"Perceived patient worthiness, rather than purely clinical need, can influence resource access decisions."
A study from New Zealand examined how general practitioners (GPs) and hospital doctors interact with patients who have life-limiting terminal cancer diagnoses. The research identified three distinct roles these doctors play in clinical practice: gatekeeper, broker, and boundary enforcer. The findings indicate that these roles influence patient access to timely care, resource allocation, and health outcomes, with particular implications for equity among Māori patients.
Doctor Roles and Behaviors
The study categorized clinician behaviors into three functional roles:
Gatekeepers
Doctors in this role limit unnecessary tests and aim to conserve medical resources. The research documented instances where this role resulted in delayed referrals.
- A patient with a history of breast cancer and mental health issues presented with breathlessness; the GP prescribed antidepressants instead of investigating further, leading to a delayed diagnosis of lung metastases.
- Another case involved a patient who found a breast lump ten years after breast cancer; the patient was initially told it was a cyst, and only after seeing a female doctor was a referral made, revealing metastatic cancer.
- In a third case, a patient with a terminal brain tumor was sent home, with treatment described as "a waste of time." Subsequent advocacy by a spouse eventually secured treatment.
Brokers
Doctors in this role advocate for patients to access scarce resources.
- A specialist advocated for a patient who had been misdiagnosed earlier, securing entry into a vaccine trial.
- Another case involved a medical professional being among 100 people in New Zealand to receive an unsubsidized medication at no cost.
- A third case involved a patient in their 30s being placed on multiple melanoma trials despite not meeting protocol requirements.
Boundary enforcers
Some practitioners exclude non-Western medical approaches from clinical practice, which affects patients who reject Western treatment due to cultural or spiritual reasons.
Factors Influencing Broker Advocacy
The study identified specific factors that may influence whether a patient receives broker advocacy. Patients were reportedly deemed "broker-worthy" if they had experienced system failures, possessed professional connections, or were younger in age.
Equity Concerns for Māori Patients
The research highlighted that for Māori patients, the gatekeeping role may reinforce existing disparities in cancer diagnosis and outcomes.
Researchers noted that Māori patients may be less likely to possess the advantages that lead to broker advocacy, such as professional connections. The study concluded that informal discretionary brokerage practices risk worsening existing health inequities.
Research Implications
The authors called for further systematic research into how doctors choose which role to adopt in clinical settings, as these decisions affect who receives timely diagnosis and treatment. The study emphasized that perceived patient worthiness, rather than purely clinical need, can influence resource access decisions.