The role of legitimacy
Kelly and May (1982) undertook a review of ‘good and bad’ patients in the nursing literature and in key sociology texts. Their critique highlighted some important points to consider when generating theories from the participant interviews in this study. They began by describing the illnesses, symptoms, behaviours, perceived patient attitudes and judgements of staff; strikingly similar to the themes and categories identified in this paper. They went on to describe the discrepancies and contradictions between the ‘good and bad’ patient studies and conclude that the topic lacked external validity. They surmised this could in part be explained by the range of research tools used; but most importantly because the concepts used were not rigorously defined. The studies explored staff opinions about patients, and made assumptions about the meanings, for example, of ‘aggressive’ or ‘inappropriate’. The studies seemed unquestioningly to locate ‘good and bad’ characteristics in the patients; rather than in the professionals’ opinions about the patients; these opinions are treated as objective facts. Kelly and May concluded that causality and consequence were also assumed, considered in a linear simplistic fashion and the links between these not made explicit [
28]. This is an important reminder for the context of this study; the labels applied should not be viewed in the same structuralist manner in which for example a clinical diagnosis might be applied.
In line with Kelly and May’s review of the ‘good and bad’ patient literature NHS staff believed ‘revolving door’ patients’ difficulties were located within the patient: they had unreasonable expectations and inappropriate behaviour. They viewed these as being beyond the expected norms of patient behaviour within the doctor patient relationship. This echoes Stokes’ qualitative work about patient removals which concluded these happened because patients broke the unwritten rules of the doctor-patient relationship [
18]. A future paper using psychological theories will re-examine the role unwritten rules might have for ‘revolving door’ patients.
Another important aspect of Kelly and May’s review was that they thought carefully about the value based assumption they considered to permeate the literature; that ‘good and bad’ patients are a problem to be fixed and that the explanation for their poor care is the fault of poor professionalism. This played a role in the initial conception of this research study and in our motivation for choosing the topic. Kelly and May argued that the literature failed to consider that professionals may have understandable reasons for so labelling patients; because such patients actually do make their work difficult. They postulated too that, with few exceptions, an intensely individualistic view of the issue was dominant; the social setting was not considered and a rigid structuralist approach to theorising was applied across the literature. Kelly and May sought to revise this and used an interactionist approach building on the background of Parson's work on the sick role. Their central conclusion was to propose that in the ‘good and bad’ patient literature:
‘it is in the process of providing or withholding legitimation that patients come to be defined as good and bad’ [
28].
They expanded on this conclusion in a follow up paper; patients are good patients if they uphold the role of the health professional; they are bad if they negate it [
27].
The concept of ‘dirty work designations’ extends the concept of legitimacy. First described by Everett Hughes in a series of studies from the 1950's and 1960s it has been used to examine work roles in a number of occupations and settings including in health [
23]. Emerson and Pollner in their study of a community mental health team in the USA; described ‘dirty work designations’ as seeming to have significance at several levels:
‘On one level the designation of a task as dirty work may be understood as a more or less faithful portrayal of its odious and onerous qualities…on an analytical level dirty work designations implicate the perspective of the worker as much as they do the quality of the work…one occupation's dirty work can be another's sought and fought for prerogative… while dirty work designations are the product of a particular perspective they are the means through which the perspective is enacted and perpetuated…dirty work reaffirms the legitimacy of the occupational moral order that has been blemished’ [
29].
This emphasised that dirty work, like the interactionist interpretation of ‘good and bad’ patients, embodies a mismatch between what the doctor sees as his/her legitimate work and the problem the patient presents [
29].
In his study of ‘dirty work’, GPs and alcohol dependent patients, Strong added a further dimension to legitimacy by viewing ‘dirty work’ as a function of the patient's ability to negate the professional's self-perceived core roles:
‘This fundamental disjunction with the role-relationship seems a more plausible account of why alcoholics should be dirty work than that of traditional morality or faulty education.’ [
30]
The core work of general practice
As the context for this study was general practice, we will consider the core role of general practice, and thus the boundaries of its legitimate work. There is consensus from the literature that core work is in two areas. The first is the technical biomedical aspect of care that GPs and practices deliver. This includes the range of problems relating to health and health care that GPs view they have a role in solving or signposting to others to do so. The second is the centrality of the relationship GPs have with their patients, the practitioner patient relationship being a focus of care [
1,
31‐
33].
Medical and moral schemas
Understanding how the technical biomedical aspect of care might relate to theory generation about ‘revolving door’ patients in general practice is helped further by Strong’s study. He drew on the work of Chalfant and Kurtz who studied social workers and their alcohol dependent clients in the 1960s. He postulated that, as for social workers, doctors’ schemas about how they conceptualise their work are important when deciding what is and is not ‘dirty work’.
‘we are currently in the middle of a long term shift from a moral to a medical theory of alcoholism and that social workers- and possibly other professionals too- apply elements from both schemas. Thus, although they are morally hostile in some ways to alcoholics, they are not entirely so and in the long run these irrational elements will fade’ [
30].
We reviewed Strong’s use of schemas. In cognitive psychology schemas are ‘organised packets of information about the world, events or people that are stored in long term memory’ that have been studied in relation to narrative memory and recall. Schema theory has been criticised in that field, because the knowledge contained in schemas is difficult to describe, and it is not clear when a particular schema might be activated [
34]. In clinical psychology, schemas are a ‘central component’ of cognitive theories of personality development, and are defined as a ‘consistent internal structure, used as a template to organise new information.’ They are viewed as the “generals’ of the information processing system and govern all other systems’ [
35]. Schema theory has also been used to develop a conceptual framework for a social theory of intercultural communication and we found this framework for schema theory helped us explore Strong’s concept of medical and moral schemas. ‘Cultural schemas’ relate to packets of information about individual’s experiences within social groups or cultures. They are
‘generalised collections of the knowledge that we store in memory through experiences in our own culture. Cultural schemas contain general information about familiar situations and behavioural rules as well as information about ourselves and people around us. Cultural schemas also contain knowledge about facts we have been taught in school or strategies for problem solving and emotional or affective experiences that are often found in our culture. These cultural schemas are linked together into related systems constructing a complex cognitive structure that underlies our behaviour’ [
36].
We interpreted Strong’s concept of a medical schema to incorporate the knowledge and experiences that health professionals use to inform their understanding of attitudes, behaviours and illnesses. This is influenced by what is learned in medical training, in professional development over a career including clinical practice context, the influence of colleagues’ practice and patients encountered. This changes over time too as medical philosophy and medical knowledge changes. There are also medical schemas of understanding influenced by medical knowledge that have everyday significance in general society and that lay people hold. We interpreted the concept of moral schemas to mean the understanding of attitudes, behaviours and illnesses based on the dominant philosophies and social values of society that also change over time. Doctors are also members of society so are influenced by moral schemas as well as the medical ones they hold, so reciprocal for both lay and medical members of society. These medical and moral schemas of understanding about attitudes, behaviours, and illnesses are locked into the ways that GP’s, other professionals in general practice and practitioner services staff understand the technical biomedical sphere-the health problems or behaviours that patients bring to them. Crucially this further shapes their expectations of the interactions they have with patients within the doctor patient relationship or the GP practice. If professionals can locate the explanation for an attitude, behaviour or health presentation within a medical schema of understanding, they will tolerate patients who do not obey the unwritten rules of the doctor patient relationship. If however these are understood within a moral schema then they are more likely to be understood as being about the patient himself or herself, as a problem located within the patient, not about their illness.
‘someone with major psychotic illness; mental health have got a lot of support services for that, intervention stuff but behaviour acceptable, paradoxically they may have little insight but you see that’s their, you can identify this person as mentally ill; and so you treat it accordingly. Someone with personality disorder with very complex diagnoses that often take ages; you are thinking ‘you are just at it; you are just out to deliberately frustrate our efforts' as it were. And I think, someone who has got a psychotic illness will be frustrating their efforts perhaps but done through their illness. There's a perception of personality disorder, frustrating all your efforts and so on, they possibly out of badness sometimes crosses- and you will get frustrated with them.’ GP5.
There was evidence from the GP participants’ accounts that they consider psychiatric illness in general practice with a medical schema of understanding that is distinct from what might reflect a lay medical schema described by the Practitioner Services participants. The GP participants described one group as patients who have serious mental health problems, represented (using the commonly used clinical phrase) as having ‘severe and enduring mental illness’ and the other group of patients as having a ‘personality disorder’. However although all the GPs described patients with personality disorder as being mentally ill but there was evidence of a moral schema of understanding too, expressed in the quote above about ideas about how much responsibility patients were able to take for their own actions. This mirrored the way in which patients with a personality disorder diagnosis were reported as often treated by psychiatry services.
It is apparent from these data that there is a medical schema of understanding for patients with a diagnosis of severe and enduring psychiatric illness such as psychosis. This is likely to be due to the prevailing diagnostic frameworks and the availability of widely accepted treatments. The conceptual framework for understanding personality disorder however remains contested and the evidence base for effective treatments has still not been absorbed into mainstream psychiatric practice [
37]. The medical professionals in this study also reflected this by applying the medical diagnosis of ‘personality disorder’ but using a moral schema to conceptualise the behaviour of patients to whom they apply this diagnosis.
Alcohol dependency and drug misuse demonstrate the central importance that medical and moral schemas of understanding have when considering these theories about ‘revolving door’ patients. The alcohol accounts support Strong’s hypothesis that alcohol dependency has undergone a shift from a moral to a medical schema of understanding in society. The professionals in this study considered and discarded alcohol dependence as an explanation for patients being ‘revolving door’ patients. So [
22] being alcohol dependent is no longer seen by doctors as a moral problem-’dirty work’ so a problem that means a patient can be struck off their list- but as a health problem within their biomedical technical role. So being alcohol dependent is not used as the explanation for why patients becoming “revolving door”, although the quantitative data tells us a proportion were. They use other aspects of patients’ presenting problems to label them ‘difficult’ within a moral schema, and for them to be categorised as ‘revolving door’ patients. Patients can have multiple identified health problems, but it is the ones that are identified as being within a moral schema and a dominant issue that leads patients to ‘revolve’.
It is evident from this study that problem drug use has undergone a similar shift in status as the professional participants described the transformation in drug use treatments and services:
‘..it really kicked off about 92, 93, a lot of people started appearing, we had no training in it, we didn’t know what to do. GPs didn’t know what to do, there was no hospital base, there was an alcohol service but there wasn’t a drug service and more people were appearing and we didn’t know what to do with them. Over time, some of these patients became so insistent and abusive and demanding of practices that eventually they would, we would try our best with them but they would cross a line. They would go to another practice, they would repeat the same behaviour, they would cross a line and eventually, they’ve gone round all the practices in the area and their behaviour would still continue.…when we got a drugs service which was effective and people were getting into treatment, and they were being stabilised, then a lot of these patients problems disappeared’ GP4.
Many participants did locate drug misusing ‘revolving door’ patients’ difficulties as being about the service not previously responding to their needs and having changed, so now within a medical schema, not located as an inherent characteristic of the patient. There was however evidence of a moral schemas of understanding too from some participants:
‘…more people are deciding that perhaps it is manageable within primary care so that was the first step; methadone. We started finding methadone; because there was a lot of people dying. I thought well I know they are obnoxious and a pain; but they are someone’s mother someone’s daughter. And there's no doubt that methadone is sedating, there's no 2 ways about it, it does sedate you, you can argue whether it’s a good thing or a bad thing; it makes life infinitely, infinitely, more manageable’ GP5.
One possible explanation for this difference between participants is that some may have a medical schema for understanding problem drug use but some may have elements of a moral schema. Could problem drug use be going through a similar transition to that reported by Strong over 30 years ago with alcohol dependency? Similarly what status does personality disorder have in relation to transition?
All the participants were clear that ‘revolving door’ patients made their professional life difficult in the range of ways described above. This resonates with Kelly and May’s review (1982) of the ‘good and bad’ patient literature and helps to place the topic in its social context. However our stance is that ‘revolving door’ patients’ attitudes, behaviours and health presentations can be framed within a GP’s medical schema of understanding. So it is our view that these negative attributes are operating within the doctor-patient relationship, rather than as inherent to ‘revolving door’ patients themselves. We have presented evidence of how a change in professional perceptions of alcohol and problem drug use changed patients’ behaviour.
We were struck by the relevance our theoretical perspectives may have for the wider problem doctor patient literature that we reviewed. Each provided evidence of patients threatening the legitimacy of the core work of general practice by having elements of a moral schema of understanding for interpreting their behaviour or health presentations. For example ‘heartsink’ patients, some groups of patients who were ‘frequent attenders’, patients with ‘medically unexplained symptoms’ threatened the legitimacy of the doctor’s technical bio-medical care by presenting with problems that GPs could not fit within a medical schema so their care was ‘dirty work’. The patients categorised in the psychodynamic literature we reviewed, for examples in Groves (1978) paper on the ‘hateful patient’, and features of the presentations of patients in the other literature areas were understood within a moral schema because moral censure was applied to their behaviour. This perspective provides a unifying theory with which to understand a diverse body of literature and may provide future helpful insights into conceptualising the issue of problem doctor-patient relationships.