"Saying no is no easy matter" A qualitative study of competing concerns in rationing decisions in general practice

Through focus group interviews with Norwegian general practitioners, we explore physicians' attitudes toward factors of influence on medical decision making and how rationing dilemmas are experienced in everyday practice.Four major concerns appeared in the group discussions: The obligation to ration health care, professional autonomy, patient autonomy, and competition. A central finding was that the physicians find rationing difficult because saying no in face to face relations often is felt uncomfortable and in conflict with other important objectives for the general practitioner.It is important to understand the association between using economic incentives in the management of health care, increasing patient autonomy, and the willingness among physicians to contribute to efficient, fair and legitimate resource allocation.The demand for health care services is rising in all Western countries and governments are concerned with controlling costs and ensuring a fair allocation of resources [1,2]. The general practitioner (GP) is increasingly regarded as holding a key role in securing equity and effectiveness [3]. In the wake of government concern, a number of studies of rationing and the role of gatekeepers in health care have appeared [4-6].Rationing can be defined as the allocation of scarce resources between patients with competing needs [7]; it implies the withholding of potentially beneficial health care through deliberate choice or through financial or organisational features of the healthcare system in question [8]. Related to studies of rationing is the concept of opportunity cost, which can be defined as the value of the best alternative which is forgone in order to get or produce more of the commodity under consideration [9]. In health care decision making this signifies that any use of health care resources should be viewed as denying the opportunity for some other patient to use the money for potentially greater benefit [10].The view of physicians as rati