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What happens when patients say “no” to offers of referral for weight loss? - Results and recommendations from a conversation analysis of primary care interactions

journal contribution
posted on 27.08.2021, 15:33 by Charlotte Albury, Helena Webb, Sue Ziebland, Paul Aveyard, Elizabeth StokoeElizabeth Stokoe
Guidelines recommend that clinicians should offer patients with obesity referrals to weight management services. However, clinicians and patients worry that such conversations will generate friction, and the risk of this is greatest when patients say no. We examined how doctors actually respond to patient refusals, and how patients reacted to clinicians in turn.

Conversation analysis of 226 GP-patient interactions recorded during a clinical trial of weight management referrals in UK primary care.

Some clinicians responded to refusals by delivering further information or offering referral again. These actions treated patient refusals as unwelcome, and acted to pursue acceptance instead. However, pursuit did not lead to acceptance. Rather, pursuing acceptance lengthened consultations and led to frustration, offence, or anger. Clinicians who accepted refusals and closed the consultation avoided friction and negative emotional displays.

Patient refusals have the potential to create negative consequences in the consultation and clinician responses were key in avoiding these. When clinicians acknowledged the legitimacy of patient refusals, negative consequences were avoided, and the conversation was briefer and smoother.

Practice Implications
When patients refuse the offer of a free weight management referral, GPs should accept this refusal, rather than trying to persuade patients to accept.


Charlotte Albury is funded by a Mildred Blaxter postdoctoral fellowship from the Foundation for the Sociology of Health and Illness and by the National Institute for Health Research School for Primary Care Research. The consultation data was from the BWeL trial which was funded by National Prevention Research Initiative. The funding partners are Alzheimer’s Research UK, Alzheimer’s Society, Biotechnology and Biological Sciences Research Council, British Heart Foundation, Cancer Research UK, Chief Scientist Office, Scottish Government Health Directorate, Department of Health, Diabetes UK, Economic and Social Research Council, Engineering and Physical Sciences Research Council, Health and Social Care Research Division, Public Health Agency, Northern Ireland, MRC, Stroke Association, Wellcome Trust, Welsh Government, and World Cancer Research Fund (Grant ref number: MR/J000515/1). Helena Webb is a Senior Researcher at the University of Oxford, funded by EPSRC. Paul Aveyard is part funded by the Oxford NIHR Biomedical Research Centre and NIHR Oxford and Thames Valley Applied Research Collaboration. Sue Ziebland is an NIHR senior investigator.



  • Social Sciences and Humanities


  • Communication and Media

Published in

Patient Education and Counseling


Elsevier BV


AM (Accepted Manuscript)

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© Elsevier

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This paper was accepted for publication in the journal Patient Education and Counseling and the definitive published version is available at

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Prof Elizabeth Stokoe. Deposit date: 27 August 2021