Risk, anxiety and defensive action: general practitioner's referral decisions for women presenting with breast problems

Abstract

Women visiting their general practitioners with breast problems are a common occurrence in the United Kingdom (UK). General practitioners can expect to see around 30 new presentations per 1000 women each year. Although routine, this aspect of their work is characterized by a considerable degree of uncertainty. Differential diagnosis is difficult and the most important problem facing the general practitioner is how to distinguish between symptoms that require immediate referral and those which can be managed in primary care. If they refer women inappropriately, specialist services will be overloaded resulting in delay in treatment for those who may have breast cancer. The paper draws on data from a study of a systematic sample of 85 women newly referred to four main specialist breast clinics and their referring general practitioners. In-depth, semi-structured interviews were conducted with the referring general practitioners. Examination of respondents' discourses revealed that in providing justification for their referral behaviour they invoked a number of arguments that served to present their referral decisions as ‘apparently’ logical and defensible. They achieved this by locating the source of risk with the ‘disease’ (breast cancer) on the one hand and the ‘litigious woman’ on the other. These became the sites of risk rather than the objective nature of individual patient's signs, symptoms and personal characteristics. Two broad defensive stances emerged in their discourses: (1) women were ‘at risk’ from a malevolent disease, the vagaries of clinical judgement and anxiety; (2) doctors were ‘at risk’ with their clinical and professional autonomy threatened by women who, in the context of breast cancer, become litigious. This has important implications for those wishing to modify general practitioners behaviour to reduce inappropriate referrals.

Keywords:

• cancer
• defensive decision making
• risk
• anxiety

Acknowledgements

The author gratefully acknowledges Sara Shaw and Victoria Ajayi, who conducted interviews and preliminary analysis. Dr. Anne Rodway and Professor Michael Calnan for their contribution to obtaining funding. The funding was provided by NHS Executive South Thames. Conflict of interest: none.