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Recommending no further treatment: Gatekeeping work of generalists at a Japanese university hospital

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  • Kushida, Shuya
  • Kawashima, Michie
  • Abe, Tetsuya

Abstract

In medical decision-making, doctors have to take into consideration whether patients' expectations can be satisfied while appropriately allocating medical resources. This study explores how recommendations for no further treatment, or gate-closing recommendations, are resisted by patients and how doctors react to resistance in outpatient consultations at a university hospital in Japan. We show how the type of patient resistance shapes doctors' reactions. Problem-focused resistance problematizes the doctor's understanding of the patient's problem or the treatment itself without focusing on the gate-closing aspect of a recommendation, and is met with doctors' persuasion through diagnosis-based accounts. Provider-focused resistance focuses on the gate-closing aspect of a recommendation, and leads doctors to manage their dual roles as patient advocate and resource steward. Two subtypes of provider-focused resistance further shape this work differently. Unwillingness-focused resistance is met with persuasion mainly through institution-based accounts. Unavailability-focused resistance is met with a concession. Doctors systematically respond to patients' resistance in order to reach an agreement during decision-making. They take measures to reconcile their dual roles, and orient themselves toward the implicit rationale of gatekeeping, which has a moral nature.

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  • Kushida, Shuya & Kawashima, Michie & Abe, Tetsuya, 2021. "Recommending no further treatment: Gatekeeping work of generalists at a Japanese university hospital," Social Science & Medicine, Elsevier, vol. 290(C).
    • Handle: RePEc:eee:socmed:v:290:y:2021:i:c:s0277953621002239
    DOI: 10.1016/j.socscimed.2021.113891
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    References listed on IDEAS

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    1. Stivers, Tanya & Timmermans, Stefan, 2021. "Arriving at no: Patient pressure to prescribe antibiotics and physicians’ responses," Social Science & Medicine, Elsevier, vol. 290(C).
    2. Toerien, Merran, 2021. "When do patients exercise their right to refuse treatment? A conversation analytic study of decision-making trajectories in UK neurology outpatient consultations," Social Science & Medicine, Elsevier, vol. 290(C).

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