Table 2.
Vulnerability determinants
| (No. of interviews mentioned/total) | Examples of illustrating quotations |
|---|---|
| 1.Health-care system (31/33) | |
| 1.1. Hospital Resources (31) | It happens sometimes that we have a problem with the number of beds and we have to make choices. (E10) |
| 1.2. Intrinsic characteristics (compensation systems) (21) | I work with people who do not have insurance and who are working illegally, everything we do outside the Community Medicine Department needs welfare service so it is true that we think very carefully before asking for an examination, especially if it’s expensive. (E12) |
| 1.3. Medical culture (26) | Here in Community Medicine, medical culture is different than internal medicine, we have less recourse to complementary examinations. (E12) |
| 1.4. Actors (18) | In Oregon, they have a budget and the population decided, voted, discussed on what cares are useful or futile or unnecessary. (E24) |
| 2.Physicians (31/33) | |
| 2.1.Knowledge (22) | It’s really by experience, by exchanges with peers, with colleagues that we acquire this reflection and also by seeing what happens in other countries, that we don’t want to see here, I mean inequality in care access. (E25) |
| 2.3.Liberty (6) | By putting a different weight on certain criteria compared with others, this leaves us a big extent of freedom, allowing us to escape pressure in a certain way. (E3) |
| 2.4.Personality (15) | I never refuse care a for patient who needs it, even if he doesn’t pay the bills and we have arrears.(E25) |
| 2.5.Feelings (11) | It happens to always be the same kind of patients who miss their appointments. These are really not reliable and faithful (...) people for who we are not motivated to care and it can happen that sometimes we say to ourselves that we want to punish them. (E27) |
| 2.6.Influenced (27) | There is a reflection for each act, especially when it’s expensive. (E7) |
| 2.7.Professional situation (25) | For example a CT-Scan that I don’t really believe in, but I say to myself: here we are on uncertain ground, it is not completely wrong to do it so that is what I do but in fact it may be excessive. (E13) |
| 3.Treatment (27/33) | |
| 3.1.Heavy side effects (5) | For example a patient with a stroke and for this one we decide not to do an echo-Doppler examination of the neck because if there is an abnormality, we won’t do a surgical intervention. (E1) |
| 3.2.Not repaid (4) | All these infertility problems are only accessible to people who can pay for treatment and not repaid by Swiss social insurances, it’s also an equity problem. (E18) |
| 3.3.No benefits (14) | The main criteria that make me think it’s reasonable to use expensive means is being entitled to expect benefits. (E11) |
| 3.4.Over-interventionism (26) | In private practice where I worked, I was scandalized by the debauchery of technical means without scientific medical justification, it was particularly terrifying. (E11) |
| 3.5.Expensive (26) | It happened to us not to give the dose because it is about one thousand francs for one milligram and we need ten milligrams to treat. (E10) |
| 3.6.Complex (4) | Every patient is different, we could do the same treatment for some of them but other will need more advanced treatment and if we start with this system [globalized care], as it’s going up in hospitals, we won’t be fair because this patient has a more complex problem and that won’t fit the standardized directives. (E25) |
| 3.7.Poly-medication (2) | Biggest limitation in treatments is often the number of drugs because if they already have ten drugs, then we think a lot before introducing an eleventh. (E1) |
| 4.Communication (30/33) | |
| 4.1.Patients’ level of understanding (7) | This patient doesn’t understand... he doesn’t speak our language and anyway we will never manage to explain to him why this is important to do or not to do, this examination or taking this medication, so we forget about it, (…)(E14) |
| 4.2.Physicians-Patients relationship (15) | We feel like doing something differently for someone which seems to us friendly or not friendly, there are many things very subtle operating but in a more individual level I think... I would say that I’m conscious of that but we try to fight against this. (E12) |
| 4.3.Medical explanations (19) | Sometimes we go too far in treating patients; sometimes we treat patients without them understanding the treatment; sometimes we go rapidly to a therapeutic withdrawal, sometimes too rapidly, it’s difficult to know who is right or wrong. (E9) |
| 4.4.Patients’ refusal (16) | I have more the impression of being inequitable if I am not able to give care for someone who needs it but for whatever reason does not want treatment, for social, psycho, psychopathologic reasons. (E22) |
| 5.Patients Characteristics (31/33) | |
| 5.1.Socioeconomic status (24) | We clearly see a part of the rich population becoming more rich, who won’t have care access problems, and a poor population, becoming more poor and having a lot of difficulties of care access. (E10) |
| 5.2.Family (20) | When we [paediatricians] have non-French speaking parents, we spend less time explaining things than when we have a child who comes in and he is the professor’s son who knows everybody then we have to speak to everyone, explaining to everyone, care is different but in the end treatment is the same but expenditure of energy is bigger, now I have many examples in memory. (E18) |
| 5.3.Social environment (21) | With these people I practice medicine but in a more accelerated manner than I would wish because I had to spend time resolving social problems or... care access. (E30) |
| 5.4.Legal status (16) | There are populations for which, for reasons of elevated insurance premiums, fear of identification or legal problems when they are illegals, care is delayed and I think that under certain conditions that could be dangerous for their health. (E12) |
| 5.5.Demographic (29) | Well, we have the reflex to limit treatment in the elderly. (E11) |
| 5.6.Personality (20) |
I think that we quickly tend to take cover by saying: well he doesn’t want it, or, for example, he is aggressive, we often hear that in emergencies: ‘When you become polite again, we will try to help you’, that’s wrong, he is aggressive, unpleasant, he is sick and all is probably linked so it’s necessary to help, to make effort to adapt. (E11) |
| 5.7.Culture (21) | They are not treated the same... or when they don’t speak French people take the liberty to do things that when we hear about them later, it’s shocking the way they are cared for or the way they are treated or the way we speak with them, we have many shocking accounts about what is happening with people not from around here. (E13) |
| 5.8.Insurance (25) | If a patient goes to the operating block, if it’s a private patient, he will be operated by the senior attending surgeon, if he has a common insurance, he will be operated by the resident or the junior attending in formation. (E10) |
| 5.9.Medical Characteristics (29) | We say to ourselves given that bad prognostic … comorbidities … reduced life expectancy. We probably won’t invest theses means if we don’t have many available beds. (E3) |
| 5.10.Habits (18) | There is a moral inequity I think in the way that...with poor patients, marginalized, drug addicted, alcoholics, with psychiatric problems, we will probably be without being totally conscious, they have less performing care because... there is less investment. (E13) |
| 5.11.Autonomy (29) | We can also imagine that in front of a patient’s insistence for a treatment... knowing it won’t be useful on the somatic level, it might be efficient on the psychological level. (E11) |
| 6. Mismatches | |
| 6.1.Patients’ characteristics - health-care system | In Africa, when you have resources, you see the professor in public service that refers you to private clinics when you immediately have all the necessary exams you need but patients who cannot pay, will stay in the public system where he may or may not have access to treatment, or it may be too late. (E15) |
| 6.2.Patients’ characteristics - physician ability to communicate | Patients have the right, even in paediatrics, to tell us when they have had enough, even if we think they are too young; although they are minors, they do not decide but they have a say. (E21) |
| 6.3.Patients’ characteristics - treatment characteristics | For certain patients we go far in extremely expensive, heavy and complicated care and we could ask ourselves if it is justified to extend a life by a few months if we allocate resources more efficiently. (E20) |
| 6.4.Patients’ characteristics - physician professional situation | Senior medics attending them (Patients from Emirates) … feel under obligation to propose examinations in their specialty as these patients often have four or five intermediates, each proposing invasive examinations. (E6) |