Resilient GP: an ethically inappropriate survey report

Resilient GP posted a survey report yesterday about inappropriate patient demand. The ethics and methodology of what they did was questioned, and they reposted a (revised) version of the post today – justified for the purpose of “debate” and “educating patients not to use up appointments” inappropriately. I’m going to look at ethical problems with this survey report here, and look at problems with methology/write-up in a subsequent post. I’ll argue that it’s not ethical to have posted this, and that Resilient GP’s arguments for posting it don’t stand up.

Patient Confidentiality

It’s important for doctors to maintain patient confidentiality, except where there are very good reasons not to (for example, the patient might die if they don’t). However, the original version of the Resilient GP survey report contained some very specific information that could identify patients. Some of this has now been removed – and it wouldn’t be ethical for me to repost this information – but there was no good justification for posting this information in the first place. Resilient GP has not publicly reflected on the removed information – so I don’t even know whether this was done for ethical reasons, let alone if any lessons have been learnt. Some of the survey report (e.g. point 5.22) is still specific enough to identify patients.

Resilient GP argued today that “[c]areful reading of the report” will show that patient confidentiality hasn’t been breached. However, it’s not classy to make this argument after removing (but not noting the removal of) potentially identifying information – readers now are unlikely to know that information has been removed and may therefore reach an overly positive conclusion about how patients have been anonymised.

Doctor-patient relationship

The doctor-patient relationship is important: mellojonny suggests that, for some, “a long-term relationship with a stable adult who knows them is literally life-saving”. One reason for maintaining patient confidentiality is so patients feel confident sharing very personal things with their doctors. Will patients now worry that what they say to their GP will be posted online? For doctors to post quite specific anecdotes about patients in what seems a derogatory way is hardly likely to help build a good relationship.

Consent

Generally, we ask research participants to give informed consent to taking part in research projects. I’d be very surprised if the patients featured in this survey report consented to this (I asked Resilient GP to confirm, but they haven’t). There are some cases where one might proceed without informed consent, but I can’t see how this is justified here.

Resilient GP’s defence of the ethics of their survey report

Resilient GP offers a defence of the ethics of posting this material. However, this is very weak. They argue that

ethics of utilitarianism are equally important here and it is a duty of doctors to challenge inappropriate use of resources

A utilitarian justification of posting this, though, would depend on having a reasonable expectation that it will have positive consequences. Resilient GP have not presented any good evidence that it will. As Betabetic has shown, it’s not at all clear whether (well-resourced, large-scale) campaigns again over-consulting will have the desired effect. It seems rather unlikely that the best way to address inappropriate demand is to post anecdotes about inappropriate demand on a website that seems largely aimed at GPs. There is significant potential for harm, though – for example, in breaching patient confidentiality or damaging the doctor-patient relationship.

Resilient GP also states that the ambulance service has “raise[d] real life examples of inappropriate appointment use” and appears to feel that this shows that it’s not unethical to do so. This is a really lousy argument, though – it might, for example, just be that others have acted in ethically problematic ways or that the GP-patient relationship is different to the ambulance-patient relationship.

Conclusions

Resilient GP should pull this post ASAP, at least till it can be revised to properly address issues related to patient confidentiality. They should also reflect on why a post with this issues was put up in the first place.

More broadly, if Resilient GP feel utilitarian ethics are the best lens to view this through, they should give more serious consideration to the consequences of their survey report: I haven’t seen good reason to expect the positive to outweigh the negative. Also, as I’ll argue in my next post on this, I don’t think the research they’ve posted is all that good – and I’m not sure that starting a ‘debate’ centred around low quality research is especially useful.

Note: I have contacted Resilient GP to suggest that they pull the post ASAP, at least till they can resolve issues with (non)anonymisation. They haven’t yet responded.

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4 responses to “Resilient GP: an ethically inappropriate survey report”

  1. Kojacked says :

    Thanks for posting this excellent blog and for raising concerns about this unpleasant “survey”.

    I have a further concern about self-selection bias and the responses to this “survey”.

    If responses were taken from members of a campaigning group (Resilient GP) who are self-selecting and are clearly oriented towards a patient-blaming stance on the issue they construct as “inappropriate demand”, then how is this representative?

    If the same “survey” were done with 2000+ Balint Group GPs who have a less judgemental stance and a more sophisticated understanding of the psychological, emotional and social determinants of healthcare-seeking behaviour, then the responses would no doubt have been different.

    When reading the list, I could think of lots of reasons behind why a patient might have consulted for the given complaint: poverty, illiteracy, poor physical or mental health, lack of social support, emotional distress, family history, low IQ, embarrassment, loneliness etc. It doesn’t take much imagination to view things from the patients’ point of view. Surely “inappropriateness” is a subjective judgement?

    Also, I think there is a further issue with confidentiality aside from patients identifying themselves in the listed anecdotes.

    Patients can see on social media which GPs are either involved with producing the survey, or those identify as members of the RGP group. And they can also see which HCPs are promoting the “survey” on social media.

    Therefore, even if you don’t identify with any of the anecdotes, you will worry that these particular HCPs hold these patient-blaming and patient-shaming attitudes and regard consultations as fodder for professional-centred campaigns and will be put off consulting with them.

    After reading the list I immediately checked to see if any of my HCPs were part of RGP or were promoting the list as a “good thing” on social media (fortunately not). If they had have been, I would never want to consult with them again due to the judgemental, unethical and ignorant attitudes displayed by RGP and the apparent disregard for patient trust and confidentiality.

    • jackedko says :

      Dear John Mendel, do you often comment on your own blog pieces, like you did here ?

      • jonmendel says :

        @jackedko: not sure what you mean – are you talking about pingbacks? The only posts/comments I’ve written on this blog are posted under my name.

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