Airing uncertainty can be positive

EDITOR—Little et al say that doctors should be aware that airing their uncertainties might reduce satisfaction and empowerment.1 This conclusion is not really supported by their research because the positive approach statements dealt with the patient's problem and not the specific diagnosis. It is possible for the doctor to acknowledge uncertainty about a diagnosis or prognosis while giving the patient a clear positive message about what they can expect to happen, or what the doctor thinks they could do about the problem and what to do if things do not go according to expectation.

This safety net is likely to be perceived as positive by the patient, who may feel even more empowered as the doctor has clearly planned for the uncertainty that all patients know exists. Pretending to know the future or exact diagnosis fools no one and is likely to lessen satisfaction and empowerment. Helping patients to handle uncertainty effectively is an important part of enablement. This clarification of what is meant by a positive approach should be addressed in future research.

Partnership of patient and doctor may provide key to patient satisfaction

EDITOR—The observational study by Little et al of the effects of patient centredness on the outcomes of consultations 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 Although this research has specific contextual limits, it also suggests a way forward that allows increased expertise on the part of the patient to be taken seriously and engages with the changing ways that medical knowledge circulates in the wider society, including the media.

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 general practitioners for information about their pharmaceutical treatments, but they distinguish between information and wider perspectives on living with HIV.4 Their negotiation of decisions about treatment occurs in 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 seem 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 understood. If we locate interactions between doctors and patients in 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. Focusing solely on the consultation increases the pressure and the likelihood of dissatisfaction with the doctor and the practice of medicine.

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 reinforces the pressures on the consultation. Counsels of perfectibility tend to produce resentment and lower self-esteem, adding to the desire to leave general practice.5

We think 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.