Family Practice Vol. 20, No. 6, 628-634
© Oxford University Press 2003, all rights reserved
Article |
Breaking up is never easy
GPs' accounts of removing patients from their lists
Department of General Practice and Primary Health Care, University of Leicester, Leicester General Hospital, Leicester LE5 4PW and a Department of Epidemiology and Public Health, University of Leicester, 22–28 Princess Road West, Leicester LE1 6TP, UK
Correspondence to T Stokes; E-mail: tns2{at}le.ac.uk
Received 24 February 2003; Revised 2 July 2003; Accepted 14 July 2003.
Stokes T, Dixon-Woods M and McKinley RK. Breaking up is never easy. GPs' accounts of removing patients from their lists. Family Practice 2003; 20: 628–634.
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Abstract |
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Objective. The aim of this study was to understand why GPs choose to end their relationship with patients by removing them from their lists.
Methods. Semi-structured interviews were carried out with 25 GPs from 22 general practices in Leicestershire. Qualitative analysis was performed using the constant comparative method. The main outcome measures were participants' accounts of removing patients from their lists.
Results. GPs use removal as a means of ending their professional relationships with problematic patients. All of the doctors indicated that they wished to retain the right to remove patients and stressed that removal is a rare event which they only use as a ‘last resort’. There are two distinct but overlapping types of patients who are most likely to become eligible for removal: ‘bad’ patients, who break the rules of the doctor–patient or practice–patient relationship, and ‘difficult’ patients, with whom the doctor–patient relationship is so strained that doctors feel they can no longer care for them. The doctors may choose to remove a patient without warning or else to write a short letter giving ‘relationship breakdown’ as the reason. They find it hard to confront the patient openly about the difficulties in the relationship.
Conclusions. The ability to remove patients is a right that GPs value. They report that it is rare for them to seek to end their relationships with patients and, when they do, it is for reasons that are important in the maintenance of professional boundaries or fulfilling professional responsibilities.
Keywords. Doctor–patient relationship, general practice.
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Introduction |
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Under their terms of service, GPs in the UK have a right to remove any patient from their lists without giving a reason.1 Removal of patients has become a contentious issue for two reasons. First, the underlying motives of GPs in removing patients have been frequently characterized by the media as mercenary or unprofessional. It has been suggested GPs may ‘strike off’ patients who jeopardize meeting targets for screening and vaccination programmes2 or who make excessive demands on their time.3 Much of the media coverage has been unsympathetic to doctors, with violence noted as one of the few acceptable reasons for a GP to remove a patient. Secondly, there has been widespread criticism of cases where GPs do not inform patients of the reasons for their removal. Despite guidance to the contrary from professional organizations,4,5 patients continue to complain that they are removed by GPs without warning or explanation. The Health Service Ombudsman has repeatedly condemned this practice as unacceptable and notes that GPs should aim to preserve the doctor–patient relationship and to explain the reasons for removal to patients.6 Notwithstanding its health policy importance, removal also offers important insights into what happens when the doctor–patient relationship ‘goes wrong’ and doctors decide to end their relationships with patients.
Research on removal has quantified the phenomenon by analysing routinely collected health authority data,7,8 but little is known about the process.9 Here we report findings from a qualitative study that explored both GPs' and patients' accounts of removal.10 We focus on the questions of why doctors choose to end their relationship with patients by removing them from their lists and why they do or do not offer reasons for their actions. We previously have reported patients' accounts of being removed from a GP's list.11
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Methods |
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Participants
Previous epidemiological research had defined the characteristics of removed patients and their general practices in Leicestershire.10,12 We sampled purposively from the list of GP principals held by Leicestershire Health Authority to construct a maximum variation sample that reflected GP and practice characteristics that may influence removal (Table 1). Recruitment of GPs took place between February 1999 and April 2000. Of 72 GPs approached, 53 agreed to take part. Interviews were conducted with 25 GPs.
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Interviews
The interviews were carried out by TS, a practising GP and researcher. Interviews were semi-structured and used a topic guide based on a literature review and discussions within the research team. The topic guide covered issues such as events leading to removals and relationships with ‘difficult’ patients. It was used flexibly to allow participants to construct their accounts in their own terms, and was revised and refined throughout the interviewing process to reflect themes emerging from the concurrent data analysis. All interviews except one were tape-recorded and transcribed verbatim.
Analysis
Data analysis was based on the constant comparative method.13 TS developed the coding framework by repeatedly reading the first six transcripts and identifying each textual ‘unit of meaning’. As a first step, initial basic codes were generated to describe each unit of meaning within the transcripts. Through an iterative process involving comparison across the transcripts, assisted by QSR NUD*IST software,14 these basic codes eventually were organized into higher order thematic categories. TS continually checked and modified the framework categories to ensure adequate ‘fit’ with the data was achieved. MDW independently assessed the plausibility and explanatory value of the categories against the transcripts, and also independently evaluated the assignment of a sample of the data to the categories. A reflexive diary of the analysis was maintained. This served a number of functions, including providing an ‘audit trail’ of the development of the framework and its categories as well as promoting reflexive research practice.
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Results |
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We interviewed a maximum variety sample of GPs (Table 1). We were able to recruit and interview GPs who reported that they never removed patients as well as those who had recently removed patients from their lists. Two interviews were group interviews with all of the GPs in that particular general practice (one group of three and one group of two). We report here the themes that emerged from the analysis of the interviews that help to explain the phenomenon of removal from the perspectives of GPs. The accounts of GPs who stated that they never removed patients produced no negative or discrepant findings that impacted on our emergent themes. In order to maintain confidentiality, we have altered some of the features of the verbatim extracts from the interviews used to illustrate the themes.
Removal as a way of dealing with ‘problematic’ patients
Although surveys and media reports have emphasized violence and economic reasons for removal, a key finding of our work is that GPs report using removal primarily as a means of ending their professional relationships with problematic patients. All GPs indicated that they wished to retain the right to remove patients. They reported that removal is a rare and unusual event, a process which they dislike initiating and which they only have recourse to as a ‘last resort’. Analysis of their accounts suggested that there are two distinct but overlapping types of patients who are most likely to become eligible for removal: ‘bad’ patients, who break the rules of the doctor–patient or practice–patient relationship, and ‘difficult’ patients, whose relationship with their GPs is so strained that GPs feel they can no longer care for them adequately. In most, but not all, cases, removal was activated by a ‘trigger event’; in other cases, termination occurred when GPs felt they had reached a point when ‘enough is enough’.
‘Bad’ patients
‘Bad’ patients were those who ‘broke the rules’ of the doctor–patient or practice–patient relationship, as defined by the GPs.
Rules governing violence, aggression and open criticism. Violence was identified by GPs as an important reason for removing patients from their lists. Reports of actual violence were rare, but fears about possible violence towards practice staff were more common. GPs saw the removal of patients who threatened or committed acts of violence, or who caused practice staff to fear for their safety, as straightforward.
"I think the only one patient I removed, I think that was very early on, was er he was very aggressive actually, virtually nearly got hold of one of my staff and was really about to grab her neck." (GP18)
Less clear cut were cases where patients were described as ‘aggressive’ but did not actually threaten violence and were instead extremely rude to practice staff.
"We chucked them off the list because they were rude and aggressive on the telephone ... the husband slagged me off once, and I just said ‘I'm sorry, I don't take that language’ and he did it again, so I actually contacted him and said ‘If you do that again, you will be off the list’ and he did it again of course, so he was off." (GP11)
In these cases, patients had breached what many GPs saw as an inviolable rule in general practice: that patients should not lose their temper. Another such rule was that patients should not openly criticize their doctors. Patients who told doctors that they were incompetent, and compared their treatment unfavourably with others, could therefore become candidates for removal. These two rules are related because they form part of a requirement for ‘respect’ which GPs sought in their relationships with patients.
Rules governing lying, making complaints and manipulation. A second theme concerns ‘trust’, and this linked three further rules in the doctor–patient relationship: that patients should not lie, that they should not make formal complaints against doctors and that they should not attempt to manipulate doctors. Patients who make formal complaints provoked fear in GPs, and made them cautious in their dealings with these patients. Sometimes their loss of trust was such that they felt they could no longer care adequately for the patient. Perceived manipulation was problematic because it suggested to the doctor that he/she is being recruited in service of the ‘illegitimate’ objectives of patients rather than being a resource for legitimate health-related problems.
"The chap came in, wanting a sick note, with no objective signs or symptoms of illness, but just felt a bit off and felt a bit pressured and wanted to get on with some work at home I think. And when the doctor refused to give him, well he just said ‘well, I'll go and see one of the other doctors then’." (GP11)
Rules governing use of the service. A final set of rules governing the relationship between patients and the practice concerned the appropriateness of their use of the service provided. ‘Abuse’ of the service included making an unusually high level of demand (much of it deemed inappropriate by GPs) on out-of-hours services, home visits or practice appointments, ‘doctor-hopping’ within the practice or failing to keep appointments.
"About quarter to twelve he phoned the surgery to say that he was having chest pain, and that he was short of breath he couldn't possibly get to the surgery, and [...] he had no transport. So I left the surgery, I went to see him, and in actual fact what he was describing was a pain in his shoulder that he consulted Dr X. about two days previously. His wife was present at the house with her car." (GP9)
GPs were at pains to point out that patients who abused the service were problematic because of the adverse effects for other patients, and not solely because of the inconvenience to themselves.
Negotiation and non-negotiation. In cases where patients were seen to ‘break the rules’ of the doctor–patient relationship, removal was not usually automatic. GPs emphasized, for example, that single instances of ‘service abuse’ were unlikely to lead to removal: the key issue here was negotiation. GPs became frustrated when patients ‘chose to ignore’ the difficulties they were causing for the practice and other patients, even when these were repeatedly brought to their attention.
"So you try and negotiate. And if it's negotiable then things can carry on, but then if the negotiated agreement just keeps breaking down, and that would be my definition of doctor–patient relationship breakdown." (GP14)
However, some violations of the rules were seen as so unacceptable that they triggered removal without any prior history of the patient being ‘bad’, ‘difficult’ or breaking the rules. Such cases included violence, but also included cases of patients behaving in ways that practice staff deemed intolerable.
"I think he'd lost his temper or something with the doctor over the inhaler issue and he was removed, which I think is reasonably OK. To start losing your temper in front of doctors because you [pause] I mean, you just can't." (GP5)
Removal as a way of disciplining ‘bad’ patients. Removal was seen by GPs as a way of disciplining ‘bad’ patients. Sometimes the GPs openly used punitive language when referring to removal, including phrases such as ‘throw off’ (eight GPs) or ‘chuck off’ (four GPs) a patient from the list. The sanction of removal was seen by some as a means of enforcing compliance with the rules of the doctor–patient relationship, through the potential for leading to an ‘improvement’ in the patient's subsequent behaviour. Half of the GPs (13) saw the removal process as ‘educative’ for patients. As this GP noted:
"The vast majority in my experience of patients who have been thrown off a practice list and then go to another doctor learn very quickly that it is to their advantage to treat their surgery appropriately. Not undemandingly, but appropriately." (GP17)
‘Difficult’ patients
Though GPs reported cases of patients who were both ‘difficult’ and ‘bad’, ‘difficult’ patients were a distinct group from ‘bad’ patients, in that the problems lay primarily in the quality of their relationship with GPs rather than in their persistent violation of the rules. This could happen when the patient provoked strong dislike in the GP. Some patients provoked dislike or negative feelings because of their particular personality characteristics: for example, GPs found some patients neurotic, unpredictable, racist, preoccupied with apparently minor health problems for which little could be done or simply very irritating. GPs also identified some groups of patients who are particularly likely to cause a loss of affective neutrality.15 These included patients with somatization, substance abuse, personality disorders and some types of mental illness. For these patients, GPs typically found it difficult to reach a shared understanding of the patient's problems or to agree a way forward. For example, substance abusers might betray their doctor by selling methadone which had been prescribed for them, while patients with mental illness might refuse to accept the need for treatment.
The GPs felt it was acceptable to have negative feelings towards such ‘difficult’ patients provided that such feelings did not affect the care the GPs felt they could offer the patient. Several GPs expressed concern that they might miss an important diagnosis in such a patient in their haste to terminate the consultation as quickly as possible, an act that might lead to a formal complaint.
"And I think we were just a bit worn out with him really ... one of the other partners who had a concern about him felt that the difficulty with patients like that was that one of these days they would have something significantly wrong, and we might miss it, and he would be the first to have you for breakfast." (GP21)
Although many removed patients were characterized by GPs as ‘difficult’ patients, being ‘difficult’ on its own was not deemed sufficient cause for removal unless the GP reached a point where he/she could no longer care for the patient because of a loss of affective neutrality and ‘breakdown in the relationship’ was felt to have occurred by the GP.
"And that was a patient who really was driving me distracted. I was beginning to sort of lose it because the patient was just so difficult to handle. It wasn't that they had no faith in me, it was just that I was beginning to lose faith in myself really, and I just really felt I had to get rid of her. Sorry, to get rid of her is unfriendly, I mean remove her." (GP3)
Removal as ‘divorce’. Rather than the language of sanction used when discussing ‘bad’ patients, GPs tended to invoke the metaphor of divorce in describing the ending of relationships with ‘difficult’ patients. This metaphor had four components: GPs saw themselves as having a long-term relationship with patients that could continue indefinitely unless it was formally ended; ending the relationship became necessary when ‘irretrievable breakdown’ occurred; ending the relationship was a ‘last resort’; and ending the relationship had benefits for both parties, resolving difficulties for the GP and allowing the patient to make a fresh start.
"I am of the opinion that some people do need new practices. You know, they do need a new doctor. You know, that can be the making of the doctor/ patient relationship. But [...] I'm not just saying I'm wonderful. What I mean is that even the patients of mine who've cleared off, you know, I'm sure it is probably a big success for the next doctor they went to after me. I think it works, you know, it's horses for courses." (GP3)
Managing removal
Many of the informal rules governing doctor–patient relationships were, by their nature, difficult to make explicit. Moreover, the GPs experienced difficulty in communicating their decision to remove the patient. Seven GPs described having no written policy on removal, while eight GPs had a procedure that was available to staff, often in the form of minutes of practice meetings. Only one GP stated that there was an explicit written policy available for consultation by patients as well as staff. Twelve GPs said that they made it a policy to explain the reasons for removal to patients. Six GPs said they would usually tell patients about the removal decision verbally, and six said they would usually write a letter setting out the reasons for removal. Because a letter was seen as a ‘public’ document, GPs were cautious about what they wrote, often simply stating that there had been a ‘breakdown’ in the doctor–patient relationship. Eight GPs said that they would not generally tell patients the reasons for removal because usually patients already ‘knew’ why they were being removed, or because telling the patient could lead to further difficulties.
GPs' accounts showed that formal removal is in fact unlikely to be the main means by which GPs terminate their relationships with problematic patients, be they ‘bad’ or ‘difficult’. More commonly, GPs might suggest to patients, either verbally or in a letter, that they register with another practice. GPs used this method of ‘informal’ removal to avoid angering patients and provoking complaints. In this extract, the GP used this strategy with a family who were ‘at loggerheads’ with the GP over a range of issues:
"We didn't actually formally tell the Health Authority to remove them from our list. But they (family) did actually accept that the professional relationship had broken down and went elsewhere." (GP4)
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Our study explores, from the perspectives of GPs themselves, why patients are removed. Our study suggests that patients become candidates for removal when their doctors feel that ending their relationship with them is the only way forward, either because the patient needs to be ‘educated’ into not breaking the rules of the doctor–patient/practice–patient relationship or because the conditions necessary for a therapeutic relationship no longer exist.
Some of our findings confirm similar findings in quantitative studies of this area,16,17 but also offer insights that are unavailable using quantitative techniques, including the findings about the informal rules that GPs draw on in decision making about removal, and the classification of patients into ‘bad’ and ‘difficult’. It is interesting that our study found little evidence of GPs using removal for ‘unprofessional’ reasons, such as financial motives, which have been given prominence in media reports. This could be explained by the functions that GPs' narratives of removal perform. The GPs' accounts could be read as asserting their identity as ‘good’ GPs and would therefore be unlikely to contain elements that would cast them in a bad light.18 GPs would avoid suggesting that they remove patients for trivial or vindictive reasons, for example, because this would damage their implicit claim to be of good professional standing. Our use of a GP to conduct their interviews, however, may have mitigated this effect to some extent, at least in comparison with having a ‘lay’ person to conduct the interviews.19 Alternatively, the GPs in our study may have offered trustworthy accounts, and media reports may have exaggerated the ‘unprofessional’ motives for removal. In reality, there is no means of estimating the size of the effect, as participant observation studies would be extremely difficult to conduct in this setting.
Notwithstanding the status of the accounts offered by the GPs, the removal of ‘bad’ patients implies that there are certain conditions that patients must satisfy for the continued viability of their relationship with their GPs: ‘bad’ patients were those who broke the rules of the doctor–patient or practice–patient relationship. Some of these rules were clear and explicit—for example that violence is unacceptable—but others were rules that emerged from the interactions between practice staff and patients. For instance, the doctor may become aware that she demands respect (shown by politeness and consideration) from patients only when a patient is rude and aggressive.
While the rules may well be apparent to practice staff (especially when they are broken), these informal rules may not be clear to patients, nor may their significance be understood. Moreover, the tacit nature of these rules, and the ways in which they are constantly being formed and reformed in relationships between individual patients and individual practice staff, mean that it may be difficult to explain what has happened without making it sound as though a patient has been removed simply because he/she affronted a doctor's sensibilities (e.g. by being rude). In fact, sociological research has shown how important the informal rules of ‘etiquette’ governing the doctor–patient (or practice–patient) relationship20,21 are, particularly in maintaining professional boundaries.22 The importance of this for GPs, as well as the importance of having a sanction such as removal available that allows them to police these boundaries, should not be underestimated. It is, however, clear that it has the potential to lead to misunderstandings and distress and anger on the part of patients. This may help to explain the patient anguish and disbelief that often accompanies removal decisions.
Patients who are ‘bad’ may also be ‘difficult’ patients (and difficult patients may also be bad), but our study appears to suggest that ‘difficult’ patients form a distinct category of patient, previously identified as ‘heartsink’.23,24 Being ‘difficult’ does not confer candidacy for removal in its own right, but in a small number of cases GPs feel that their ability to care for the patient has been so badly compromised that the only option is to end their relationship. That GPs invoke the metaphor of ‘divorce’ to describe this is telling. Empirical work on the nature of divorce, while acknowledging that it is stressful for both parties, shows that there is an important difference between the party who initiates divorce (petitioner) and the potentially unwilling partner (respondent).25 For the petitioner, the marriage may well be seen as having ‘irretrievably broken down’ and may represent a release from an oppressive relationship. The petitioner is able to plan the transition from being married to being separated. In contrast, the respondent may be unwilling to accept that the marriage has ended and may still hope for a reconciliation, and may find the transition from being married to being separated much more stressful and distressing. Applying this to the GP/removed patient ‘divorce’ suggests that one should be cautious about accepting the GPs' claim that removal benefits both parties. In contrast, it offers a reason why removal may be very distressing for patients. A more general criticism of the ‘divorce’ metaphor is that removal may not in fact be analogous to ‘divorce’. There are substantive differences between divorce law and a GP's terms of service. A patient may be removed immediately and without any prior notice and the patient has no access to reconciliation or any means of redress.1 The ‘divorce’ metaphor also obscures the fact that the doctor–patient relationship relies on a power differential between doctor and patient.26 As has been argued elsewhere, removal can be seen as an open display of power by the GP in which the patient is coerced into leaving the list of the GP.10,11
GPs may choose to remove a patient without warning or else to write a short letter tersely stating ‘relationship breakdown’ as the reason. It is clear they find it hard to confront the patient openly about the difficulties in the relationship. Research on personal relationships suggests that there is good reason for the use of such strategies: an attempt by one party to end the relationship by ‘mutual consent’ is unlikely to succeed, because it leads to the development of strategic cross-complaining. In such a situation, the fact that one party openly broaches ending the relationship leads to the other becoming angry at the suggestion and, as a result, a confrontation develops, in which positions become entrenched—a complaint by one party is countered by a complaint from another, and so on.27 An alterative approach that might allow GPs to be open with patients about the ‘difficulties’ they cause is mediation. Third-party mediation is successful in resolving disputes because it allows for disputes to be discussed and agreement reached without argument,28 but it can only occur if both parties are willing to co-operate, both are competent to make decisions and there is equality of bargaining power.29
Conclusions
The ability to remove patients is a right that GPs value. GPs report that they seek to end their relationships with patients only rarely and, when they do, they have reasons that appear to them to be important in maintaining professional boundaries or fulfilling their professional responsibilities. However, the importance of these reasons may not be recognized by others (including patients), so that there is the potential for these reasons to be characterized as vexatious, trivial or discriminatory. In addition, the informal and constantly renegotiated nature of the rules governing doctor–patient and practice–patient interactions means that patients cannot easily identify what the rules are, and may only become aware of how seriously their actions are viewed when they are removed.11 This qualitative study helps to explain not only why patients are removed, but also why GPs often do not want to give precise reasons for removal and wish to continue to have the right to remove patients without having to explain why.17
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Acknowledgments |
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We thank all the GPs in Leicestershire who took part in the study. The study was carried out as part of a doctoral thesis and was funded by the Scientific Foundation Board of the Royal College of General Practitioners.
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References |
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