Patient removals: time to rethink exclusion in general practice?

Natassia Brenman; Francesca H Dakin; Jessica Drinkwater; Anne-Laure Donskoy; Kelly Howells; Clive Rowe; Sara E Shaw; Jackie van Dael

doi:10.3399/BJGP.2025.0751

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Patient removals: a symptom of a changing doctor–patient relationship era
Paulo Santos

Published on: 13 January 2026

Published on: (13 January 2026)
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Patient removals: a symptom of a changing doctor–patient relationship era
Paulo Santos, General and Family Medicine physician, MEDCIDS, RISE-health@RISE, Faculty of Medicine, University of Porto, Porto, Portugal
Violence against health providers has become a structural challenge across health systems, including general practice, where clinicians often serve as the first point of contact for distressed or frustrated patients.^1-3 Yet discussion frequently focuses on visible episodes rather than the underlying causes.

Violence arises from multiple pressures: declining institutional trust, bureaucratic delays, unrealistic expectations, and the reframing of the doctor–patient relationship as a transactional service encounter rather than a professional, human bond.^{2, 4} Consultations risk becoming sites of conflict rather than cooperation.

Many moments of tension do not reflect hostility but a lack of relational fit. Suffering amplifies emotions, and not every clinician naturally connects with every patient. As in all relational life, mismatch is common and shapes the encounter.⁵ Medicine depends on connection, trust, and the capacity to understand the other. In primary care teams, mismatches can often be resolved by identifying the professional profile that best suits the patient, making attention to team composition and leadership essential.

Difficult patients have always existed. Proposals to create parallel services for “difficult patients” induce segregation. They do not solve the problem and may legitimise the idea that mainstream services cannot cope with the realities of human suffering ^{6, 7...}
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Violence against health providers has become a structural challenge across health systems, including general practice, where clinicians often serve as the first point of contact for distressed or frustrated patients.^1-3 Yet discussion frequently focuses on visible episodes rather than the underlying causes.

Violence arises from multiple pressures: declining institutional trust, bureaucratic delays, unrealistic expectations, and the reframing of the doctor–patient relationship as a transactional service encounter rather than a professional, human bond.^{2, 4} Consultations risk becoming sites of conflict rather than cooperation.

Many moments of tension do not reflect hostility but a lack of relational fit. Suffering amplifies emotions, and not every clinician naturally connects with every patient. As in all relational life, mismatch is common and shapes the encounter.⁵ Medicine depends on connection, trust, and the capacity to understand the other. In primary care teams, mismatches can often be resolved by identifying the professional profile that best suits the patient, making attention to team composition and leadership essential.

Difficult patients have always existed. Proposals to create parallel services for “difficult patients” induce segregation. They do not solve the problem and may legitimise the idea that mainstream services cannot cope with the realities of human suffering ^{6, 7}

Meanwhile, the universal right to health has become operationalised in the creation of health services, where the original dyad evolved into the patient-system-doctor triangle. This proletarian evolution of medical work, driven by rigid protocols and productivity metrics, made communication noisier and responsibility blurred. Some patients have become “uninteresting” to the system because they did not fit established pathways, generated higher costs, or scored poorly in performance indicators.⁴ They were swept under the rug in a new form of paternalism, not from doctors, but from their subordination to management expectations in a “dictatorship” of acquired rights. Instead of equity and equality of opportunity, the system risks offering the tyranny of the majority and the illusion of equal outcomes.

Restoring safety and dignity requires confronting the causes of violence directly, reinforcing the legitimate authority of clinicians, strengthening patient accountability, and rebuilding the relational foundations of care.

References

1. Brenman N, Dakin FH, Drinkwater J, Donskoy AL, Howells K, Rowe C, et al. Patient removals: time to rethink exclusion in general practice? Br J Gen Pract. 2026;76(762):10-1. DOI: 10.3399/BJGP.2025.0751.
2. Kuhlmann E, Brinzac MG, Czabanowska K, Falkenbach M, Ungureanu MI, Valiotis G, et al. Violence against healthcare workers is a political problem and a public health issue: a call to action. Eur J Public Health. 2023;33(1):4-5. DOI: 10.1093/eurpub/ckac180.
3. Zangao MO, Gemito L, Serra I, Cruz D, Barros MDL, Chora MA, et al. Knowledge and Consequences of Violence Against Health Professionals in Southern Portugal. Nurs Rep. 2024;14(4):3206-19. DOI: 10.3390/nursrep14040233.
4. Kuhlmann E, Falkenbach M, Lotta G, Tenbensel T, Dopfer-Jablonka A. Violence against healthcare workers in the middle of a global health crisis: what is it about policy and what to learn from international comparison? Front Public Health. 2023;11:1182328. DOI: 10.3389/fpubh.2023.1182328.
5. Green CA, Polen MR, Janoff SL, Castleton DK, Wisdom JP, Vuckovic N, et al. Understanding how clinician-patient relationships and relational continuity of care affect recovery from serious mental illness: STARS study results. Psychiatr Rehabil J. 2008;32(1):9-22. DOI: 10.2975/32.1.2008.9.22.
6. Iversen HW, Riley H, Rabu M, Lorem GF. Building and sustaining therapeutic relationships across treatment settings: a qualitative study of how patients navigate the group dynamics of mental healthcare. BMC psychiatry. 2025;25(1):424. DOI: 10.1186/s12888-025-06874-5.
7. Porcerelli JH, Eissa R, Morris P. Difficult Doctor-Patient Relationships and Attachment Style in Primary Care. Healthcare (Basel). 2025;13(22). DOI: 10.3390/healthcare13222952.

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Competing Interests: None declared.