Partnership of patient and doctor may provide key to patient satisfaction.
The observational study of the effects of patient centredness on the
outcomes of the consultation in general practice is empirically rich and
informative (1). We would like to comment on the way studies such as this
construct a dyadic model that implicitly presumes that the doctor bears
the major responsibility for patient satisfaction. Social research with
HIV positive people in Australia suggests an alternative approach in which
doctors and patients are seen as agents operating in ‘clinical space’ that
is wider than the consultation (2)(3). While this research has specific
contextual limits, it also suggests a way forward that allows increased
patient expertise to be taken seriously and engages with the changing ways
that medical knowledge circulates in the wider society, including the
The consultation is a key element in the constitution of ‘clinical
space’, but it is not definitive of it. HIV positive people in Australia
rely heavily on specialist HIV GPs for information about their
pharmaceutical treatments, but distinguish between information and wider
perspectives on living with HIV (4). Their negotiation of decisions about
treatment occurs within a framework of self-care. Patients may pre-empt
the consultation at different times and on different issues. For example,
decisions about adherence, ‘drug holidays’ and the use of recreational
drugs appear to be made in the context of mostly, well informed self-care
practices rather than on the basis of a clinical consultation alone. We
are currently exploring the ways in which some of these decisions come
home to roost in the consultation and how self care and self harm are
If we locate doctor-patient interactions within an expanded notion of
‘clinical space’ then both doctors’ and patients’ perceptions of what is
possible in a brief consultation and doctors’ expectations of themselves
can be shifted into a more productive understanding of how self-care
occurs. Focussing solely on the consultation simply increases the pressure
and the likelihood of dissatisfaction with the doctor and the practice of
Patients exercise an increasingly well informed medical gaze as an
ordinary part of everyday life. Expecting or requiring doctor
consultations to be responsible for all aspects of this by measuring
quantifiable units of practice without querying the realism of patients’
expectations simply reinforces the pressures on the consultation. Counsels
of perfectability tend to produce resentment and lower self-esteem, adding
to the desire to leave general practice (5).
We suggest that a wider understanding of clinical space and cultures
of care allows recognition of the productivity of consultations, even as
the inherent challenges are acknowledged.
1. Observational study of effect of patient centredness and positive
approach on outcomes of general practice consultations. Little, P.,
Everitt, H., Williamson, I., Warner, G., Moore, M. Gould, C., Ferrier, K.
and Payne S. British Medical Journal 2001; 323: 908-911.
2. Hurley M (2000) ‘Media loops. Information circuitry in the
community’, National AIDS Bulletin, 14 (1), 27-28.
3. Hurley M (2001) Strategic and Conceptual Issues for Community-
based HIV/AIDS Treatments Media, Monograph Series Number 20, Australian
Research Centre in Sex, Health and Society, La Trobe University,
4. Grierson, J., Bartos, M., de Visser R., and McDonald, K. (2000)
HIV Futures II. The Health and Well-being of People with HIV/AIDS in
Australia: Australian Research Centre in Sex, Health and Society, La Trobe
5. Quarter of GPs want to quit, BMA survey shows. Kmietowicz Z.
British Medical Journal 2001; 323: 887.
Competing interests: No competing interests