Monday, 11 May 2026, 8:49 am
Article: The Conversation
Kevin
Dew, Te
Herenga Waka — Victoria University of Wellington;
Chris
Cunningham, Te
Kunenga ki Pūrehuroa – Massey University; Elizabeth
Dennett, University
of Otago; Kerry
Chamberlain, Te
Kunenga ki Pūrehuroa – Massey University, and Richard
Egan, University
of Otago
General practitioners (GPs)
and hospital doctors are usually the first contact point for
patients, but as our new research
shows, they can take on different roles, acting either as
gatekeepers or brokers.
As gatekeepers they make
sure unnecessary investigations are avoided and scarce
resources used efficiently. As brokers, they advocate for
their patients’ access to the limited resources available.
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For people living with life-limiting disease, the
role a doctor adopts can mean the difference between timely
care and dangerous delay.
Our research focused on
people who had lived with a terminal cancer diagnosis for a
long time. The impact of these different roles can be seen
clearly.
When GPs were concerned a person’s
symptoms could indicate cancer, most patients were referred
to specialist services quickly so diagnostic work could be
undertaken.
But there were also cases where
patients, even with a history of cancer, were not referred
quickly. There are several reasons why this might occur.
One is that the GP thinks the
patient’s symptoms are due to a different condition. For
example, one of the people in our study had a history of
breast cancer, but also of mental health issues. When they
presented with breathlessness, their GP prescribed an
antidepressant.
The breathlessness persisted and
the patient returned to the GP and eventually ended 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 said it was a
cyst, and it was not until she saw a female doctor that she
was sent to her specialist to find the cancer had
metastasised.
Even in the hospital sector resources
could be withheld from patients.
One study
participant was found to have a terminal brain tumour and
was sent home and told treatment would be “a waste of
time”. It was only due to the tenacity of their spouse
that the patient was eventually sent for possible
treatment.
Doctors as advocates
In
contrast, for some patients a health professional will
broker access to resources others might not be given.
Again, reasons for this vary, but can often come
down to some assessment about who is worthy of this extra
effort.
One of the patients we spoke to had
malignant melanoma that had been misdiagnosed years earlier
as benign. Their specialist went in to bat for them, working
to get them onto a vaccine trial, trying to make up for that
system failure.
Another patient, a medical
professional, was one of only 100 people in New Zealand put
on an unsubsidised medication at no cost to them. Yet
another, who was in their 30s, was placed on a number of
trials for melanoma, even in circumstances where they did
not meet the trial protocol.
We can see some 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 because of their
work, and they may be regarded as being more worthy because
of their age.
There will be many other factors, but
we have no systematic research on this issue. What we do
have, though, is a situation where health professionals are
making determinations about who is worthy of access to
resources.
These decisions are not mere judgements
about need or likely clinical
benefits.
Reinforcing existing
inequities
For Māori, gatekeeping and brokering
may have very different effects.
Gatekeeping may
not be malicious but 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 the system
nominally wants to reduce.
A third role we saw 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.
GPs
and hospital specialists will always have to balance finite
resources, uncertain evidence and competing obligations. But
whether they primarily act as gatekeepers, brokers, boundary
enforcers or as 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 those 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
analyse whether these decisions are fostering equitable
outcomes.
Kevin
Dew, Professor of Sociology, Te
Herenga Waka — Victoria University of Wellington;
Chris
Cunningham, Professor of Māori and Public Health,
Te
Kunenga ki Pūrehuroa – Massey University; Elizabeth
Dennett, Associate Professor of Surgery, University
of Otago; Kerry
Chamberlain, Professor of Social and Health Psychology,
Te
Kunenga ki Pūrehuroa – Massey University, and Richard
Egan, Associate Professor of Health Promotion, University
of Otago
This article is
republished from The
Conversation under a Creative Commons license. Read the
original
article.