The (non) use of prioritisation protocols by surgeons

Abstract

Priority setting and rationing is a dominant feature of contemporary health policy. In New Zealand, clinical priority assessment criteria (CPAC) tools have been developed to make access to elective surgery more equitable and efficient.Research was undertaken to identify how surgeons used these tools in the consultation. Forty-seven consultations with 15 different surgeons have to date been video-and audio-recorded. There were no instances where CPAC tools were explicitly used in the consultation. Drawing on the methodology of conversation analysis and the concept of news delivery as developed by Maynard, this paper argues that the delivery of diagnoses and treatment plans can usefully be seen in part as the delivery of bad or good news. Using three case studies to illustrate the argument, it is suggested that the interactional work required in the delivery of such news challenges the ability of clinicians to use protocols such as CPAC. The analysis sheds light on important consultation processes that need to be more carefully considered when designing interventions to influence clinician behaviour. In order to influence the behaviour of clinicians to achieve policy goals, greater attention needs to be paid to the interactional demands of the consultation process.

Integrating health and social care: Interprofessional relations of multidisciplinary teams in Italy

“…Greatbatch et al (2005) reported that British nurses operating a telephone triage service (NHS Direct) departed from protocols and tailored them to their own professional expertise. Dew et al (2010), in their study of surgeons in New Zealand, observed similar behaviours with regard to protocols designed to regulate clinical priority assessment criteria.…”

The Impact of Brief Alcohol Interventions in Primary Healthcare: A Systematic Review of Reviews

“…(2012) acknowledge, the issue of treatment fidelity presents an additional obstacle to our understanding of brief alcohol intervention effectiveness. For a variety of reasons, busy physicians dealing with alcohol in routine practice settings may deviate from guidelines and protocols of care (Moriarty et al , 2012), as happens in other areas of clinical practice (Dew et al , 2010). Thus, even when practitioners can be persuaded to engage in brief alcohol intervention, it is not possible to establish conclusively the causal chain between interventions as designed, and their subsequent outcomes (an issue that further complicates questions around which intervention components have most impact on alcohol-related outcomes (McCambridge, 2013)).…”

Challenges to alcohol and other drug discussions in the general practice consultation

“…However, this finding is not unique to GPs or to AOD discussion. Non-use of guidelines and protocols is seen elsewhere in clinical practice21 and there may well be good reasons for seemingly ‘bad practice’ 34,39. Possible reasons for this should be explored to inform future strategies to enhance AOD conversations within general practice settings.…”

“…The recorded consultations used for this project are a subset of a larger dataset that was collected for two prior projects using interactional data: a study of clinical decision making in general practice and surgical consultations11 , 19 and a longitudinal study where a cohort of patients were tracked and recorded throughout an episode of care 21. In both cases, participants were informed they were being recorded for the general purpose of studying health communication.…”