How general practitioners decide on maxims of action in response to demands from conflicting sets of norms: a grounded theory study

Abstract

Background The work of general practitioners (GPs) is infused by norms from several movements, of which evidence based medicine, patient-centredness, and virtue ethics are some of the most influential. Their precepts are not clearly reconcilable, and structural factors may limit their application. In this paper, we develop a conceptual framework that explains how GPs respond, across different fields of interaction in their daily work, to the pressure exerted by divergent norms. Methods Data was generated from unstructured interviews with and observations of sixteen Swedish GPs (who have by definition more than five years of experience after license to practice) and family medicine residents (with less than five years of experience) between 2015 and 2017. Straussian Grounded Theory was used for analysis. Results We found that GPs’ maxims of action can be characterised in terms of dichotomous responses to demands from four distinct sets of norms, or “voices”: the situation, the self, the system, and the profession. From the interactions between these voices emerge sixteen clusters of maxims of action. Based on the common features of the maxims in each cluster, we have developed a conceptual framework that appears to be rich enough to capture the meaning of the ethical decisions that GPs make in their daily work, yet has a high enough level of abstraction to be helpful when discussing the factors that influence those decisions. Conclusions Our four-dimensional model of GPs’ responses to norms is a first step toward a middle-range theory of quality from GPs’ perspective. It brings out the complexity of their practice, reveals tensions that easily remain invisible in more concrete accounts of their actions, and aids the transferability of substantive theories on GPs’ ethical decision making. By explaining the nature of the ethical conflicts that they experience, we provide some clues as to why efforts to improve quality by imposing additional norms on GPs may meet with varying degrees of success.

Multidimensional Property Supplementation: A Method for Discovering and Describing Emergent Qualities of Concepts in Grounded Theory Research

“…As an example, although it was obvious at an early stage that the voice of the self tended to drive GPs toward self-protection, an effect that was expected to be more pronounced the greater the perceived threat to the self (Johnsson & Nordgren, 2019), the precise nature of this relationship eluded me until I had elaborated the concept. An early insight was that GPs tended to act in their own interests when they perceived their labor to be useless rather than effective .…”

“…(On a side note, these terms are not contradictory; while a hier archy can be made deep to avoid it becoming wide and vice versa, it is perfectly possible to end up with a hierar chy which is both deep and wide.) To illustrate what they entail, I introduce here a concept from an emerging theory (Johnsson & Nordgren, 2019) on the ethical decision making of general practitioners (GPs).…”

The voice of the self: a typology of general practitioners’ emotional responses to situational and contextual stressors

“…Lastly, we coded selectively by organising the categories around a core category—the GP’s choice of maxim of action [ 24 ]—that had intimate ties to all other categories. The core category of our theory describes the divergent norms that exert pressure on the GP and how acting on some of those may require others to be sacrificed.…”

“…What appears to be lacking is a comprehensive account of the emotional reactions that shape GPs’ experiences and affect their choices. In the present article we shall attempt to address this lack by developing the concept of the voice of the self , which is part of our emerging theory of quality from the perspective of GPs [ 24 ], into a typology that encompasses and distinguishes between various types of strain. If this is feasible, we might be able to better understand how aspects of individual encounters and features of the work environment interact to affect the work of GPs.…”

They are my worries, so it’s me the doctor should listen to—adolescent males’ experiences of consultations with general practitioners

“…Yet, adolescents describe in some, but not all, studies experiences of meeting unengaged and dismissive GPs who made them feel disbelieved and not listened to [ 7 , 8 , 10 , 18 ]. Such findings clash both with their right to be listened to [ 19 , 20 ] and with the emphasis that GPs themselves place on the importance of responding to the patients’ needs [ 21 ], indicating that GPs sometimes fail in their intended efforts.…”