Family Practice Vol. 21, No. 5 © Oxford University Press 2004, all rights reserved.
Ending the doctor–patient relationship in general practice: a proposed model
a Division of General Practice and Primary Health Care, Department of Health Sciences, University of Leicester, Leicester General Hospital, Leicester LE5 4PW and b Division of Epidemiology and Public Health, Department of Health Sciences, University of Leicester, 22–28 Princess Road West, Leicester LE1 6TP, UK
E-mail: tns2{at}le.ac.uk
Received 26 August 2003; Revised 3 February 2004; Accepted 17 May 2004.
Stokes T, Dixon-Woods M and McKinley RK. Ending the doctor–patient relationship in general practice: a proposed model. Family Practice 2004; 21: 507–514.
 |
Abstract |
|---|
 Top Abstract IntroductionEnding the doctor-patient...The removal of patients...Ending the doctor-patient...DiscussionDeclarationReferences |
|---|
Background. The doctor–patient relationship in general practice is often viewed by practitioner and patient alike as a long-term ‘personal’ relationship. Little, however, is known about how such relationships are ended in general practice.
Methods. This paper uses theoretical insights obtained from the sociology and social psychology of social relationships, together with the authors' own empirical work on the removal of patients from GPs' lists, to develop a theoretical model of ending the doctor–patient relationship in general practice.
Results. Ending the relationship involves ‘breakdown’ and ‘termination’. ‘Breakdown’ in the relationship occurs when one party decides that the other has acted in such a way as to threaten that party's identity as a ‘good’ patient or doctor. ‘Termination’ may be patient initiated, doctor initiated or by mutual consent.
Conclusions. It is proposed that further research is needed to delineate the rules and rituals governing entry into and maintenance of the doctor–patient relationship in general practice as well as those that govern its ending.
Keywords. Doctor–patient relationship, general practice.
|
Introduction |
|---|
|
TopAbstractIntroductionEnding the doctor-patient...The removal of patients...Ending the doctor-patient...DiscussionDeclarationReferences |
|---|
‘It is on this basis of mutual satisfaction and mutual frustration that a unique relationship establishes itself between a general practitioner and those who stay with him [sic]... we termed it ‘a mutual investment company’. By this we mean that the general practitioner gradually acquires a very valuable capital invested in his patient and, vice versa, the patient acquires a very valuable capital bestowed in his general practitioner.’1
The doctor–patient relationship in general practice is often viewed by practitioner and patient alike as a long-term ‘personal’ relationship.2 Such a relationship is a key component of patient-centred medicine3 and may have positive health outcomes for patients as it allows a ‘therapeutic’ relationship to develop between GP and patient, one in which the GP displays empathy, genuineness and unconditional positive regard to effect therapeutic change in patients.4 However, it is also recognized that GPs may experience difficulties in their relationship with some patients over time and this may lead to negative health outcomes for patients. GPs may categorize such patients as ‘heartsink’ patients5 who invoke feelings of ‘angry helplessness’ in their GPs.6 One possible response is to terminate relationships with such patients. Equally, patients may have difficulties in their relationships with GPs, which they may respond to in a variety of ways. This may include ending their relationships with GPs.
Little, however, is known about the ending of relationships in general practice.7 In particular, the questions of why and how GPs choose to end their relationship with patients have been the subject of very limited empirical study and there is only a small literature on patients' termination of their relationships with doctors.8–11 This paper uses theoretical insights obtained from the sociology12–14 and social psychology15 of social relationships, together with our own empirical work on the removal of patients from GPs' lists,10,11,16 to develop a model of ending the doctor–patient relationship in general practice.
|
Ending the doctor–patient relationship: insights from sociology and social psychology |
|---|
|
TopAbstractIntroductionEnding the doctor-patient...The removal of patients...Ending the doctor-patient...DiscussionDeclarationReferences |
|---|
G and M McCall's theory of social relationships
One influential way of conceptualizing social relationships, such as the doctor–patient relationship, has been to view them as a form of social organization similar to small groups, bureaucracies and communities. This approach is associated with the sociologists George McCall12 and Michal McCall13 who proposed that a social relationship has a history and a career that is constantly redefined by each participant at each social encounter. G and M McCall proposed that a social relationship should also be seen as having rules and rituals governing its initiation, maintenance and ending, similar to those that Goffman17 proposed govern social encounters.
An important characteristic of a social relationship is that it has a focus for its members' activities, and has boundary rules for maintaining that focus. Boundary rules are partly determined by societal norms and partly emergent, i.e. they are accomplished through interaction, rather than being externally defined and imposed. Thus a personal relationship such as a marriage may have intimacy as its focus, with boundary rules—such as private terms of endearment—maintaining intimacy. In contrast, the doctor–patient relationship has a different focus and a different set of boundary rules. For example, the doctor–patient relationship may require emotional detachment—what Parsons18 has termed ‘affective neutrality’—as a boundary rule to maintain the professional objectivity that doctors require to treat their patients. This rule requires that doctors become neither too intimate with their patients, nor too hostile towards them; they must maintain an emotional impartiality.
As a social relationship changes over time, a party to the relationship may become dissatisfied with the boundary rules or become alienated from its focus. Alienation occurs when one party no longer finds the focus as important as it had been previously. The alienated party may choose to break the boundary rules to indicate that there is a need to redefine the relationship. The ending of a social relationship can thus be seen as the ultimate breaking of the boundary rules in an attempt to redefine the relationship.13
G and M McCall's work12,13 has influenced social psychologists working in the field of personal relationships.15,19–21 Duck15 provides a critical review of the social psychological literature on the ending of personal relationships. He stresses that in describing the process of ending a relationship, it is important to get the terminology right: the term ‘breakdown’ means different things to different researchers. Duck proposes that there is a distinction between ‘breakdown’ and ‘dissolution’. ‘Dissolution’ or ‘termination’ refers to the permanent erasure of an existing relationship, whereas ‘breakdown’ refers to disorder in the relationship that may or may not lead to dissolution. This distinction will be used in this paper.
Hayes-Bautista: ‘termination of the patient–practitioner relationship: divorce, patient style’
The sociologist Hayes-Bautista14 placed his work on the termination of the doctor–patient relationship within G and M McCall's12,13 model of social relationships. ‘Termination’ was seen as a particular stage in the ‘career’ of the doctor–patient relationship. Hayes-Bautista used grounded theory22 to determine the theoretical properties of termination as derived from patients' accounts of doctor–patient encounters. His study population was ‘around 200’ Mexican-American patients (mostly women) in San Francisco. He used both participant observation and open-ended interviews with the patients. His findings are summarized as follows. Termination is defined as the end of a particular doctor–patient relationship. It may be initiated by either the patient or the medical practitioner, or it may be the result of ‘over-riding conditions’, such as when the patient moves out of the area served by the practitioner. Patient-initiated termination comes about as a result of the patient evaluating the practitioner's medical care and concluding that it is inadequate. This inadequacy may be absolute or only come to light when the patient consults another practitioner and thereafter decides that their original practitioner is inadequate in comparison with the new practitioner. Practitioner-initiated termination is perceived by patients as being the result of their unwillingness to comply with the practitioner's advice, or due to the practitioner's self-recognized inability to handle an episode (e.g. termination consists of a referral to another physician with particular clinical expertise). Hayes-Bautista noted that when patients felt that the relationship was being terminated because they did not comply with medical advice, the patients perceived that the practitioner wanted either a permanent termination or a temporary one that would resume once the patient had learnt ‘how to behave’.
Hayes-Bautista was also able to describe the various methods by which termination was accomplished by both practitioner and patient, and these are summarized in Box 1. Hayes-Bautista's work described the process by which the doctor–patient relationship may be ended by patient and practitioner and, through a rigorous application of grounded theory,22 he was able to derive a model of termination that can be tested and refined in other health care settings. The title of the paper, ‘Termination of the patient–practitioner relationship: divorce, patient style’, is also revealing as it suggests that the use of metaphors derived from marital relationships might usefully be applied to the doctor–patient relationship. It should be noted, however, that his account of termination is only based on the accounts of patients; practitioners' accounts of terminating the doctor–patient relationship are absent.
| BOX 1 Methods by which termination of the relationship is accomplished by both practitioner and patient14 Mutual withdrawal: when both parties come to an agreement that the relationship has not worked out as either hoped and termination is the only way forward. Confrontation: when mutual withdrawal is attempted by one party but the other angrily refuses. The ‘fade-out’: when patients, having decided to terminate the relationship, choose not to return to that particular practitioner. The ‘hand-off’: when a practitioner refers a patient to another practitioner and does so for the specific purpose of terminating the relationship. The ‘put-off’: when a practitioner, seemingly on purpose, refuses to accede to a patient's demands so that the patient loses patience with the practitioner and consults another doctor.
|
|
The removal of patients from GPs' lists |
|---|
|
TopAbstractIntroductionEnding the doctor-patient...The removal of patients...Ending the doctor-patient...DiscussionDeclarationReferences |
|---|
The removal of a patient from a GP's list offers a unique insight into what happens when the doctor–patient relationship ‘goes wrong’ and a doctor decides to end his/her relationship with a patient. The methods and principal findings of our analysis of GPs' and patients' accounts of removal have been reported elsewhere.10,11,16 In brief, accounts were obtained from 25 GPs of removing patients from their list. Accounts of being removed from a GP's list were also obtained from 28 recently removed patients. Data analysis, based on the constant comparative method,22 was undertaken separately for these two sets of accounts.
We found that GPs used 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 were two distinct but overlapping types of patients who were 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 the doctors felt they can no longer care for them.
The removed patients felt that their removal was unjustified. They were concerned to show that they were ‘good’ patients who complied with the rules they understood governed the doctor–patient relationship: they tried to cope with their illness and follow medical advice; used general practice services ‘appropriately’; were uncomplaining and were polite to doctors. Removed patients also used their accounts to characterize the removing GP as one who broke the lay rules of the doctor–patient relationship. These ‘bad’ GPs were rude, impersonal, uncaring, clinically incompetent and lied to patients. Being removed from their GP's list was experienced by patients as very threatening.
A key feature common to both sets of interviews is that both GP and patient recognize that there are formal and informal ‘rules’ that govern conduct in the doctor–patient relationship and each party typifies the other party as ‘good’ or ‘bad’ depending on whether they conform to or break these rules. An analysis of the role of the rules in determining power relations in the relationship shows that removal amounts to a coercive use of force by the GP in response to perceived rule breaches by patients.23
This research offers a detailed description of the process of removal as perceived by both practitioner and patient and also places removal in a wider framework of theory in relation to the ‘difficult’ doctor–patient relationship. We now wish to integrate these findings with other empirical and theoretical work, including that described earlier, to produce a model of how doctor–patient relationships end in general practice.
|
Ending the doctor–patient relationship in general practice: a proposed model |
|---|
|
TopAbstractIntroductionEnding the doctor-patient...The removal of patients...Ending the doctor-patient...DiscussionDeclarationReferences |
|---|
‘Breakdown’ of the doctor–patient relationship
Figure 1 presents a model of ‘breakdown’ of the doctor–patient relationship, based on our research on patient removal.10,11 ‘Breakdown’ in this model is usually preceded by a variable period of time in which each party views, or at least narratively reconstructs, the other as being either ‘bad’ or ‘difficult’. ‘Bad’ patients or doctors are viewed by the other party as breaking either the formal or the tacit rules of the doctor–patient or practice–patient relationship. ‘Difficult’ patients are a distinct group from ‘bad’ patients, in that the problems lie primarily in the quality of their relationship with GPs rather than in their violation of the rules of the relationship. This can happen when the patient provokes strong dislike in the GP, as noted in previous research with ‘heartsink’ patients.6 The GPs in our study 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.
|
Being a ‘bad’ or ‘difficult’ patient or doctor does not appear, however, to be sufficient for the doctor–patient relationship to break down. Breakdown can happen in one of two ways, which can be explained in terms of social relationship theory. First, there is a major breach of the rules of the relationship to the extent that one party feels this act constitutes ‘breakdown’. GPs' and patients' accounts of what constitutes such a violation have been explored in detail elsewhere.10,11 Analysis of these suggests that breaches of the rules such as rudeness and losing one's temper and pursuing a formal complaint violate the core properties of ‘trust’ and ‘respect’. Thus each party would view ‘losing one's temper’ as a major breach of the rules. Similarly, an allegation by the patient that the GP is incompetent or lies to the patient would be seen as a major breach of the rules. Other work, including that by Gandhi et al.,8 has similarly identified that a patient's decision to change GP was often triggered by the GP and/or practice staff being ‘rude’, the GP not being ‘interested’ in the patient and by the patient viewing the GP as clinically incompetent. Hayes-Bautista14 also found that the evaluation by a patient that the practitioner was incompetent led to a patient-initiated termination of the relationship. Thus violation of the conditions of social relationships through serious rule breaking can result in breakdown in relationships between professionals and patients.
The second way that the doctor–patient relationship can break down is when one party has been experiencing difficulties with the other's actions for a considerable period of time. Minor rule violations not amenable to negotiation with the patient and committed over a period of time risk breaching a key boundary rule13 of the doctor–patient relationship: ‘affective neutrality’.18,24 The GPs become emotionally exhausted or develop such strong negative emotions towards the patient that medical care is potentially compromised. They recognize that a serious loss of affective neutrality is so disruptive that it threatens the viability of the relationship. In our study on removal,11 GPs drew on the metaphor of ‘divorce’ to account for such a state of affairs. This metaphor has four components: (i) GPs saw themselves as having a long-term relationship with patients that could continue indefinitely unless it was formally ended; (ii) ending the relationship became necessary when ‘irretrievable breakdown’ occurs; (iii) ending the relationship was a ‘last resort’; and (iv) ending the relationship had benefits for both parties, resolving difficulties for the GP and allowing the patient to make a fresh start. The sustainability of this metaphor is questionable, especially as patients are not given the rights and status of the ‘respondent’ in a divorce petition in these accounts, but it nonetheless demonstrates important aspects of how GPs characterize their relationships with patients.
A third important contribution to breakdown in professional–patient relationships is ‘identity threat’. A key feature of research on problems in professional–patient relationships is that both parties regard it as important to maintain professional and personal identity. The concept of ‘personal identity threat’, developed from research exploring the meaning of patients' ‘dissatisfaction’ with health care25 and how doctors respond to complaints from patients, is very relevant here.26,27 Such research has shown that a wide range of problems encountered with the provision of health care, from practitioners failing to take the concerns of patients seriously to patients complaining about the care provided by doctors, are perceived by practitioner and patient alike as a threat to personal identity and as undermining their sense of self: they report negative experiences that lead to them feeling dehumanized, disempowered and devalued.
‘Breakdown’ may therefore occur when one party decides that the other has acted in such a way as to threaten that party's identity as a ‘good’ patient or doctor. For example, a formal complaint by a patient against a ‘bad’ GP accusing the GP of incompetence is a threat to the professional identity of a doctor: ‘good’ doctors are competent. Similarly, a GP openly accusing a ‘bad’ patient of being awkward, complaining or hypochrondriacal constitutes a threat to the identity of the patient as a ‘good patient’.
‘Termination’ of the doctor–patient relationship
Figure 2 presents a model of ‘termination’ of the doctor–patient relationship. It should be re-emphasized that ‘breakdown’ and ‘termination’ are not synonymous. Termination may occur in the absence of any breakdown in the relationship. Two good examples of this would be when a GP leaves or retires from a practice or when a patient genuinely moves outside the practice area. Conversely, breakdown may occur without termination; the patient may, while remaining registered, simply stop attending the practice, or the receptionists may always give the patient appointments with staff other than the individual with whom the relationship has broken down, for example.
|
Termination of the doctor–patient relationship can be conceived as being by mutual consent, patient initiated or doctor initiated (removal). Hayes-Bautista14 proposed that when termination is achieved by mutual consent, both parties come to an agreement that the relationship has not worked out the way both had hoped and that there appears to be no remedy other than mutually agreeing to terminate the relationship. He notes that this can only occur if both parties mutually agree to termination. There is little empirical research in this area in general practice.
The issue of patient-initiated termination of the doctor–patient relationship has been explored using qualitative interviews with patients who have changed GP without changing address in both the UK8 and New Zealand,9 and was also explored by Hayes-Bautista.14 Hayes-Bautista coined the phrase the ‘fade out’ to refer to patients who, having decided to terminate the relationship, choose not to return to that particular practitioner. In UK general practice, this can observed in patients who stay registered with a particular group practice but who choose to consult another GP in the practice. Hayes-Bautista also identified the ‘walk out’. Here, patients choose to terminate the relationship with a particular practice by voluntarily re-registering with another local general practice. Although Gandhi et al.8 do not offer a theoretical model of relationship breakdown or termination, choosing instead to describe the patients as ‘dissatisfied’, their empirical findings offer support for the hypothesis that relationship ‘breakdown’ can lead to the ‘walk out’: their participants recount stories of ‘voting with their feet’ and re-registering with another GP. In our study of GPs' accounts of removal, it was clear that GPs themselves recognize that patients may well ‘vote with their feet’ and ‘walk out’ of the relationship without being asked to do so explicitly by the GP.
Doctor-initiated termination was conceptualised by Hayes-Bautista14 as the use of disengagement tactics by the doctor to ‘rid himself’ of a patient. Two commonly used strategies were the ‘hand-off’ and the ‘put-off’. The ‘hand-off’ is when a practitioner refers a patient to another practitioner and does so for the specific purpose of terminating the relationship. Empirical evidence for this strategy in general practice comes from a qualitative study of the process of referring patients for minor mental illness.28 Nandy et al.28 found that referring a patient with minor mental illness to a counsellor was a commonly used tactic when the GP had ‘had enough’ of a particular patient and wanted relief from the negative emotions engendered by the patient. Using the theoretical framework employed here, this can be seen as a particular example of doctor-initiated termination—the ‘hand-off’—following ‘breakdown’ due to a breach of affective neutrality. In contrast, the ‘put-off’ is when a practitioner, seemingly on purpose, refuses to accede to a patient's demands so that the patient loses patience with the practitioner and consults another doctor; either within the same practice or by choosing to leave the list. The GP thus provokes a ‘walk out’.
The theoretical categories developed by Hayes-Bautista14 can be extended by exploring the phenomenon of the removal of a patient from a GP's list. Two categories of doctor-initiated termination of the doctor–patient relationship were identified from our study of GPs' accounts:11 ‘informal’ removal and formal removal. The first category, ‘informal removal’, or, following Hayes-Bautista's14 lead, what is termed the ‘push out’, is when the GP suggests to the patient that he/she would be better served by re-registering with another doctor. ‘Informal’ removal could also be used as a prelude to ‘formal’ removal if, after a defined period of time, the patient had not left the practice ‘voluntarily’. ‘Formal’ removal occurs when the practice writes to the Health Authority requesting removal of a patient. The GPs present formal removal as ‘divorce’; it is a ‘last resort’ and ‘final act’ when all practicable attempts to fix the doctor–patient relationship have failed. Removal is presented in the GPs' accounts as allowing this breakdown to be managed appropriately. The patients, in contrast, present removal as an abuse of power by ‘bad’ GPs. The extent of this abuse is shown by GPs being able to remove patients and their families from their lists without warning, without the need to justify their actions and without the patient having any right of appeal or redress. In contrast to the GPs' use of the divorce metaphor, the patients are reluctant divorcees, rather as if they have been ‘locked out’ of the marital home. We propose the phrase ‘lock out’ to describe formal removal.
The final stage of termination may be termed ‘grave dressing’, to use Duck's20 vivid phrase. In the final phase of disengagement, the parties in a relationship explain why it decayed and died. Each participant may ‘dress up’ the grave of the relationship by promoting a positive self-image of his or her role in the relationship. Each party, in telling his/her story of removal some time after the event, uses the narrative of removal strategically29,30 to reassert their identity as ‘good’ GPs and ‘good’ patients. This involves the attribution of blame to the other party31 and an attempt to repair the damaged aspects of their identity. These accounts may function as an important form of closure. We propose the phrase ‘narrative shut-out’ to describe this phase of relationship termination.
What is striking is how termination by mutual consent, while it would seem to be an ideal type of termination, rarely happens in practice. Instead, each party goes to considerable lengths to engage in confrontation avoidance. Thus patients, rather than confronting the GP, may choose to re-register with another practice. Similarly, GPs may choose to remove a patient without warning or else to write a short letter tersely stating ‘relationship breakdown’ as the reason. There is, in fact, good reason for the use of such strategies, as research in other areas suggests that an attempt by one party to terminate by mutual consent is unlikely to succeed because it leads to the development of strategic cross-complaining.21 As Hayes-Bautista14 notes, the fact that one party openly broaches termination 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. Indeed, it may not be possible to avoid confrontation and thereby achieve termination by mutual consent unless mediation is used.32 Third-party mediation is successful in resolving disputes because its interactional organization allows disputes to be discussed and agreement reached without argument.33 However, the effectiveness of such approaches in addressing doctor–patient relationships in danger of breakdown has not been evaluated systematically.
|
Discussion |
|---|
|
TopAbstractIntroductionEnding the doctor-patient...The removal of patients...Ending the doctor-patient...DiscussionDeclarationReferences |
|---|
GP–patient relationships are among the few professional relationships that may persist over many years, but the ending of these relationships has been subject to surprisingly little scrutiny. This paper shows how research exploring the removal of patients from GPs' lists can be combined with theoretical insights obtained from the sociology12–14 and social psychology15 of social relationships to develop a model of how the doctor–patient relationship is ended in general practice. It is acknowledged that the model focuses on the doctor–patient ‘dyad’ and that attention also needs to be paid to the ‘practice–patient’ relationship, as difficulties between the patient and their general practice may first occur in their interactions with receptionists and other practice staff. It is unclear as to whether the model will need to be revised in the light of recent UK policy changes, notably the British GP contract. Although the GP contract will lead to patients being registered with practices rather than an individual doctor, in most cases this simply institutionalizes a long-standing trend in the development of group practices with shared lists, where patients may consult with any doctor.34
The current model suggests that doctor–patient relationships are subject to a range of strains that arise from problems in the focus of the relationship or the maintenance of boundary rules, and may end in one of several ways, depending on which party first initiates action to end the relationship. It is possible, as in other social relationships, that ending the doctor–patient relationship may be the most satisfactory way of resolving some types of problems. Discontinuity of care may sometimes be valued by both GP and patient: to echo Balint,1 mutual frustration may well lead to mutual separation. For example, patients may value being able to change GPs if they feel that their current practitioner has failed to identify or deal with significant difficulties that they may be experiencing.7 Such ‘sought’ discontinuity of care is a phenomenon that requires further exploration, touching as it does on the difficulties both parties face in maintaining the boundary rules of a relationship that, in general practice, may last for many years.
However, ending of doctor–patient relationships may also be a very negative experience that is profoundly disrupting, producing new problems rather than resolving old ones. For patients, the consequences of the ‘lock-out’ by GPs may be far more serious than the consequences of the ‘walk-out’ by patients. Given the impact on patients, there is a need to recognize the phenomenon of broken-down relationships in general practice and for them to be dealt with in ways that are sensitive to the needs of both parties. A key way in which this could be achieved is to develop the concept of the doctor–patient relationship as a ‘career’.12,14 Empirical work, using an interpretive approach, is needed to delineate the rules and rituals governing entry into and maintenance of the doctor–patient relationship in general practice as well as those that govern its ending. This work could help to find ways of identifying relationships at risk of breakdown at an early stage and facilitate the development of interventions aimed at finding solutions. Such methodologically challenging work echoes recent calls for research on continuity of care that explore the process by which continuity develops as well as what health outcomes result from it being present.7 A final area where further research and sound evaluation is needed is mediation, which may help resolve disputes. There is a need to evaluate the role and effects of mediation-type interventions on fragile relationships in general practice.
|
Declaration |
|---|
|
TopAbstractIntroductionEnding the doctor-patient...The removal of patients...Ending the doctor-patient...DiscussionDeclarationReferences |
|---|
Funding: Scientific Foundation Board of the Royal College of General Practitioners funded the research on the removal of patients from GPs' lists.
Ethical Approval: Leicestershire Research Ethics Committee approved the research on removal of patients from GPs' lists.
Conflicts of interest: None.
|
Acknowledgments |
|---|
We would like to thank Chrystal Jaye, University of Otago, for her helpful comments on an earlier version of this paper.
|
References |
|---|
|
TopAbstractIntroductionEnding the doctor-patient...The removal of patients...Ending the doctor-patient...DiscussionDeclarationReferences |
|---|
1 Balint M. The Doctor, His Patient and the Illness, 2nd edn. London: Pitman Medical; 1964: 249–250.
2 Freeman G, Hjortdahl P. What future for continuity of care in general practice? Br Med J 1997; 314: 1870–1873.
3 Weston WW, Brown JB. Overview of the patient-centered method. In Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR (eds). Patient-centered Medicine Transforming the Clinical Method. Thousand Oaks (CA): Sage; 1995: 21–30.
4 Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med 2000; 51: 1087–1110.[CrossRef][Web of Science][Medline]
5 O'Dowd TC. Five years of heartsink patients in general practice. Br Med J 1988; 297: 528–530.
6 Mathers NJ, Jones J, Hannay D. Heartsink patients: a study of their general practitioners. Br J Gen Pract 1995; 45: 293–296.[Web of Science][Medline]
7 Freeman G, Shepperd S, Robinson I, Ehrich K, Richards S. Continuity of Care Report of a Scoping Exercise for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO). London: NCCSDO; 2001.
8 Gandhi IG, Parle JV, Greenfield SM, Gould S. A qualitative investigation into why patients change their GPs. Fam Pract 1997; 14: 49–57.
9 Nicholls W, Jaye C. Opting out: why patients change doctors. NZ Fam Physician 2002; 29: 402–407.
10 Stokes T, Dixon-Woods M, Windridge K, McKinley RK. Patients' accounts of being removed from their general practitioners' list: qualitative study. Br Med J 2003; 326: 1316–1319.
11 Stokes T, Dixon-Woods M, McKinley RK. Breaking up is never easy: general practitioners' accounts of removing patients from their lists. Fam Pract 2003; 20: 628–634.
12 McCall GJ. The social organization of relationships. In McCall GJ, McCall MM, Denzin NK, Suttles GD, Kurth SB (eds). Social Relationships. Chicago: Aldine; 1970: 3–34.
13 McCall M. Boundary rules in relationships and encounters. In McCall GJ, McCall MM, Denzin NK, Suttles GD, Kurth SB (eds). Social Relationships. Chicago: Aldine; 1970: 35–61.
14 Hayes-Bautista DE. Termination of the patient–practitioner relationship: divorce, patient style. J Health Soc Behav 1976; 17: 12–21.[Medline]
15 Duck S. Towards a research map for the study of relationship breakdown. In Duck S, Gilmour R (eds). Personal Relationships in Disorder. London: Academic Press; 1981: 1–29.
16 Stokes TN. Ending the doctor–patient relationship: an investigation of the removal of patients from general practitioners' lists. PhD thesis, University of Leicester; 2002.
17 Goffman E. Encounters: Two Studies in the Sociology of Interaction. Indianapolis: Bobbs-Merril; 1961.
18 Parsons T. The Social System. London: Routledge and Kegan Paul; 1951.
19 Hinde RA. Towards Understanding Relationships. European monographs in social psychology 18. London, Academic Press; 1979.
20 Duck S. A topography of relationship disengagement and dissolution. In Duck S (ed.). Dissolving Personal Relationships. London: Academic Press; 1982: 1–29.
21 Duck S. A perspective on the repair of personal relationships: repair of what, when? In Duck S (ed.). Repairing Personal Relationships. London, Academic Press; 1984: 163–184.
22 Glaser BG, Strauss AL. The Discovery of Grounded Theory Strategies for Qualitative Research. Chicago: Aldine; 1967.
23 Stokes T, Dixon-Woods M, Windridge KC, McKinley RK. Breaking the ceremonial order: patients' and general practitioners' accounts of removal from a GP's list. Sociol Health Illness [submitted].
24 May C, Dowrick C, Richardson M. The confidential patient: the social construction of therapeutic relationships in general medical practice. Sociol Rev 1996; 44: 187–203.[Web of Science]
25 Coyle J. Exploring the meaning of ‘dissatisfaction’ with health care: the importance of ‘personal identity threat’. Sociol Health Illness 1999; 21: 95–124.
26 Mulcahy L. From fear to fraternity: doctors' construction of accounts of complaints. J Soc Welfare Fam Law 1996; 18: 397–412.
27 Allsop J, Mulcahy L. Maintaining professional identity: doctors' responses to complaints. Sociol Health Illness 1998; 20: 802–824.[CrossRef]
28 Nandy S, Chalmers-Watson C, Gantley M, Underwood M. Referral for minor mental illness: a qualitative study. Br J Gen Pract 2001; 51: 461–465.[Web of Science][Medline]
29 Riessman CK. Strategic uses of narrative in the presentation of self and illness: a research note. Soc Sci Med 1990; 30: 1195–1200.[Medline]
30 Hyden L-C. Illness and narrative. Sociol Health Illness 1997; 19: 48–69.[CrossRef]
31 Felstiner WLF, Abel RL, Sarat A. The emergence and transformation of disputes: naming, blaming, claiming... Law Soc Rev 1980; 15: 631–654.
32 Roberts M. Mediation in Family Disputes Principles of Practice, 2nd edn. Aldershot (UK): Aren; 1997.
33 Garcia A. Dispute resolution without disputing: how the interactional organization of mediation hearings minimizes argument. Am Sociol Rev 1991; 56: 818–835.[CrossRef][Web of Science]
34 Freeman GK, Olesen F, Hjortdahl P. Continuity of care: an essential element of modern general practice? Fam Pract 2003; 20: 623–627.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  N. Elder, R. Ricer, and B. Tobias How Respected Family Physicians Manage Difficult Patient Encounters J Am Board Fam Med, November 1, 2006; 19(6): 533 - 541. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||