REASONS FOR CHANGE OF GENERAL PRACTITIONER-STUDY AMONG PATIENTS

The health reform carried out in our country has resulted in a number of both positive and undesirable results in outpatient medical care, which requires an increase in the level of public health in the country. The introduction of free choice of GPs in our country made it possible for his patients to change freely. The purpose of this study is to analyze the patient’s motives for changing GP. Material/methods: A survey was conducted among respondents in the period 1-30 September 2018 in the Pleven region. Patients visited their GPs during the study period. A direct individual anonymous survey was conducted containing 35 questions, of which 29 closed questions, 4 semi-open and 2 open-ended questions. The results were processed through Microsoft Office Excel 2007. Results: The analysis of a number of authors, as well as our own empirical research, show the existence of a number of motives for changing the choice of patients for a personal physician. The patient’s prior knowledge of the qualities and competencies of the chosen physician is very low. This choice of patients is most often spontaneous, random and not sufficiently substantiated with specific information. In any case, this reduces the effectiveness of the free choice of doctor. Conclusions: It is necessary to improve the organization of admission of patients by GPs.


INTRODUCTION
The World Health Organization's 2008 World Health Report, entitled "Primary care now more than ever," clearly states the need for knowledge about primary care not as one of the ordinary structures of the national health system but as its leading priority. [1] The past 19 years since the start of health reform in Bulgaria have shown that the choice and change of a GP by patients is most often spontaneous, random and having not enough specific information about the qualities of the GP. This, in any case, reduces the effectiveness of the free choice of a doctor. [2] Healthcare is a type of interaction between the doctor and the patient during the diagnostic and treatment process. The modern patient has relatively higher general and medical knowledge, which is why his/her expectations and claims to medical care get higher. This puts the doctor in front of new increased requirements and responsibilities for an effective partnership between the doctor and the patient, based on mutual respect and trust. [3] A tendency to increase the workload in general practice is observed in European countries, including Bulgaria, which leads to problems with hiring staff and concerns for the well-being of both GPs and patients. [4,5] The health insured persons have the right to freely choose a doctor in a medical institution for primary medical care on the territory of the whole country. [6] It is considered that the main general medical practice advantages are the lasting connection between doctors and patients, the integrated nature of medical services and aid, the universal availability of these services, the involvement of patients and families in solving health problems, the possibility for coordination with doctors from other healthcare sectors. [7] The purpose of this study is to analyze the patient's motives for changing GP.

MATERIALS AND METHODS
A survey was conducted among respondents in the period from 1st to 30th September 2018 in the Pleven region. The participants in the survey were selected at random. Twenty-five offices of general practitioners from three settlements in Pleven region were visited. Patients who visited their GPs during the study period were interviewed. A direct individual anonymous survey was conducted con-

RESULTS
It was established that 830 (78.8%) of the 1053 respondents on the territory of Pleven region have changed their personal doctor. Of these, 19% given as an objective reason for this their change of residence.
The motives are given by the patients for changing, their personal doctor, are given in Table 1, but the three leading motives are: long wait in front of the GP's office -https://doi.org/10.5272/jimab.2021273.3847 30.2%, permanent lack of referrals for a specialist -11.7%, reluctance to explain one's health problems -6.0%.
In Fig. 1, we present data of rural and urban residents on the reasons for the change of their GPs.
In the context of the reasons for changing a GP, it is particularly important to analyze the doctor's attitude towards his/her patients.
As can be seen from (Fig. 2), a higher percentage of the surveyed patients positively assess the attitude of the GP to them. 132 (12.6%) of the respondents rate their personal doctor as rude, being always in a hurry, nervous or not giving any answer at all.
In Fig. 3, we present data of waiting time in front of the doctor's office at the place of residence.

DISCUSSION
These data show that the reasons to seek a new healthcare provider are of an organizational and communication nature.
The long wait in front of the GP's office is mainly a result of the lack of regulated admission of patients, i.e. this is an organizational problem.
The lack of referrals (according to the patient) is probably the result not only of such an objective lack but also of poor doctor-patient relationship with a lack of mutual discussion of the patient's diagnostic problem. The doctor's unwillingness to explain to the patient his /her health problem, which is often the doctor's inability to deal with problems, is a purely communicative and ethical problem for the healthcare provider.
There is some difference in the motives of rural and urban residents to change the GP (Fig. 1). In rural areas, relatively common motives for choosing a new GP are a change of residence and non-response to calls for home visits.
In urban areas, relatively more frequent reasons for changing doctors are longer waiting in front of the doctor's office, rude attitude by the doctor and a lack of clear explanation of the patient's health problems. Rural and urban residents have the same percentage of "Lack of referrals for a specialist" as a motive for changing the GP.
The organization of work and the waiting in front of the cabinet are one of the leading reasons for patient dissatisfaction. Similar findings are established by other authors.
[8] R. Zlatanova, B. Borisova and other authors state unjustifiably long waiting time in front of the doctor's office, which leads to significant patient dissatisfaction. [1,9,10,11,12]. The main reason for the long waiting of patients in front of the doctor's office is the continuing lack of regulated admission of patients, a method Fig. 3. Waiting time in front of the doctor's office at the place of residence that is relatively simple and comes down to pre-determining and recording the specific time necessary for the patient's examination. Regulated admission has an undoubtedly positive effect both on the quality of the healthcare provider's activity and on achieving an optimal doctor-patient relationship. Therefore, the introduction of regulated admission of patients in primary care is an objective necessity.
The data cited above show that a still unresolved organizational problem in general medical practice is the long waiting time for the patient in front of the doctor's office, which is more pronounced in rural areas. The main reason for this is the lack of a regulated admission system, which is a relatively simple but effective mechanism.
The long wait in front of the doctor's office is a particularly serious problem for patients of active working age, which undoubtedly determines their less frequent attendance at the GP's office compared to patients in the older retirement age. This issue deserves to be the subject of a future more specific analysis, as it concerns not only the need to pre-determine and record an appointment but also the differentiated approach to the admission of patients depending on the different reasons for visiting the doctor's office: illness, diagnostic and treatment activity, prophylactic examination, documents, etc. Such an approach can contribute to a better organization of the reception and, accordingly, to better satisfaction of the patients from their personal doctor.
Physician-patient interaction is a two-way process. The feedback between the two groups is necessary. Patients' opinions are important, but not the only ones. It is appropriate to conduct audits and independent evaluations of the work of doctors. This will contribute to the motivation of general practitioners to change their behavior in practice and improve care. [13]