Ending the doctor-patient relationship : an investigation of the removal of patients from general practitioners' lists

The removal of a patient from a general practitioner's (GP's) list offers unique insight into 'what happens' when a doctor decides to end his/her relationship with a patient.;The study aim was to obtain a detailed description of the process of removal as perceived by both practitioner and patient and to place removal in a wider framework of theory in relation to the 'difficult' doctor-patient relationship.;Semi-structured interviews were undertaken with twenty-five Leicestershire GPs and twenty-eight patients who had been recently removed from a GP's list. Analysis was conducted using the constant comparative method.;GPs account for why they remove patients using the narratives of removal as 'divorce', 'breaking the rules', and removal as 'sanction'. These narratives constitute a form of strategic interaction in which the GP presents him/herself as acting as any 'good' GP would when the boundary rule of 'affective neutrality' between GP and patient has been breached or when faced with a 'bad' patient who 'breaks the rules' of conduct of the doctor-patient encounter. The patients account for their removal using the narratives of the 'good' patient, 'bad' GPs and 'good' GPs and removal as a threatening event. The narrative of removal as a threatening event demonstrates that removal causes a high level of emotional distress and threatens a person's identity as a 'patient'. The patients use the narratives of the 'good' patient and the 'bad' GP and 'good' GP in a strategic manner to accomplish valid patienthood. The patients assert their identity as a 'patient' by showing that they have behaved according to the lay rules of conduct of the patient-doctor relationship even though the removing GP 'breaks the rules'.;These findings are used to develop a model of ending the doctor-patient relationship in general practice and to make policy recommendations on removal.