Intended for healthcare professionals

Rapid response to:

General Practice

Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes

BMJ 2000; 321 doi: (Published 07 October 2000) Cite this as: BMJ 2000;321:867

Rapid Response:

Social class, educational status and trust in doctors


The McKinstry study might be summarised as follows:

1. at present relatively few patients would like to be involved in a
decision-making dialogue with their GP [1];

2. those who do show such an interest are mainly well-educated,
higher-income earners;

3. no attempt is made to explain the low interest in collaborative
decision-making amongst low-income poorly educated people, or the
correspondingly higher interest in this among better educated, higher
income earners;

4. low-income earners will probably not want this type of
involvement, as their knowledge of medicine is very scant and their
confidence in dealing with well-educated people like GPs is limited. Their
ability to mount a credible critique of medicine or to articulate
confidently any challenge to a medical decision are obviously limited.
They are likewise limited in making any meaningful input to GP on a more
collaborative basis. Being largely deferential and compliant people, they
prefer to leave clinical decisions to their doctors and are confident and
secure in doing so - most of the time. It is only when “things go wrong”
for such patients, that their confidence in their doctor is thrown into
question [2]. Thus, it is trust in one’s doctor that can be identified as
the single most likely primary reason for their not wishing to be involved
in the clinical decision-making process.

5. The higher income better educated people are members of the same
general class as clinicians themselves, being better educated, more
confident and generally articulate. Being more questioning, critical and
assertive, they are therefore more likely to be able to present a
convincing challenge to any medical position they disagree with, and
express their views with some confidence and credibility. They are also a
group of people, which studies have also shown may have some experience of
alternative therapies [3], which may also derive from or give them a
certain ambivalence towards orthodox medicine and hence possibly less
trust in their doctor. They may have acquired a more critical or sceptical
view of medicine than most lower class people may. On a more positive
note, these people are also willing and able to make a viable input to the
clinician by collaborating with him/her about the consultation process.
Practitioners often label them as ‘difficult’ or ‘rebellious’, i.e. non-
compliant with authoritarian clinicians;

6. in recent medical scandals [2], we have seen that it is only under
duress, in extremis and when coming together into organised groups, with
the assistance of legal and ethics experts, that low income and less
educated people feel able or willing to make convincing challenges of, or
inputs to, clinical decisions;

7. numerous studies have shown that smoking rates are always highest
among low-income and less educated people than the reverse [4]. This is
true not just in Scotland, but also in many other countries. On average
and across all age groups, for both men and women, the commonest pattern
is that members of social class 1 and 2 are about half as likely to smoke
as people in social class 5 [5]. Smokers’ desire for greater collaboration
with doctors, shown in this study, therefore seems surprising, if assessed
purely on social class grounds, but it is understandable in terms of their
awareness of the health effects of smoking, and this probably shows a
greater willingness on smokers’ part to collaborate with their doctor,
regardless of their social class, income group or educational status;

8. The article does not explore how or why future and more
transparent collaborations between GP and patient might be (a) desirable
or (b) established. It therefore appears to reinforce a complacent view of
the clinician as the dominant partner and offers nothing to those who
would question this status quo.


[1] BMJ article 7 October 2000, Do patients wish to be involved in
decision making in the consultation? A cross sectional survey with video
vignettes, Brian McKinstry.

[2] e.g. Griffiths Inquiry, Shipman murders, Neale case, etc

[3] Vickers and Zollman series BMJ 1999

[4] some examples include:

“The higher one's income, the less likely he or she will be to
smoke...higher education in general is inversely related to smoking. There
is a pattern of higher smoking prevalence among blue-collar workers than
white-collar workers.”

Cigarette smoking by socioeconomic group, sex, and age: effects of
price, income, and health publicity, J Townsend, P Roderick, J Cooper ,
BMJ 8 Oct 1994

[5] Scottish smoking survey:
Smoking and Income Since the 1960s smoking rates have declined more
sharply in higher income groups.
“In 1994 data from the General Household Survey shows a smoking rate that
is more than twice as high among women in households with an unskilled
manual head of household than women in social class I....Women in higher
social groups have changed their smoking behaviour in line with health
education advise earlier and in larger numbers than women in low income

“smokers are twice as likely to be in social class V than I or II.
49% as opposed to 23%...”

“As can be seen from Table 4.17, informants in manual social classes
were not only more likely to smoke than those in non-manual social
classes, their average consumption of cigarettes was also higher.”

Competing interests: No competing interests

10 October 2000
Peter Morrell
Hon Research Associate, History of Medicine
Staffordshire University