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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.
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 patient 14 Mutual withdrawal: The methods and principal findings of our analysis of GPs' and patients' accounts of removal have been reported elsewhere.
Accounts of being removed from a GP's list were also obtained from 28 recently removed patients.How patient volunteers help train future doctors
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.
There were two distinct but overlapping types of patients who were most likely to become eligible for removal: The removed patients felt that their removal was unjustified. Removed patients also used their accounts to characterize the removing GP as one who broke the lay rules of the doctor—patient relationship.
Being removed from their GP's list was experienced by patients as very threatening. 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. 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.
Breakdown can happen in one of two ways, which can be explained in terms of social relationship theory. GPs' and patients' accounts of what constitutes such a violation have been explored in detail elsewhere.
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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. Hayes-Bautista 14 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 rule 13 of the doctor—patient relationship: They recognize that a serious loss of affective neutrality is so disruptive that it threatens the viability of the relationship.
This metaphor has four components: 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. Termination may occur in the absence of any breakdown in the relationship.
Shared decision making
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.
Hayes-Bautista 14 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.
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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 UK 8 and New Zealand, 9 and was also explored by Hayes-Bautista.
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. Here, patients choose to terminate the relationship with a particular practice by voluntarily re-registering with another local general practice.
Although Gandhi et al. Empirical evidence for this strategy in general practice comes from a qualitative study of the process of referring patients for minor mental illness.
The theoretical categories developed by Hayes-Bautista 14 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: Removal is presented in the GPs' accounts as allowing this breakdown to be managed appropriately. 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 the final phase of disengagement, the parties in a relationship explain why it decayed and died. This involves the attribution of blame to the other party 31 and an attempt to repair the damaged aspects of their identity. These accounts may function as an important form of closure. 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.
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.
Indeed, it may not be possible to avoid confrontation and thereby achieve termination by mutual consent unless mediation is used.
Interactions between managers, doctors and others
I just took it that doctor would know, or the surgeon would know best, and I never sort of knew that there were different treatments. But I did find out, we had a talk from the breast surgeon and they sort of divided the breast up into sections and mine was right near the nipple.
And apparently that area they prefer to do a mastectomy anyway rather than just a lumpectomy. So I was quite relieved about that. I thought' "Oh well, I did have the right treatment then," you know. And I was grateful because really it's a case of a gift of life more than anything. So I'd never ever think that a surgeon was giving me the wrong treatment.
I think it's difficult for people nowadays if they're asked which sort of treatment they like because it's quite a responsibility. And often people, although the surgeon explains, I think it's often people feel they'd rather just be told what the surgeon would like to do. Apparently nowadays that is the choice, well it is in our breast clinics - that they can have a choice of just whether they want the whole breast off, whether they want a lumpectomy, or whether they'd like to leave it to the surgeon to think what he'd like best.