Family Practice Vol. 20, No. 3, 254-261
© Oxford University Press 2003
Communication |
GPs facing reluctant and demanding patients: analysing ethical justifications
Department of Medical Ethics, Lund University, Lund, Sweden and
a Institute of Oncology, Ljubljana University, Ljubljana, Slovenia.
Correspondence to Stefan Bremberg; E-mail: stefan.bremberg{at}telia.com
Bremberg S, Nilstun T, Kovac V and Zwitter M. GPs facing reluctant and demanding patients: analysing ethical justifications. Family Practice 2003; 20: 254–261.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodResultsDiscussionConclusionReferences |
|---|
Background. Several studies have explored the physicians’ preferred actions when facing a reluctant or a demanding patient, but only a few studies have explored the physicians’ justifying reasons.
Objective. The aim of this study was to assess how GPs would act and how they would justify their choice.
Method. A postal questionnaire with questions about preferred actions and justifying reasons was sent to a random sample of GPs in Slovenia (n = 160) and Sweden (n = 200) using four vignettes: (i) a healthy patient reluctant to quit smoking; (ii) a healthy patient demanding an X-ray; (iii) a pulmonary cancer patient reluctant to quit smoking; and (iv) a pulmonary cancer patient demanding immunotherapy.
Results. The majority of GPs would bring up the question about smoking with the patients reluctant to quit. They justified their choice by referring to promotion of medical benefit and to protection from harm. Swedish GPs were less inclined to bring up smoking than were their Slovenian colleagues. Those who would not bring up the question referred to respect for self-determination and an enhanced relationship as their justifying reasons. With reference to the demanding patients, a minority of GPs would grant the healthy patient’s request for an X-ray that was not medically motivated. The answers were similar with respect to the seriously ill patient requesting non-medically motivated immunotherapy. Slovenian GPs were much more inclined to grant the request than were their Swedish colleagues. Enhancing the relationship and respect for self-determination were the most important reasons for granting the demands. When the demands were denied, the GPs mostly referred to promotion of fair distribution of resources.
Conclusion. Many of the GPs considered their patients’ right to self-determination less important than other values, e.g. the obligation to promote medical benefit, to protect from harm, to distribute public resources fairly and to enhance the patient–physician relationship.
Keywords. Harm, justice, medical benefit, questionnaire, self-determination.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
Many patients in general practice suffer from smoking-related symptoms and diseases, and some of them are reluctant to quit smoking. However, the advantage of smoking cessation is well established, and is one of the most important preventive acts in medical services.1,2 However, how to achieve this goal is still controversial.3 The physicians’ attitudes (e.g. the physicians were more likely to discuss smoking with patients who have smoking-related problems) and how the patient was perceived (e.g. lack of motivation) have been identified.4
The situation is similar with reference to patients who request a medical intervention.5,6 The demanding patients’ expectations and the doctors’ actions have been explored (e.g. they often wanted to maintain a good patient–physician relationship, overestimated the patients’ expectation and were not willing to deal with unconventional cancer therapies).7,8
The literature about how the GPs justify their behaviour is, however, limited. One study, using videorecorded surgery sessions and semi-structured interviews, described GPs’ desire for harmonious relationships with patients and their perceptions of patients’ responses to advice.9 Another study, exploring four typical issues in general practice, concluded that respect for patient autonomy is an ideal. The author also raised a number of questions about the legitimate limits of medical responsibility and of patient demands, and the strength of professional beliefs.10 The physicians’ general duty to benefit their patients has been questioned recently.11 The author claimed both that physicians cannot be expected to know what will benefit the patient and that the physicians will be constrained by other duties or interests. Another paper, discussing case reports, has emphasized the obligation to follow medical guidelines, and to involve the patient in a mutual discussion.12 All these conclusions were based on either interviews, case reports or only presentation of arguments.
To elucidate justifying reasons as part of the decision-making process is difficult,13,14 and in-depth interviews with and observational studies of GPs would probably be the most reliable and valid way to explore the issue. However, even with good internal validity, the external validity is questionable. The number of respondents in interviews and observational studies is too few to make the relevant generalizations about justifying reasons. They are also very costly, with reference to both time and money.
In an attempt to make generalizations possible, a postal questionnaire with six vignettes was developed.15 The respondents were asked questions about considered action and a ranking of possible reasons for the chosen action. Such attempts to generalize are important, and the aim of our study was to assess how GPs would choose facing reluctant and demanding patients and how they would justify their choice of action.
|
Method |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
Only one questionnaire about justifying reasons with the ambition of generalizing was found in the literature. We had a similar purpose but also wanted to test other justifying reasons. Thus, we had to modify the instrument. Further, we questioned whether the respondents should use fixed alternatives presenting possible justifying reasons or should they be completely free to formulate their own justifications. Inspired by the literature on justification, we have chosen the first alternative.16–18 We wanted to explore GPs’ opinions about the relevance of particular justifying reasons.19,20 This approach also has the advantage of making comparisons between countries possible.
Choice of countries
In a previous study, including, among other countries, Slovenia and Sweden, we found differences between physicians’ choice of actions.21 We wanted to explore these differences further. Slovenia (US$9500/capita) and Sweden (US$19 000/capita) use a similar proportion of their Gross National Product (GNP) on their respective health care system (8%) and comparable proportions of GPs in relation to the population (2000 inhabitants/GP). However, there are not only cultural differences between north and south Europe, but also differences in smoking habits among the general public (Slovenia 
25% smokers and 2900 cigarettes/capita, and Sweden 18% smokers and 850 cigarettes/capita).
Development of questionnaire
Several vignettes, using real cases as a point of departure, were discussed. The cases referred to smoking habits, some with and others without smoking-related cancer. The patients were either reluctant or demanding. A guiding principle was to use vignettes that GPs in both countries would find familiar in everyday practice. In order to simplify comparison and to avoid identifications of the real cases, slight modifications were made.
The possible vignettes were discussed in seminar groups. The participants represented different professions such as clergymen, nurses, philosophers and physicians. The main purpose of these rather informal discussions was to improve face validity.22 Consensus was reached about four of the vignettes: (i) a healthy patient reluctant to quit smoking; (ii) a healthy patient demanding an intervention; (iii) a pulmonary cancer patient reluctant to quit smoking; and (iv) a pulmonary cancer patient demanding an intervention (Box 1
).
The questionnaire was then translated and back-translated from English to Slovene and Swedish, respectively. After pilot tests with both Swedish and Slovenian GPs, it was modified and retested a number of times. The questionnaire was improved in terms of test–retest reliability.22 Further, the option ‘Not relevant’ was added and the relationship between action and justifying reason was made more precise.
For each of the four vignettes and with reference to how the GPs answered that they would act, they were also asked to state their opinion about possible justifying reasons. We wanted to compare justifying reasons from an ethical point of view. The four ethical principles about self-determination, beneficence, non-maleficence and fair distribution are all well established in the literature on medical ethics, though their ranking is controversial. Our fifth justifying reason referred to the patient– physician relationship and was added after the pilot tests. The respondents in the pilot tests often referred to this relationship as a justifying reason. In answering, the respondents had five options: ‘Strongly agree’, ‘Agree’, ‘Uncertain’, ‘Disagree’ and ‘Strongly disagree’. The alternative ‘Not relevant’ was offered as a possible answer. The respondents were also invited to provide comments on each vignette. Further, demographic questions about age, sex, smoking habits and experience of taking care of cancer patients were asked.
If surveying situations other than smoking and cancer patients or using other justifying reasons, the results may be different. Therefore, generalizations to other types of situations should be made with great care.
| BOX 1 The vignette question about action and the five statements about justifying reasons, as presented in the questionnaire First vignette (healthy and reluctant): In this case, the woman is at your surgery for a clinical examination due to a sore throat. The results, laboratory tests included, are unremarkable. At a former visit, you brought up her smoking for discussion, but she ended the conversation with "I don’t want to quit smoking".1 Would you as her physician once again bring up her smoking for discussion? Yes, absolutely Yes, probably Uncertain Probably not Absolutely not [ ] [ ] [ ] [ ] [ ] If you answered "Uncertain", go to the next vignette. Otherwise, assume your answer and state your opinion of the following considerations: To act according to your position would be: 2 to respect her right to self-determination. Strongly agree Agree Uncertain Disagree Strongly disagree Not relevant [ ] [ ] [ ] [ ] [ ] [ ] 3 to promote her medical benefit. 4 to protect her from harm. 5 to promote a fair distribution of the health care resources. 6 to positively affect the patient–physician relationship. Second vignette (healthy and demanding): In this case, the woman’s best female friend, who also smoked, died 3 weeks ago of lung cancer. The woman recently managed to quit smoking and now wants a referral for a chest X-ray. Reading her medical records, you find out that she had a chest X-ray 4 months ago and it was unremarkable. Would you as her physician refer her for a new chest X-ray? Third vignette (cancer and reluctant): In this case, the woman has inoperable, locally advanced non small-cell lung cancer without clinically overt metastases. Radiotherapy has been completed and she is due for a follow-up visit. At a previous visit, you brought up her smoking for discussion, but she ended the visit with "I am under such stress that I am unable to quit smoking". Would you as her physician once again bring up her smoking for discussion? Fourth vignette (cancer and demanding): In this case, the woman, now a former smoker, has a metastatic non small-cell lung cancer in progression after standard treatment. On the Internet, she has found information about a new immunotherapy, which she strongly believes in and solicits. The drug is very expensive but is covered by the national health insurance system. Among physicians, it is well known that this treatment, although with side effects, is of no benefit for lung cancer patients. Only supportive care is medically indicated. Would you as her physician help her to obtain this immunotherapy?
|
Sampling frame
In Sweden, the sampling frame, made up of a random sample of 200 GPs, was obtained from Läkemedelsstatistik AB. In Slovenia, the sampling frame was obtained from the medical chamber and made up of a random sample of 160 GPs. The questionnaire was mailed to the physicians at the end of 1999. Since the survey was anonymous, a reminder was sent to all physicians 3 weeks later.
All data was transferred into StatView (5.0.1 Win). The responses to the four questions about action were analysed as ordinal data with the Mann–Whitney U-test. When comparing how the respondents replied with reference to the five justifying reasons, the data were also analysed as ordinal data and the Friedman test was used. This test indicates a ranking order by giving each of the justifying reasons a mean rank.
|
Results |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
The response rate was 55% in Slovenia and 66% in Sweden. Characteristics and experiences of the responding GPs are presented in Table 1
.
|
The GPs attitudes
Choice of actions and justifying reasons with reference to the reluctant patients.. Most GPs would bring up the question about smoking with the healthy patient. However, they were hesitant with reference to the cancer patient. GPs who chose to bring up smoking again referred to promotion of medical benefit and protection from harm as the most important justifying reasons.
Respondents not inclined to bring up smoking again justified their choice by referring to respect for self-determination and enhancement of the relationship (Tables 2 and 3).
|
|
With respect to the cancer patient, males who were inclined to bring up smoking again more often emphasized an improved relationship, while female colleagues more often referred to medical benefit and protection from harm. Irrespective of the patient’s health status, promotion of a fair distribution of resources was seldom seen as a justifying reason, and this was most prominent among Slovenian female GPs.
Current smokers were, compared with former smokers and non-smokers, most inclined to bring up smoking again. When facing the cancer patient, even many non-smokers held that position. GPs without experience of cancer patients were more inclined to bring up smoking again than those with experience of such patients.
Choice of actions and justifying reasons with reference to the demanding patients.. With reference to both the new X-ray and the immunotherapy, the GPs were more inclined to reject than to accept the patients’ request. The answers to both these vignettes also reflect an uncertainty among the Swedish GPs about how to respond to a demanding patient. The Slovenian GPs indicated such uncertainty only with reference to immunotherapy. Those granting the demand of both patients justified their position by referring to respect for self-determination and enhancement of the relationship.
In both countries, GPs who would not grant the healthy patient’s demand for a new X-ray referred to promotion of medical benefit and protection from harm as justifying reasons. Swedish GPs also emphasized promotion of a fair distribution to justify their position. In not granting the demand of the severely ill patient, promotion of a fair distribution was used unanimously as a justifying reason (Tables 4 and 5).
|
|
Two out of three younger GPs would not accept the healthy patient’s demand for a new X-ray. Current smokers were also more reluctant compared with non-smokers. GPs experienced with cancer patients were those who most often rejected the healthy patient’s demand for a new X-ray, but also those most willing to accept the cancer patient’s demand for immunotherapy.
Current smokers, compared with non-smokers and former smokers, referred to protection from harm as a justifying reason for rejecting the healthy patient’s demand. GPs without experience of cancer patients justified their rejection of both patients’ demands by referring to medical benefit as their primary reason.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
Participants
The response rate was relatively low—Slovenia 55% and Sweden 66%. With regard to sex and age, those who answered and those who did not were similar. However, we cannot exclude the possibility that the high attrition rate may have affected the results.
The GPs’ attitudes
In our study, many of the physicians did not give priority to the patients’ right to self-determination. The obligations to promote medical benefit, to protect from harm, to distribute public resources fairly and to enhance the patient–physician relationship sometimes were more important. However, Slovenian GPs emphasized the patients’ right to self-determination more often than their Swedish colleagues.
With respect to the five justifying reasons, the alternative ‘Not relevant’ was used most frequently for ‘fair distribution’ (25–50%). Several respondents indicated that this justifying reason implied a duty to make financial considerations. GPs seem to be reluctant to include such considerations in a single consultation. The alternative ‘Not relevant’ chosen so frequently may have affected the statistical analysis to some degree, but would not have changed the rankings.
Reluctant patients.. Most GPs would bring up the question about smoking with the healthy patient, but they were more hesitant with reference to the cancer patient. To bring up the question of smoking was not seen as an infringement of the patient’s autonomy, and many GPs emphasized their obligation to bring up the question. They argued that a reluctant patient would realize the benefits of smoking cessation later on. By bringing up the question, some GPs argued that they showed empathy and thereby enhanced both the patient’s autonomy and the patient–physician relationship. This was emphasized especially with reference to the healthy patient. Slovenian GPs seem to be more inclined to bring up smoking with the healthy patient compared with their Swedish colleagues. Differences in smoking habits in the two countries may explain some of this difference.
GPs experienced in cancer treatment were less inclined to bring up smoking again with the cancer patient. Experience and knowledge of whether or not smoking would affect such a patient seem to have influenced the respondents’ position. A few mentioned hope, indicating that a patient may not feel completely hopeless with respect to the outcome of their cancer.
Those who would not bring up smoking again referred to the patient’s right to autonomy and the patient– physician relationship. The Swedish GPs’ unease in bringing up the question with the healthy patient may reflect discomfort with the question and the ongoing debate of patients’ rights. The comments indicate that many wanted to avoid the extreme positions sometimes adopted by anti-smoking campaigns. The patient’s responsibility for her health was also used as an argument. With regard to the cancer patient, a wish to avoid psychological harm was also mentioned.
Demanding patients.. With reference to both the new X-ray and the immunotherapy, the GPs were more reluctant to grant the patient’s request. The answers to both vignettes reflect an uncertainty among the Swedish GPs about how to respond to a demanding patient. The Slovenian GPs indicated such uncertainty only with reference to immunotherapy. Comments referred to the patient’s right to self-determination and to an improved relationship. Others argued that an X-ray was fairly cheap and would hardly do any harm. An ambition to promote psychological and emotional well being was also indicated. Not to grant her demand might also lead to frustration and an excessive consumption of medical care. The differences between countries may reflect the discussion in Sweden on shared decision making and the GPs’ obligation to promote a fair distribution of health care resources.
In both countries, GPs argued that respect for self-determination as well as the patient’s confidence in the treatment would influence their action. An improved relationship was also mentioned as a justifying reason. The Slovenian GPs were those most inclined to accept the cancer patient’s demand for immunotherapy and they also emphasized medical benefit as a justifying reason.
GPs not inclined to grant these patients’ requests for treatment referred to the physician’s obligation to promote a fair distribution and actively take part in priority settings. With respect to the costly immunotherapy, several GPs referred to financial considerations. Despite poorer public economy, the Slovenes seem to be less influenced by priority settings. Some GPs argued that accepting the healthy patient’s demand for an X-ray could create a permanent anxiety of cancer. With regard to the cancer patient, many GPs feared side effects and had limited knowledge about the possible benefit of immunotherapy. Hence, they rejected the patient’s demand. Instead they emphasized the obligation to discuss palliative care with the severely ill cancer patient.
|
Conclusion |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
Despite the public discussion on patients’ rights to autonomy, many of the GPs in Sweden and Slovenia considered other values more important. These were the obligation to promote medical benefit, to protect from harm, to distribute public resources fairly and to enhance the patient–physician relationship.
Our study has explained neither the similarities nor the differences between the two countries. Hence, further research is necessary. Further, new health care expectations might affect the decisions and justifying reasons, as well as the development of improved diagnostic tests and treatments.
|
Acknowledgments |
|---|
This study was supported by grants from ‘Stig and Ragna Gorthon Foundation for Medical Research’ and ‘Thelma Zoèga Foundation for Medical Research’.
|
References |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
|---|
1 WONCA News October 2000. Fam Pract 2000; 17.
2 Lancaster T, Silagy C, Fowler G, Spiers I. Effectiveness of training health professionals to provide smoking cessation interventions: systematic review of randomised trials. In Lancaster, Silagy C, Fullerton D. Addiction Module of the Cochrane Database of Systematic Reviews. The Cochrane Collaboration: Issue 1. Oxford: Update Software, 1998.
3 Butler CC, Pill R, Stott NCH. Qualitative study of patient’s perceptions of doctor’s advice to quit smoking: implications for opportunistic health promotion. Br Med J 1998; 316: 1878–1881.
4 Coleman T, Wilson A. Anti-smoking advice in general practice consultations: general practitioners’ attitudes, reported practice and perceived problems. Br J Gen Pract 1996; 46: 87–91.[Web of Science][Medline]
5 Webb S, Lloyd M. Prescribing and referral in general practice: a study of patients’expectations and doctors’ actions. Br J Gen Pract 1994; 44: 165–169.[Web of Science][Medline]
6 Maizes V. Setting limits on demanding patients. Am Fam Physician 2000; 61: 881–882.[Medline]
7 Steinmetz D, Tabenkin H. The ‘difficult patient’ as perceived by family physicians. Fam Pract 2001; 18: 495–500.
8 Gray RE, Fitch M, Greenberg M. A comparison of physician and patient perspectives on unconventional cancer therapies. Psychooncology 1998; 7: 445–452.[Medline]
9 Coleman T, Murphy E, Cheater F. Factors influencing discussion of smoking between general practitioners and patients who smoke: a qualitative study. Br J Gen Pract 2000; 50: 207–210.[Web of Science][Medline]
10 Rogers WA. Whose autonomy? Which choice? A study of GPs’ attitudes towards patient autonomy in the management of low back pain. Fam Pract 2002; 19: 140–145.
11 Veatch RM. Doctor does not know best: why in the new century physicians must stop trying to benefit patients. J Med Philos 2000; 25: 701–721.[CrossRef][Medline]
12 Brett AS, McCullough LB. When patients request specific interventions. N Eng J Med 1986; 315: 1347–1351.[Web of Science][Medline]
13 Mears R, Sweeney K. A preliminary study of the decision-making process within general practice. Fam Pract 2000; 17: 428–429.
14 Grol R, Wensing M, Mainz J et al. Patients’ priorities with respect to general practice care: an international comparison. Fam Pract 1999; 16: 4–11.
15 Hoffmaster CB, Stewart MA, Christie RJ. Ethical decision making by family doctors in Canada, Britain and the United States. Soc Sci Med 1991; 33: 647–653.[CrossRef][Web of Science][Medline]
16 Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 5th edn. Oxford: Oxford University Press, 2001.
17 Gillon R, Lloyd A (eds). Principles of Health Care Ethics. Chichester (UK): John Wiley & Sons, 1994.
18 Pellegrino ED. Patient and physician autonomy: conflicting rights and obligations in the physician–patient relationship. J Contemp Health Law Policy. 1994; 10: 47–68.[Medline]
19 Rogers WA. A systematic review of empirical research into ethics in general practice. Br J Gen Pract 1997; 47: 733–737.[Web of Science][Medline]
20 Braunack-Mayer AJ. What makes a problem an ethical problem? An empirical perspective on the nature of ethical problems in general practice. J Med Ethics 2001; 27: 98–103.
21 Zwitter M, Nilstun T, Knudsen LE et al. Professional and public attitudes towards unsolicited medical intervention. Br Med J 1999; 318: 251–253.
22 Neuman WL. Social Research Methods. Qualitative and Quantitative Approaches, 3rd edn. Boston: Allyn and Bacon, 1997.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||