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.
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 receives funding from the Marsden Fund
Chris Cunningham receives funding from The Marsden Fund, the Health Research Council and National Science Challenges.
Kerry Chamberlain receives funding from the Marsden Fund.
Richard Egan receives funding from the Marsden Fund and the Health Research Council.
Elizabeth Dennett does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
