The art of refusal

‘Bartleby, the Scrivener’ should be mandatory reading for all GP registrars

Every day, while I am busy with patients, messages land unrelentingly in my inbox, sent on by the secretarial staff; copies of emails and telephone requests for patient information from well-meaning health professionals and administration staff. Nurses working in specialist hubs looking for a summary of a medical history, a list of patient’s medications, a copy of an MRI report. Private hospital medical staff looking for reports from public consultants. Health insurance companies asking me to verify the timeline of a patient’s claim. It appears that everyone wants access to the carefully compiled and curated GP medical records.

Any GP will understand the irritation that these requests engender. I will not elaborate on that here, except to say that when we say yes to one thing in the moment, we are saying no to everything else, and there are only so many moments in the day. There is also the risk that our records may not be accurate at that time as medical problems evolve and pharmacists and consultants can issue medicines that never come to the attention of the GP. What I am most interested in, however, is how to refuse such requests. How do I say no politely and respectfully? How do I resist the expectancy of instant or swift compliance and take self-directed action to focus on what is important to me. This is a subject that I have given much thought to recently. Can I simply refuse such requests or is there a space I can occupy between yes, and no? A third space where I can do meaningful and collaborative work without acceding to what I consider time-wasting demands? And can I do this without having to explain myself?

I believe I found an answer in a story by Herman Melville, published in 1853 called Bartleby, the Scrivener. In this story, Bartleby is newly employed as a scrivener by a successful lawyer. A good and conscientious worker, he takes his employer by surprise one day when instead of checking his own writing against an original document, as requested, he simply replied, “I would prefer not to.” From then on when asked to do similar tasks Bartleby offered the same response. Eventually, Bartleby stopped working altogether, locked himself in the lawyer’s office and when asked to open the door, gave the now expected response, ‘I would prefer not to.’ An interesting aspect of this story is not Bartleby’s actions, but the lawyer’s reactions. Faced with Bartleby’s linguistic strategy of neither complying nor refusing, the lawyer was compelled to read two treatises on the possibility of free will. His studies led him to believe that Bartleby and people in general were entitled to exercise free will. Exercising free will may shock or irritate, amuse or anger, but it is still within our power to exercise it or not.

I decided to take a leaf out of Bartleby’s book. I began with an email request from an allied health professional looking for a summary of a patient’s medical history for her file. I took a deep breath, summoned my inner Bartleby and typed: “In the interest of patient safety, I would prefer not to forward a summary of the medical history as requested.”

I worried that the recipient would suspect I was simply being a gadfly, so I added another sentence by way of explanation:

“My records may not be accurate at this time.”

This was true. The patient had recently been discharged from hospital and had not attended me since discharge, so it was likely that her history and medications had changed. I didn’t want to do too much explaining, but I thought I better offer her something, so I added a third and final sentence.

“I suggest you ask Mrs G about her recent medical problems and her medications when you meet her.”

Satisfied with these three sentences I pressed send.

You may be thinking that it would have taken less time to simply send the requested information and you would probably be right. But a version of these three sentences has become a template response to all such email requests saving me much time and irritation in the past few weeks.

One of the most enjoyable things about being a GP is the sense of autonomy and agency that goes with the job. I was in danger of losing that sense of agency amidst the myriads of unnecessary demands that impacted my day. Sometimes when we stand so completely within a system, we cannot see what is working effectively and what is mere busyness. It appeared to me that every new service that was established created additional unnecessary workload for the GP, much of which amounted to busyness. I have concluded that Bartleby, the Scrivener should be mandatory reading for all GP registrars, even those who prefer not to.