When describing discretionary choices, respondents' answers centred around four major topics:
In the following section, we report the results of our analysis of the four major issues of special concern. Many of the citations are related to more than one of the major topics. This is quite illustrative of how the different factors seem to be constantly weighed against one another but also intertwined when the informants are describing incidents of making discretionary choices.
The obligation to ration health care
Participants described many cases of how demanding patients induce them to act as patients' advocate and neglect the gatekeeper role, although some of them stressed that in most instances they have no problems balancing the two roles, for instance through informing and reasoning with the patient. Others stated that they experience a predicament between rationing on society's behalf and offering the best service available to the consulting patient. In the words of one of the participants: Saying no is no easy matter.
Below three informants are discussing reasons for giving in to patients' claims for referrals:
Informant 1: The patients who want a referral to a specialist have made up their mind beforehand that that's what they want. And then I find it quite difficult to explain to them that they don't need it.
Informant 2: And it takes twice as much time.
Informant 3: I feel in a way that I have to offer good service. I don't want anyone to leave my list. I don't want a bad reputation, do I? I live in the same place that I work and I want to please people.
(Three participants in a spesialists' group, Oslo)
Many times informants exclaimed that they just can not bring themselves to say no when patients are insistent. Instead of saying no, other strategies are used to evade conflict as this story illustrates:
I often find it hard and very time consuming to get people to change their minds. The most recent example that comes to mind was an elderly lady. I finally ended up saying, "Yes, I think that before we go any further I should refer you to a rheumatologist who can assess your need for this treatment, and then we can talk." It was perhaps a bit cowardly of me. I could have told her, "You won't get that treatment from me and if you want me to be your doctor that's the way it's going to be." But I couldn't face doing that so I referred her; so now she has to go to the rheumatologist and then come back to me and then we'll see. Hopefully he agrees with me.
(Male GP specialist, 26 years of experience as a GP)
Another finding, however, was a lack of awareness among several of the respondents about the need for rationing and the reasons behind government guidelines and regulations. Some said that they do not see the point in rationing when the costs involved are small.
I believe that as GPs we very rarely consider the aspect of public finances, that we for instance refrain from making a referral because of high public costs. We usually use more rational arguments related to what is best for the patient, then we argue that the patient will not benefit much from a certain referral and therefore we will not refer. We try not to think too much that this implicitly means less public expenditure, so that only to a small degree do we make our decisions based on the common good.
(Male GP, 4 years of experience as a GP)
Many were unsure of what are expected of them as gatekeeper. Several seemed to have solved the quandary by concluding that when a GP spends time and effort in trying to convince the patient that there is no indication for a requested intervention, the GP is an active gatekeeper even if the result is that the patient gets his or her own way in the end.
But aren't we gatekeepers when we put up barriers for people by discussing things and putting forward arguments, even when the conclusion is that the person gets what he wants? Isn't that another way of being a gatekeeper?
(Male GP, 3 years experience as a GP)
Most of the informants were concerned about the degree of professional autonomy and freedom in their work, both in rationing decisions and in how to run their practice. Hence the concept of professional autonomy as it is used here is dual, incorporating autonomy in relation to patients and autonomy in relation to the health authorities.
Some stated that the relative freedom of GPs compared to for example hospital physicians was an important reason for their initial career choice. During interviews, some informants initially claimed that their professional autonomy is not at all complicated by patients' demands and government guidelines for rationing, but during the discussions it became evident that many informants are fearful that they are gradually losing their traditional freedom and autonomy in clinical decision making. Many illustrative examples were given of how difficult it is to maintain an autonomous position.
Early in the interviews several informants claimed that, in situations where there is room for discretionary choice, they are influenced neither by patients nor by health authorities.
I would never compromise my own judgement and give patients what they want all the time just to keep them on my list. [...] I have to say that professional concerns always come first, before that sort of selfish need.
(Female GP specialist, 20 years of experience as a GP)
In contrast a few informants explained how they refer to government rules and guidelines because it makes it easier to refuse demands from patients.
If they come in and say that they're depressed and so on, it can be difficult, but it's tidier if you follow the rules. So I prefer to tell them that these are the rules instead of making exceptions in individual cases, because that's a dangerous path.
(Female GP specialist, 16 years of experience as a GP)
There were several informants who conveyed a feeling of conflict between professional autonomy and rules and guidelines set by central health authorities. One example much discussed was the use of statins and anti-hypertensives:
Question: Do you find that the limits the government has set are clear when it comes to anti-hypertensives and statins?
Informant: No. I tend to stick to my own, let's say, professional judgement and not to any official limitations. That is definitely the case.
(Female GP specialist, 15 years of experience as a GP)
Another matter is the kind of public finance decision about which level of spending to choose. How much money does Norway as a society want to spend on anti-hypertensives, and how much does Russia want to spend? It's a political decision. The reason why it's sensible to have a spending limit in a country is of course that if all physicians have different limits and some of them are treating patients too aggressively while others are not treating aggressively enough, then the cost-benefit of the use of medicines is less, and it becomes more or less random which group of patients gets help. If there had been an absolute limit, and the limit was set at a reasonable level, maybe not a cholesterol level of 8.2 but let's say 7.5, then the physicians would have to respect the rule and the patients who did not fulfil this criterion but still were eager to get treatment could pay for it themselves. [The levels as they are set today] are not respected by GPs, and that may be because the criteria are unrealistic, and we are trying to satisfy our patients.
(Male GP specialist, 4 years of experience as a GP)
Others said that the rules for remunerated prescribing are perfectly clear and that they never bend them. However, such statements tended to be moderated or even contradicted later in the discussion. Sometimes one of the participants provoked this openness by admitting to bending the rules for remunerated prescriptions or to referring without sufficient medical indications.
A fear of losing professional autonomy because of economic incentives and competition was expressed by many of our informants, although not always in a straightforward or personal manner. Below are two quotes from the same informant, the first early in the interview and the second later as the discussion had accelerated:
1: Our decisions are always based on our professional judgement. The reform [the new capitation- and list-based system] has had no influence whatsoever.
2: A relatively serious drawback [of the reform] is that you are forced to become a peddler. At the start it made the hairs at the back of my neck stand on end. It feels very unpleasant. Once you've gone along with this premise I think it's a terribly sad situation for our health services as a whole. It has huge consequences ...
(Male GP, 6 years of experience as a GP)
There were repeated claims that patients have become better informed about their rights as patients, and that they appear increasingly demanding. When discussing why they give in to patients' demands even when the claims are not clearly within what would be defined as medically necessary; many referred to the ideal of patient autonomy and patient centred care which implies respect for patients' subjective experience and sharing decisions with patients.
What we see as trivial and marginal can be very important for the patient for some reason or other that is not immediately clear. When it comes to referrals for instance, it's incredible how manywomen want to see a gynaecologist for no apparent reason. Most are persuaded not to, but some have had an aunt who had ovarian cancer and they tell you that they're worried because of that. One woman told me that she had found a whole new life after she started visiting the gynaecologist once a year. Then it is not marginal after all.
(Female GP, 4 years of experience as a GP)
I have not experienced much conflict when it comes to saying "no", maybe because we manage to rationalise it so that it becomes reasonable to say "yes", i.e. you refer a patient for a CT scan, or something like that, even though it is obvious to you that medically the patient doesn't need it. But they can become quite anxious, and this is one of your regular patients, and you know that one way of getting rid of the problem is to do it even though you know that medically it is absolutely unlikely that they will find anything. And of course there is always a risk that they do find something. I have been asking myself whether I am able to give a categorical "no" to a demanding patient with whom I expect to have a long-term relationship.
(Male GP specialist, 21 years of experience as a GP)
A common explanation for why it is difficult to say no was the need for social approval.
What's quite typical for the way some colleagues work, and maybe sometimes for the way we work too, is that we're interested in getting the patient admitted to the right place, to the right hospitals, to the right specialists, because then we get happy and satisfied patients.
(Male specialist GP, 20 years of experience as a GP)
The participants were also concerned about avoiding conflicts with patients. The physicians described in detail how they manage to avoid conflict by explaining their medical opinion and sharing decisions with patients. The majority claimed that talking with and convincing the patient virtually kept them out of conflict with patients.
Most often, to avoid conflict, I try to get the patient to share my view.
(Male GP, 3 years of experience as a GP)
However, they often give in when the patient is not convinced:
You might call it gatekeeping if you could explain to him [a patient] that he could manage without the CT scan that it ended up with. But it was quite obvious that to him having the scan was a reasonable way of getting rid of the worry. So that is probably the way it works. You could define gatekeeping as pushing it until you see that there is a real need that is reasonable. Then you rarely get into that conflict. But you would get into that conflict if you received a message from the radiology department telling you that the monthly budget was up, but we don't, you know.
(Male specialist GP, 21 years of experience as a GP)
The physicians generally agreed that they find themselves increasingly drawn into a health care market, where patients act as demanding consumers and they as physicians compete to please these consumers.
Some patients put pressure on the physician to write out a sick leave certificate or prescribe when it perhaps isn't necessary. And if you don't do it, you might be pressured and they might leave for another GP.
(Male GP, 2 years of experience as a GP)
For others it was problematic to admit to being influenced by economic incentives. One of the informants initially answered "no" to our question whether the economic and social incentives in the patient list system influenced his discretionary choices, and he continues:
1: It can't be that one suddenly should treat patients differently in consultations. That would be strange, wouldn't it? Because I believe that would mean that we are driven by organisational moves rather than our own medical understanding.
(Male GP, 3 years of experience as a GP)
Later in the interview session, the same informant comments on the same question:
2: I think maybe that GPs are behaving differently [after new incentives were introduced]. Why on earth one would do that is of course a question, but ...
A general impression from the interviews was willingness to departure from adherence to government rules for e.g. reimbursed prescriptions, in order to satisfy the patients:
I suppose we have all prescribed cortisone creams and asthma medication and things like that as standard prescriptions [i.e. covered by the National Insurance Scheme]. Isn't that right? I mean, the combination of regular patients and the demands made by consumers in the health care market, they won't wait or take no for an answer, right? And I am not sure we are good at setting limits to control it.
(Male specialist GP, 21 years of experience as a GP)
One reason given for not adhering to the remuneration guidelines was that it is pointless to ration if patients can get what they want from somebody else. This argument clearly also touches on the element of competition for patients.
A new patient came in who had several things she wanted me to look at. I had just given her three prescriptions and then she adds that she just wanted a prescription she had had before, which I didn't know about as she was a completely new patient. So I wrote out a private prescription [i.e. not covered by the National Insurance Scheme] for her, and then she says, "But I usually get a standard prescription!" Then her time was up, and I thought "I can't stand listening to all the details and discussing them," so I just said "Fine" and wrote her the standard prescription.
(Female specialist GP, 15 years of experience as a GP)
Competing and compatible motivators
A key finding is that the obligation to ration health care is not generally embraced by GPs. Professional norms and respect for patient autonomy on the other hand, are strongly emphasized as integrated and at the very core of their professional judgement. When it comes to the role of economic incentives, the statements are more ambiguous. The idea of economic incentives is sometimes dismissed as an external factor without power to influence GP decision making whatsoever, while some informants state that they are worried that market mechanisms are gradually undermining professional autonomy.
General practitioners in our study find themselves caught in a web of conflicting concerns presented here as the four main topics. Some of these motives are easy to combine and some are often experienced as conflicting. In the paragraphs about rationing and patient autonomy we reported the participants descriptions of how a firm professional autonomy in relation to patients is experienced as a necessary requirement to fulfil the rationing role, because in the current system with universal coverage by a third party payer and free choice of healthcare provider combined with capitation and competition for patients, it is tempting to go along with patients' wishes. At the same time rationing is often presented as in conflict with respect for patient autonomy. On the other hand, as the findings in the paragraph about competition suggest, respect for patient autonomy is easily combined with the situation of competition and the economic incentives of fee-for-service and capitation. So a central line of conflict seems to be how to balance the obligation to ration health care combined with professional autonomy in relation to patients on the one side and the demand for patient autonomy combined with concerns about competition for patients on the other.