Recommending no further treatment: Gatekeeping work of generalists at a Japanese university hospital
Recommending no further treatment: Gatekeeping work of generalists at a Japanese university hospital
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建议不再接受进一步治疗：日本大学医院全科医生的把关工作
DOI：
10.1016/j.socscimed.2021.113891
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发表时间：
2021
影响因子：
5.4
通讯作者：
Michie Kawashima and Tetsuya Abe
中科院分区：
文献类型：
--
作者：
Shuya Kushida;Michie Kawashima and Tetsuya Abe
在医疗决策中，医生必须考虑在适当分配医疗资源的同时，是否能满足病人的期望。这项研究探讨了患者如何抵制不进一步治疗的建议或关闭大门的建议，以及医生如何应对日本一所大学医院门诊咨询的阻力。我们展示了患者的抵抗类型如何塑造医生的反应。以问题为中心的抵抗问题化了医生对患者问题或治疗本身的理解，而没有关注建议的关闭方面，并通过基于诊断的叙述来满足医生的说服。以提供者为中心的抵抗关注建议的关闭方面，并引导医生管理他们作为患者倡导者和资源管理者的双重角色。两种以提供者为中心的抵抗亚型进一步以不同的方式塑造了这项工作。以不情愿为中心的抵制主要通过基于制度的叙述得到说服。以不可用性为重点的抵制得到了让步。医生系统地回应病人的阻力，以便在决策过程中达成一致。他们采取措施来协调自己的双重角色，并将自己定位于具有道德本质的守门的隐含理由。
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 resistanceproblematizes 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 resistancefocuses 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.