The capacity of professional medicine to resist change

and also concordance is impressive, but perplexing. It is one of the issues I seek to address in this book. I suggest that a preoccupation with trying to change the relationship between the professional-patient dyad has deflected attention from the extent to which such relations are embedded in, and constrained by, wider administrative and organisational structures, especially as these relate to the operation of professional hierarchies and interprofessional deference and allegiances.

Barriers to change also result from the inertia of a system which has evolved a highly stylised etiquette as an adaptive mechanism to contain the difficulties and tensions intrinsic to the medical consultation. Its therapeutic purpose and potential are often subordinate to the goal of achieving success as a social encounter.

The principles of concordance are deeply challenging to traditional professional roles and status. However, medicine has always displayed an ability to block change through tactics of appropriation and incorporation. Professionals have often shown particular difficulty giving up their monopoly of expertise and in acknowledging the legitimacy of the patient perspective.

Although the term concordance has become quite widely used, its meaning is usually subverted by its employment as a synonym for compliance, albeit informed compliance. A slightly more sophisticated version values professional elicitation of the patient perspective in order to more accurately tailor information as a means of overcoming the unhelpful misconceptions that impede compliance.

The original emphasis on the consultation as a negotiated exchange, in which the professional has something of value to learn from the patient, has largely been lost. The rhetoric of modernity and change provides an effective mask for inertia and conservatism.

Preface.