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How will Australian general practitioners respond to an influenza pandemic? A qualitative study of ethical values

Olga Anikeeva, Annette J Braunack-Mayer and Jackie M Street
Med J Aust 2008; 189 (3): 148-150.
Published online: 4 August 2008

Abstract

Objectives: To explore general practitioners’ perceptions of their preparedness for an influenza pandemic, the changes they would make to their practice, and the ethical justifications for their planned actions.

Design and setting: A qualitative study was performed among South Australian GPs between March and October 2007. A semi-structured interview was carried out with each participant in his or her practice, and the interviews were audio-recorded, transcribed and analysed thematically.

Participants: 10 GPs were recruited: five from a metropolitan Division and five from a rural Division of General Practice.

Results: Some participants felt they would not be able to cope with an influenza pandemic, while others felt it would simply mean an increase in their workloads. Most respondents considered creating separate waiting rooms, moving the reception desk outside of the practice and delaying all non-urgent consultations in order to deal with a pandemic more effectively. Respondents mentioned the conflict between their various roles and responsibilities as a primary source of tension when thinking about the way they would organise their work in the event of a pandemic. A number of GPs said they would not practise in the event of a pandemic, as they felt their responsibility to their families outweighed that to their patients.

Conclusions: Professional codes of ethics should include guidance about the scope of the duty to treat during infectious disease outbreaks. The community has to uphold the value of reciprocity, and ensure that GPs and their families are provided with support during a pandemic and are given the opportunity to be actively involved in pandemic preparedness planning.

General practitioners have a key role in surveillance and early detection of emerging diseases.1 For this reason, if Australia is affected by pandemic influenza, GPs will be at the frontline of the response.2

Australian state and national pandemic influenza management plans provide broad details about how pandemic influenza will be managed within primary care, and the tasks that GPs will be expected to carry out.3-6 There is an expectation that GPs will have a role in surveillance and early detection of cases and in treating influenza patients in their practices or specialised flu clinics.7 It is likely that the expectation that GPs will continue to work during an influenza pandemic is shared by the wider Australian community.

However, it is unclear how GPs feel about working during an influenza pandemic, and whether their planned actions are consistent with what is expected of them. A study among Tasmanian GPs found that, although they expressed a willingness to practise during a pandemic, they were relatively unprepared and felt that government had a duty of care to stockpile protective resources on behalf of the general practice workforce.8

The purpose of this study was to explore the perceptions of GPs in South Australia of their preparedness for a pandemic, the changes they would consider making to their practice, and the ethical justifications for their planned actions. In particular, we focused on the impact that GPs’ understanding of their core obligations and responsibilities has on their decision making. The professional and private roles of GPs create a variety of obligations, responsibilities and interests.9 Given the potential for conflict between these areas, it is important that GPs’ core values be considered, as these will affect how they organise their work during a pandemic.

Methods

Participants were recruited through the medical directors of two South Australian Divisions of General Practice, who provided details of GPs willing to be contacted by mail about the study. Owing to the nature of the sampling methodology and sample size, the study findings provide only an indication of the issues that confront GPs. Ten GPs were invited and agreed to participate in a semi-structured interview between March and October 2007.

Before interview, each participant was asked to read a one-page scenario, based on the scenario used by Shaw et al,8 which outlined how a pandemic might unfold in SA and how general practices might be affected. An interview schedule consisting of 18 open-ended questions was developed (Box 1). All interviews were audio-recorded and transcribed, and the transcripts were thematically analysed. In open-coding the transcripts, we used the respondent’s own words to create labels for emerging themes. Similar codes were grouped, and a number of key themes such as “responsibility to patients” emerged. The final stage of data analysis involved finding connections between codes and explanations for these connections.

The University of Adelaide’s Human Research Ethics Committee approved the study.

Results

Characteristics of the 10 participating GPs are shown in Box 2. Their responses to questions about the practice changes they would make in an influenza pandemic were similar; their responses to questions about core values and the rationale for planned actions were much more varied.

Preparedness for a pandemic

Respondents differed in how they predicted pandemic would affect their work. Some felt that no major changes in their practice would be required, while others believed it would be difficult to manage the impact on their practice.

It’s going to have to be business as usual plus extra work. (Practitioner 3)

Horror. Horror in how we would cope with it . . . I just hope it doesn’t happen. (P2)

All but one respondent felt that they were not adequately prepared.

I of course feel under-prepared, not really knowledgeable about what’s going to be available in terms of personal protective equipment and how effective that’s likely to be. (P4)

Changes to the operation of general practices

When asked to consider organisational changes they might make, most respondents mentioned creating separate waiting rooms for influenza and non-influenza patients, moving the reception desk outside of the practice, designating different doctors to perform various tasks, and delaying non-urgent consultations.

Well, there’s people being advised to stay at home, so I would say that we would probably cancel all non-essential appointments, so that well people would not come in for things like Pap smears and get exposed and be at risk. And that would also open up a lot of appointments for people who are sick, so that they can be seen. (P10)

It may be worthwhile designating one doctor not to see flu patients who would actually do the nursing home visits, just in case some of us become asymptomatic carriers. (P3)

Nearly all respondents emphasised the importance of minimising physical contact with influenza patients, as they felt that this was the most effective way of reducing disease transmission.

Personal protective equipment

All respondents recognised the importance of using personal protective equipment such as masks, gowns and gloves to protect their own health and minimise the spread of infection. They also felt that such equipment should be provided to other practice staff.

I think reception staff would need to have access to masks and gowns because, for example, if someone were to collapse or faint in the waiting room, our staff would attend to them. (P8)

When asked what they would consider doing if such equipment were not available for other staff members, all respondents stated that they would either make alternative arrangements for staff so they did not come into contact with potential influenza patients, or that they would work without other staff members during the pandemic.

All respondents believed that government has a reciprocal duty to ensure that working conditions are as safe as possible during an influenza pandemic by providing essential protective resources.

I’d expect if I was to be dealing with people during the flu pandemic I would expect and hope to get the appropriate equipment to protect myself and my staff. (P5)

Antiviral medication

When discussing antiviral drug use, most GPs appeared more concerned about their families having access to the medication than they were about themselves. One respondent stated that she would be unwilling to see influenza patients unless her children were given antiviral medication:

. . . if my children were protected with antiviral medication, then I can fulfil my responsibility to my patients and treat them. (P7)

. . . almost certainly the people involved in clinical care would be receiving antivirals, that’s the plan. And that would include access to that for families. (P1)

Another respondent believed that antiviral drugs would be ineffective in reducing the risk of contracting pandemic influenza, and stated that he would continue to practise if antiviral medication were not available:

The last research that I read suggested that it wasn’t actually that much help anyway. Maybe the research was wrong, but I wouldn’t be terribly fussed about the antiviral medication. (P3)

GPs’ justification of planned actions

The participants indicated that they would find it difficult to balance their various roles and responsibilities, particularly in an emergency. The relative importance that GPs attached to these roles and responsibilities had a major impact on what they planned to do in the event of an influenza pandemic.

Some respondents said that the reason they would see influenza patients during a pandemic was their general sense of commitment to the public good. They saw this as a basic core value for medical practitioners.

Just [a] sense of good, public good or something like that, I suppose. I mean the reason that you’re a doctor is to do with that. (P1)

Another respondent referred specifically to his fundamental moral obligation to provide assistance to patients:

As medical practitioners and health practitioners, we have the skills to deal with this situation and we are morally obliged to do so. In other words, I think we do have a duty of care to society. (P2)

However, three GPs gave quite different responses: they were hesitant to see influenza patients during a pandemic because they felt that their responsibility to themselves to stay healthy and to protect their families outweighed their responsibility to continue working:

I would try to see what I can do to work; it’s just that I don’t want to sacrifice my life. (P4)

I think that anybody that works in general practice has some sort of responsibility to their patients, but I would still say that my primary responsibility is towards my family. (P7)

Discussion

The GPs in this study identified the conflict between their core values and their responsibilities as the primary source of tension when thinking about how they would practise in the event of a pandemic. Although all respondents agreed that as GPs they have a responsibility to their patients, for most this stemmed primarily from personal core values. It is notable that only one respondent described this responsibility as a professional duty.

Huber and Wynia proposed that, for medical practitioners to accept their duty to treat patients in the event of an epidemic, three aspects of medical care are necessary.10 Firstly, medical practitioners need to recognise and be aware of the risk of infection, as a discussion about a duty to accept personal risk is meaningless in the absence of a perception of risk. Secondly, a coherent professional identity is necessary to separate professional duties from personal choices and promote profession-wide acceptance of the duty to treat patients. Finally, there needs to be a public expectation for medical practitioners to practise according to a social contract for which they are rewarded by society.10 If we examine the responses of the participants in this light, we can identify possible reasons why our respondents did not identify their responsibility to their patients as a “professional duty”. The fact that most spoke about their responsibility to continue working as primarily stemming from personal values suggests that currently there is no clear separation of professional duties from personal choices when it comes to the duty to treat patients in emergencies.

Modern codes of medical ethics are largely silent about the expected roles of GPs in infectious disease outbreaks. With the introduction of vaccines and antibiotics, infectious disease outbreaks declined dramatically and were no longer viewed as an important issue in health care.10 Instead, greater emphasis has been placed on professional autonomy and the right of health care professionals to choose whom to treat.10

The lack of profession-wide acceptance of a duty to treat during infectious disease outbreaks has negative implications for health care workers. GPs who worked during the epidemic of severe acute respiratory syndrome (SARS) in Hong Kong experienced significant anxiety, primarily due to the lack of professional guidance from government.11 As a consequence, some GPs used personal protective equipment incorrectly and made prescription errors, which contributed to the spread of infection.11 To avoid such errors, the value of transparency needs to be upheld by the community: GPs must be provided with regular updates about the progress of the pandemic and the changes they need to make to the way they organise their work. Furthermore, it is essential that professional codes of ethics include statements about health care workers’ duty to treat during infectious disease outbreaks, and that GPs be made aware of their professional obligations. Such statements are likely to be accepted only if GPs are actively involved in their development.

In addition to being GPs, these individuals are also family members and community members. Therefore, they have responsibilities beyond their patients and staff, to their families and themselves. Such conflicts of obligation are inherently unavoidable.12 An encouraging finding in this study was that GPs felt that their obligations would be easier to manage if they were provided with personal protective equipment, antiviral medication and other resources that would protect their health and their families’ health. However, the results also suggest that GPs do not have sufficient information about protective measures: participants were unsure about the effectiveness and appropriate use of antiviral medication and wanted clarification about stockpiling personal protective equipment. These issues need to be resolved to ensure availability and appropriate use of resources in general practice in a pandemic.

To make it easier for GPs to resolve conflicts of obligation, the community has to uphold the value of reciprocity, and ensure that GPs and their families are provided with support during a pandemic. Efforts also need to be made to involve GPs in decision making about pandemic influenza planning. GPs should be strongly encouraged through incentives to develop preparedness plans for their practices and ensure that staff are familiar with these plans. One option is to include pandemic planning as part of an education module for GPs through the continuing education scheme of the Royal Australian College of General Practitioners.

1 Issues covered in the interview

  • Measures general practitioners would put in place during a pandemic

  • Factors that influence GPs’ planned actions

  • Support that GPs expect to receive during a pandemic

  • Impact of GPs’ core values on their planned actions

  • Any other concerns or comments related to pandemic influenza

2 Characteristics of the general practitioners interviewed

Characteristic

Number


Female

4

Male

6

Age (years)

30–39 

2

40–49 

2

50–59 

5

60 +

1

Practice location

Metropolitan

5

Rural

5

Practice owner

Yes

6

No

4

Received 22 February 2008, accepted 23 May 2008

  • Olga Anikeeva1
  • Annette J Braunack-Mayer2
  • Jackie M Street3

  • Discipline of Public Health, University of Adelaide, Adelaide, SA.


Acknowledgements: 

We thank Kelly Shaw for allowing us to use the format of the interview scenario and schedule, the 10 GPs who participated, the two Divisions of General Practice that supported the study and helped recruit participants, and the FluViews research team.

Competing interests:

None identified.

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  • 9. Rogers W, Braunack-Mayer A. Practical ethics for general practice. Oxford: Oxford University Press, 2004.
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