'My patients are "gunning for a fight" that I don't want': reflecting on feeling dismissed and conflict- expectant consultations.

Patients describe feeling dismissed, ignored, and ‘fobbed off’ by healthcare professionals. They are understandably angry about it, and we — as clinicians and researchers — need to better understand this. The theme of dismissal has been shared by patients across many healthcare fields including endometriosis, menopause, urogynaecological conditions, and infant cow’s milk allergy. We use exemplars from our research to illustrate this phenomenon, but suggest from our clinical experience that this likely resonates across many other symptoms and conditions. To respond to the perceived likelihood of ‘dismissal’, patients are advised to ‘advocate’ for themselves or their family members: to do their ‘own research’ and to go to their appointment ‘armed’ with the knowledge, tools, and determination to get the management they believe they need.1 Patients are encouraged to ‘work the system’ and share ‘hacks’ on how to get the outcome they are looking for.1 The language of conflict — of having to ‘fight’ and ‘battle’ for sufficient care — is rife in patient narratives of women’s health, and in some areas of infant health. The latter is an area that is traditionally gendered, incorporating notions of ‘good’ maternal/parental responsibility.1 Conflict-expectancy is arguably an attempt to reject and redress silences and power imbalances perpetuated through the sociocultural history of patriarchy and misogyny, including in medicine.2 Patient voices matter and we need to hear them; the movement towards highlighting inequalities in care and encouraging patient advocacy is vital. However, we suggest that a possible unintended consequence of this movement may be that it risks generating or driving what we conceptualise as conflict-expectant encounters between patients and healthcare professionals, whereby patients arrive at consultations ‘gunning for a fight’. We are concerned that these conflict-expectant encounters potentially create challenges during the consultation, undermining the potential for supportive, collaborative care and shared decision making. In this article, we look to some of the sources of conflict- expectancy that patients may bring to their consultations and highlight the need to carefully consider the potential unintended consequences of these. The current NHS landscape The reality of system constraints within a publicly funded NHS are undeniable and well documented, with language and media depicting a national NHS crisis3 and an NHS under pressure.4 Women’s health experiences, including waiting lists for treatment, are a powerful and well-documented exemplar of this.5,6 NHS services under strain can contribute to patients feeling that they must manage their own care or risk ‘falling between the cracks’. Patients with urogynaecological symptoms and conditions, such as pelvic organ prolapse and urinary incontinence, described feeling ‘lost’ in the healthcare system and ‘passed from pillar to post’, with some citing this as a reason to disengage from help seeking or, if able to afford to do so, to turn to private care.7 While transparency and honesty about these challenges is key to bringing about improvement in services, increased awareness of these problems may also contribute to patient expectations of rationed care, mistakes, and poor care provision. We have concerns that this may inadvertently deter help seeking or drive pre-emptive disengagement from healthcare services for those in need of support. Portrayals in the media Reciprocally feeding into this perception and contributing to conflict-expectant interactions is the image of the NHS in the media. The media portrayals of the NHS as a service ‘failing’ feeds into a perception that the NHS is inadequate,8 which can diminish trust that services will meet people’s needs, and adds to conflict-expectancy. We observe that polarising, controversial, and shocking stories are more likely to be reported in the media at the expense of more balanced representation, including good experiences of care. Additionally, pervasive narratives of GP ignorance and a knowledge deficit have frequently been proposed as explanations for poor care. For example, media and academic portrayals have repeatedly framed healthcare professionals as ill equipped to recognise endometriosis, although our qualitative study with GPs described how they are often balancing multiple diagnostic and management pathways or investigations, of which endometriosis is one they consider.9 Patients may engage with condition- or health topic-related content before their consultation, utilising sources such as print, television, and social media. While this is a welcome driver to spread awareness and empower patients, it can create an attendant risk of priming a conflict-expectant consultation. Additionally, these sources of information can be sponsored by commercial industries or hold other conflicts of interest. For example, online forums for excessive infant crying (which can be linked to allergy) include encouragement to ‘push’ for answers and shape expectations that healthcare professionals’ reactions will likely be dismissive, incorrect, or unsatisfactory.1 Similarly, a recent review of endometriosis-related Instagram posts highlighted the prevalence of content related to ‘medical distrust’ that could potentially fuel the perception of conflict during healthcare interactions.10 Analysis British Journal of General Practice, May 2025 ANALYSIS | 235 Our concern is that patients may pre-empt and overestimate the anticipated conflict they are likely to encounter during a consultation, and an unintended consequence may be that conflict becomes self-fulfilling. Clinicians describe how their experience of working in an environment where ‘the GP is being cast as the villain’ can make their work offering care more complex, and put barriers up between them and their patients.11 While valuing patient self- advocacy, they recognised that this could sometimes risk more ‘adversarial consultations’.11 Navigating consultations when clinicians are presented with potentially inaccurate or incomplete information can be difficult, a task arguably made harder when contextualised in an expectation of conflict and that the clinician will not know or be willing to listen. Benefits for political ideology and commercial industries The adversarial atmosphere between healthcare professionals and patients may serve commercial or political purposes, including private healthcare provision, pharmaceutical companies, technology manufacturers, and alternative healthcare products. A recent Lancet breastfeeding series highlighted that infant formula companies are positioning normal infant behaviours (such as crying, wanting to be held, and waking frequently) as ‘problems’ that can be fixed with specialist formula.12 This raises concern about public health risks and the possible negative consequences for health inequities, as well as the exploitation of families for commercial gain.12 In addition, an analysis of marketing strategies by formula companies13 shows how commercial gain has been leveraged through the creation of a perceived conflict between breastfeeding and formula-feeding parents. This demonstrates that the use of controversy as a marketing tool is a familiar strategy in this context. Taken together, we suggest that products such as infant formula or prescriptions for specific drugs may be benefiting financially from developing an adversarial atmosphere in the healthcare consultation about the unsettled baby. We argue that marketing strategies may also contribute to conflict in the consultation by encouraging parents to seek specific diagnoses and prescriptions from healthcare professionals in the absence of exploring other avenues or needs for further information and support. Narratives that reduce confidence in the capacity or capability of NHS services or GP care can act as drivers towards utilisation of private health care, which risks creating new and exacerbating existing health inequities. While conflict between patients and NHS healthcare professionals may benefit private care providers and insurers, it arguably does not benefit patients, and certainly not all patients equitably. Public and political narratives around privatisation of the NHS are highly contentious, with independent think tanks and government departments debating radical options for the future of the NHS as a public service.14 We argue that conflict-expectancy and the public narratives surrounding this could be used selectively to serve political ideologies, as well as commercial industry. Who might be harmed by conflict-expectant consultations? Conflict in the consultation can not only cause harm — first and foremost to the patient, but also to the clinician who may or may not be aware of how their advice and actions might be received. For example, offering hormonal treatment to people with symptoms suggesting possible endometriosis is evidence based and embedded in national and international guidance as a step to be considered prior to referral.15 However, offering this is sometimes experienced by the patient as dismissal or fobbing off, and reported as contributing to delays in diagnosis,15 seemingly leaving both sides of the encounter in a bind.9 When patient expectations are unmet, it highlights the need to remain open to different interpretations as to why this is the case and develop solutions accordingly. For example, this may enable the identification of opportunities to bridge gaps in communication. However, we recognise that a conflict-expectant approach renders these solutions more challenging. Patient satisfaction in general practice is falling, and professional burnout, stress, and failing retention are at a record high.4 GPs are carrying a heavy burden from the lack of access to specialist care and long NHS waiting lists.6,16 Fewer GPs will not help deliver the care that people are calling for and desperately need. With these ever-increasing pressures on consultations, it seems likely that more effective and efficient ones will be possible if the patient and clinician enter the conversation as collaborators working together towards a shared aim, rather than as opponents. With squeezed resources presenting challenges for maintaining relational aspects of care,11 and when practitioners are feeling defensive, it becomes more difficult to be honest about uncertainty or to be open with the patient about the possible impacts of labelling, diagnosing, testing, or treating. GPs do not set out to do a bad job or to ignore their patients,11 but it is undeniable that patients feel unheard, dismissed, and ignored. This is particularly problematic for patients who are women and/or are from minority groups, and these individuals further experience barriers regarding access to and experience of services as well as disparities in health outcomes.17 Examples include having a reduced likelihood of being diagnosed with endometriosis18 or receiving hormone therapy as part of menopause care.19 When trust is eroded in the individual clinician and in the healthcare system as a whole, patients may be less likely to seek care when it is needed. Wealthier patients may turn to private care, and we worry that this movement may exacerbate existing inequities or create a ‘two-tiered system’.20 As reflective practitioners and researchers, we must ask ourselves how biases and expectations — both our own and our patients — impact our work. When might care be experienced as dismissal? How can we move towards care that is experienced as collaborative, while also following best- practice and evidence- based medicine? Patients might be holding preconceived notions about the thought processes, decisions, or actions of healthcare professionals, which the healthcare professional may or may not be aware of. How might we constructively engage to reassure patients that their best interests are our priority too and bring about better alignment? What evidence, skills training, and resources could help equip clinicians to respond constructively and collaboratively to requests for support positioned as conflict- expectant? As a wider society, we need to ask ourselves how we can navigate emotive or divisive health topics with sensitivity, empathy, and kindness in both directions. 236 | ANALYSIS British Journal of General Practice, May 2025 Analysis

In response to observing conflict-expectancy in healthcare encounters in our clinical practice and research, this article considers some of the likely sources and potentially detrimental impacts. There are, however, likely many more interfaces where this is relevant, and ways in which they are maintained and experienced. We write this as a starting point and a call for future research to further consider the real-world impacts of conflict- expectancy and how to navigate this in a way that strives for meaningfully improved healthcare experiences for both patients and healthcare professionals. We explicitly call for greater transparency in reporting and interrogating potential conflicts of interest from commercial organisations and private healthcare providers, among others, where they feed into this discourse. Conflict in consultations might be serving a political agenda or a commercial industry, but we are worried that it is not helping patients, healthcare professionals, or the NHS.

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Healthcare (Basel) 2024; 12(1): 121. DOI: 10.3390/ healthcare12010121. 11. Toye F. MacLellan J, Dixon S, McNiven A. Understanding primary care perspectives on supporting women’s health needs: a qualitative study. Br J Gen Pract 2023; DOI: https://doi.org/10.3399/BJGP.2023.0141. 12. Rollins N, Piwoz E, Baker P, et al. Marketing of commercial milk formula: a system to capture parents, communities, science, and policy. Lancet 2023; 401(10375): 486–502. DOI: 10.1016/S0140- 6736(22)01931-6. 13. Whipps MDM, Iqbal Y. Feeling better, doing worse: ‘mommy wars’ infant formula advertising, collective action, and breastfeeding inequities. J Hum Lact 2021; 37(2): 343–347. 14. Wickens C, Brown T. The NHS in crisis — evaluating the radical alternatives. 2023. https://www.kingsfund.org.uk/insight-and- analysis/long-reads/nhs-crisis-evaluating-radical-alternatives (accessed 7 Mar 2025). 15. Malbon K, Goodwin A, Shotton H, et al. Endometriosis: a long and painful road. A review of the quality of care provided to adult patients diagnosed with endometriosis. 2024. https://www.ncepod.org. uk/2024endometriosis/Endometriosis_A%20Long%20and%20 Painful%20Road_full%20report.pdf (accessed 7 Mar 2025). 16. Salisbury H. Managing feelings of failure. BMJ 2022; 377: o1218. 17. Department of Health and Social Care. Women’s Health Strategy for England. 2022. https://www.gov.uk/government/publications/ womens-health-strategy-for-england/womens-health-strategy-for- england (accessed 7 Mar 2025). 18. Bougie O, Nwosu I, Warshafsky C. Revisiting the impact of race/ ethnicity in endometriosis. Reprod Fertil 2022; 3(2): R34–R41. DOI: 10.1530/RAF-21-0106. 19. Bawden A. White women most likely to get HRT prescriptions in England, study finds. Guardian 2024; 21 Oct: https://www. theguardian.com/society/2024/oct/21/white-women-hrt- prescriptions-study-england (accessed 7 Mar 2025). 20. Khan N. Sleepwalking into a two-tiered healthcare system. Br J Gen Pract 2023; DOI: https://doi.org/10.3399/bjgp23X731853. Abigail McNiven, (ORCID: 0000-0001-5041-2095), Senior Qualitative Researcher, University of Oxford, Oxford. Amy Dobson, (ORCID: 0000-0002-7795-2232), Senior Research Assistant, University of Southampton, Southampton; Health Visitor. Katie Read, (ORCID: 0009-0003-0029-1725), PhD Candidate, University of Southampton, Southampton. Sharon Dixon, (ORCID: 0000-0002-7469-6093), NIHR Doctoral Research Fellow, University of Oxford, Oxford; GP. Funding No funding was received for the writing of this article. However, the National Institute for Health and Care Research (NIHR) School for Primary Care Research (SPCR) funds PhDs being undertaken by Amy Dobson (reference: C008) and Katie Read (reference: C090), and Sharon Dixon is undertaking a PhD funded by an NIHR Doctoral Research Fellowship (reference: NIHR301787). The discussion draws on research conducted as part of these PhDs in addition to published research from the following studies: the PURSUE and WEAVE studies funded by the NIHR Policy Research Programme (reference: NIHR202450) and a study on GP perspectives on suspected endometriosis funded by the NIHR SPCR (reference: 403). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Provenance Freely submitted; externally peer reviewed. Competing interests The authors have declared no competing interests. DOI: https://doi.org/10.3399/bjgp25X741561 CORRESPONDENCE Abigail McNiven University of Oxford, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6GG, UK. Email: [email protected]