who advocate such an approach. I will argue that the strategy of refusing to allow families into a clinic unless they agree to vaccinate their children is misguided, and the arguments for doing so fail to stand up to close scrutiny. Such a strategy does not benefit the child or the health of the community, and may have a negative impact on both. Furthermore, some of the arguments in support of dismissal policies ignore the importance of professional obligation and appear to favor self-interest over the interest of the patient.

Understanding "revolving door" patients in general practice: a qualitative study

BACKGROUND

'Revolving door' patients in general practice are repeatedly removed from general practitioners' (GP) lists. This paper reports a qualitative portion of the first mixed methods study of these marginalised patients.

METHODS

We conducted qualitative semi-structured interviews with six practitioner services staff and six GPs in Scotland, utilizing Charmazian grounded theory to characterise 'revolving door' patients and their impact from professionals' perspectives.

RESULTS

'Revolving door' patients were reported as having three necessary characteristics; they had unreasonable expectations, exhibited inappropriate behaviours and had unmet health needs. A range of boundary breaches were reported too when 'revolving door' patients interacted with NHS staff.

CONCLUSIONS

We utilise the 'sensitising concepts' of legitimacy by drawing on literature about 'good and bad' patients and 'dirty work designations.' We relate these to the core work of general practice and explore the role that medical and moral schemas have in how health service professionals understand and work with 'revolving door' patients. We suggest this may have wider relevance for the problem doctor patient relationship literature.

Examining the validity of the unitary theory of clinical relationships: comparison of observed and experienced parent-doctor interaction

OBJECTIVE

We explored parent-doctor relationships in the care of children with leukaemia from three perspectives simultaneously: parents', doctors' and observers'. Our aim was to investigate convergence and divergence between these perspectives and thereby examine the validity of unitary theory of emotionality and authority in clinical relationships.

METHODS

33 audiorecorded parent-doctor consultations and separate interviews with parents and doctors, which we analysed qualitatively and from which we selected three prototype cases.

RESULTS

Across the whole sample doctors' sense of relationship generally converged with our observations of consultation, but parents' sense of relationship diverged strongly from each. Contrary to current assumptions, parents' sense of emotional connection with doctors did not depend on doctors' emotional behaviour, and parents did not feel disempowered by doctors' authority. Moreover, authority and emotionality were not conceptually distinct for parents, who gained emotional support from doctors' exercise of authority.

CONCLUSIONS

The relationships looked very different from the three perspectives. These divergences indicate weaknesses in current ideas of emotionality and authority in clinical relationships and the necessity of multisource datasets to develop these ideas in a way that characterises clinical relationships from all perspectives.

PRACTICE IMPLICATIONS

Methodological development will be needed to address the challenges posed by multisource datasets.

Integrative qualitative communication analysis of consultation and patient and practitioner perspectives: towards a theory of authentic caring in clinical relationships

OBJECTIVE

We developed a method whereby relationships can be studied simultaneously from the perspectives of each party and researchers' observations of their dialogue. Then we used this method to study how to recognise authentic, caring clinical relationships.

METHODS

Participants were 20 patients who had recently received surgery for breast cancer and nine surgeons with whom they had a post-operative consultation. We audiorecorded consultations, before interviewing patients and surgeons about their perceptions of the consultation and each other. Cross-case qualitative analyses (analysing consultations and surgeon and patient interviews, respectively) were supplemented by integrative, within-case analysis.

RESULTS

Surgeons and patients described their relationship as personal and emotional, but emotional talk was absent from consultations. For patients and surgeons, their relationship depended, instead, on surgeons' expertise and character.

CONCLUSION

Our integrative approach suggested that authentic caring in these relationships lay in practitioners' conscientious execution of their role and, contrary to currently influential views, not in an explicit emotional engagement.

PRACTICE IMPLICATIONS

Relationships between patients and practitioners cannot be described adequately using analyses of interactions between them. Researchers will need to triangulate between these observations and the patient and practitioner perspectives in order to understand what makes for authentically caring relationships.

Continuity and trust in primary care: a qualitative study informed by game theory

PURPOSE

The relationship between continuity of care and patient trust in primary care is not fully understood. We report an empirical investigation, informed by game theory, of patients' accounts of their trust in general practitioners (GPs).

METHODS

We conducted an analysis based on the constant comparative method of 20 semistructured interviews with patients about trust in GPs in the United Kingdom.

RESULTS

People use institutional trust, derived from expectations of medicine as an institution and doctors as professionals, as a starting point for their transactions with unfamiliar doctors. This expectation may be enough to allow patients the minimum of what they want from doctors and is often sufficient for single-episode encounters, where patients have specific goals. Repeated interactions with the same doctor can allow patients to develop more secure expectations, based on a history of other interactions and anticipation of future interactions. Secure trust can develop over time, especially if patients are convinced that the doctor has their interests at heart.

CONCLUSIONS

This work identifies dynamics inherent in repeated interactions that enable secure trust to develop. These findings have important implications for the design of services, which in the United Kingdom and elsewhere are increasingly focused on enhancing access rather than continuity. They suggest that patients do not see GPs as interchangeable and that the move toward organizing services around single encounters may disrupt the development of secure trust.

'Breaking up is hard to do': perspectives of general practitioners and patients towards removals from GP lists

BACKGROUND

The numbers of removals of patients from General Practitioner lists in Ireland is increasing and is a cause for some concern.

AIMS

To examine the views of both general practitioners and patients toward removals of patients from general practitioner lists.

METHODS

Questionnaire survey to general practitioners in North Inner City Dublin who had removed patients from their list over a 1-year period (n = 45) and to the patients they had removed (n = 86). Follow up semi structured interviews were carried out with five general practitioners and ten patients.

RESULTS

For doctors, the decision to remove a problematic patient from their list is generally a positive experience, providing relief and being associated with certainty in both the decision and the process. For the patient, being removed from a GP's list is a negative experience, stressful and confusing.

CONCLUSIONS

There is a need for the development of a clear responsive, transparent and supportive system for removing patients from a GP list.

Breaking the ceremonial order: patients' and doctors' accounts of removal from a general practitioner's list

The removal of patients from general practitioners' (GPs) lists in the UK offers important sociological insights into what happens when the doctor-patient relationship 'goes wrong'. An interactionist analysis shows how removers (doctors) and removed (patients) strategically invoke 'rules of conduct' to account for difficulties in the doctor-patient relationship and for GPs' decisions to end their relationships with patients. In this paper we extend this analysis through recourse to Bourdieu's theory of practice, by juxtaposing 'paired' accounts of the same removal event by both remover and removed. Our analysis demonstrates the unthinking or non-reflective nature of people's understanding of the rules governing social interactions, but also demonstrates how apparent rule violations make the rules explicit and expose patterns of power distribution. We argue that removal of patients amounts to a strategic exercise of symbolic power by GPs, and that this is experienced as an overtly violent symbolic act by patients. A theoretical reconciliation of interactionist theories of the doctor-patient relationship with Bourdieu's theory of practice is both possible and profitable, providing a micro-macro link in which issues of capital and power within the health (care) field are brought to the fore.

The removal of patients who live outside the practice boundary: a study of outside-area removals in Northern Ireland in 2001-2002

It has been suggested that there are significant overlaps between removals due to deregistration and removals arising because patients live outside the practice area. If this is true, it would mean that the current estimates of deregistration would need to be revised upwards. All outside-area removals for the calendar years 2001 and 2002 were reviewed and characterised by age, sex and Jarman score of the enumeration district of the patients' residence and distance from the practice. The average outside-area removal rate was just over one removal per practice per year. Removal rates were highest between the ages of 18 and 44 years; there were no significant differences between the sexes. Rates of removal increased exponentially with distance, although even at marked distances from the practice there were about 10 patients remaining on the list for each one removed. Residents in deprived areas were more likely to be removed, although because areas most distal to the practice tend to be affluent, overall there was a predominance of affluent patients among those who are removed. In Northern Ireland rates of outside-area removal are only slightly higher than those of deregistration. It is evident that GPs are exercising some discretion as to which of the outside-area patients they retain on their list. This has the potential to cause some misunderstanding and resentment among patients, as has been reported previously.