title: Breaking up is never easy: GPs' accounts of removing patients from their lists.
abstract: OBJECTIVE
  The aim of this study was to understand why GPs choose to end their relationship with patients by removing them from their lists.
  
  
  METHODS
  Semi-structured interviews were carried out with 25 GPs from 22 general practices in Leicestershire. Qualitative analysis was performed using the constant comparative method. The main outcome measures were participants' accounts of removing patients from their lists.
  
  
  RESULTS
  GPs use removal as a means of ending their professional relationships with problematic patients. All of the doctors indicated that they wished to retain the right to remove patients and stressed that removal is a rare event which they only use as a "last resort". There are two distinct but overlapping types of patients who are most likely to become eligible for removal: "bad" patients, who break the rules of the doctor-patient or practice-patient relationship, and "difficult" patients, with whom the doctor-patient relationship is so strained that doctors feel they can no longer care for them. The doctors may choose to remove a patient without warning or else to write a short letter giving "relationship breakdown" as the reason. They find it hard to confront the patient openly about the difficulties in the relationship.
  
  
  CONCLUSIONS
  The ability to remove patients is a right that GPs value. They report that it is rare for them to seek to end their relationships with patients and, when they do, it is for reasons that are important in the maintenance of professional boundaries or fulfilling professional responsibilities.
authors.affiliation: Department of General Practice and Primary Health Care, University of Leicester, Leicester General Hospital, Leicester LE5 4PW, UK. tns2@le.ac.uk
authors.forename: Tim
authors.initials: T
authors.lastname: Stokes
authors.forename: Mary
authors.initials: M
authors.lastname: Dixon-Woods
authors.forename: Robert K
authors.initials: RK
authors.lastname: McKinley
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D005194:Family Practice; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010817:Physician-Patient Relations; D016079:Refusal to Treat; D006113:United Kingdom