The Complex Roles of Doctors in Patient Care
General practitioners (GPs) and hospital doctors often serve as the first point of contact for patients, but their roles can vary significantly. Our recent research highlights that these medical professionals can act either as gatekeepers or brokers, each role having a profound impact on patient outcomes.
As gatekeepers, doctors ensure that unnecessary investigations are avoided and that scarce resources are used efficiently. However, as brokers, they advocate for their patients’ access to limited resources. For individuals living with life-limiting diseases, the role a doctor adopts can mean the difference between timely care and dangerous delays.
Our research focused on people who had lived with a terminal cancer diagnosis for an extended period. The effects of these different roles are evident in the experiences of our study participants.
When GPs suspect that a person’s symptoms could indicate cancer, most patients are referred to specialist services quickly so that diagnostic work can be undertaken. However, there have been instances where patients, even those with a history of cancer, were not referred promptly. There are several reasons why this might occur.
One reason is that the GP believes the patient’s symptoms are due to a different condition. For example, one participant in our study had a history of breast cancer and mental health issues. When they presented with breathlessness, their GP prescribed an antidepressant. The symptoms persisted, and the patient returned to the GP before eventually ending up in the emergency department, where they were diagnosed with lung metastases.
Another patient had a lump on her breast ten years after breast cancer. Her GP initially thought it was a cyst, and it wasn’t until she saw a female doctor that she was sent to her specialist, where it was discovered that the cancer had metastasized.
Even within the hospital sector, resources can sometimes be withheld from patients. One study participant was found to have a terminal brain tumour and was sent home with the message that treatment would be “a waste of time.” It was only due to the persistence of their spouse that the patient was eventually sent for possible treatment.
Doctors as Advocates
In contrast, some health professionals act as brokers, facilitating access to resources that others might not receive. The reasons for this vary, but often come down to an assessment of who is deemed worthy of this extra effort.
One patient we spoke to had malignant melanoma that had been misdiagnosed years earlier as benign. Their specialist took it upon themselves to advocate for them, working to get them onto a vaccine trial to make up for the system failure.
Another patient, a medical professional, was one of only 100 people in New Zealand placed on an unsubsidised medication at no cost to them. Yet another, who was in their 30s, was enrolled in several trials for melanoma, even in circumstances where they did not meet the trial protocol.
We can see clear reasons why a health professional may broker access to scarce resources for their patient. The patient may have been let down by the health system earlier, they may have strong connections with the health system due to their work, or they may be regarded as more worthy because of their age.
There will be many other factors, but we have no systematic research on this issue. What we do know is that health professionals are making determinations about who is worthy of access to resources. These decisions are not merely about need or likely clinical benefits.
Reinforcing Existing Inequities
For Māori, the roles of gatekeepers and brokers can have very different effects. Gatekeeping may not be malicious, but it can reproduce the experience of later diagnosis and poorer outcomes, which is already more common for Māori.
Māori are also less likely to start with the advantages that make a patient “broker-worthy.” If brokerage is informal and discretionary, it risks reinforcing inequities that the system nominally aims to reduce.
A third role we observed was less about tests and treatments and more about what kinds of knowledge and practice are allowed into the clinic. Some practitioners acted as boundary enforcers, defending the edge of Western evidence-based medicine by excluding or ignoring other approaches to cancer and healing.
One patient in our study rejected Western medicine, concluding that doctors did not listen to them or understand their cultural and spiritual world.
The Consequences of Medical Roles
GPs and hospital specialists will always have to balance finite resources, uncertain evidence, and competing obligations. Whether they primarily act as gatekeepers, brokers, boundary enforcers, or bridge builders across these roles has real consequences for who is diagnosed, who is treated, and who lives well with cancer in Aotearoa.
For Māori, whose cancer journeys are already shaped by structural inequity, getting these roles right is not an abstract policy debate. It is a matter of life and death.
We need to understand medical practitioners’ decisions about which role they take on. This knowledge may help patients to advocate for themselves and researchers to analyze whether these decisions are fostering equitable outcomes.
