Volume 51, Issue 8, August 2022


Sophia Samuel   
doi: 10.31128/AJGP-08-22-1234e   |    Download article
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Persuasive words enter into my words and rearrange them from within. Whereas authoritative words might be accepted or rejected.1

My first exhilarating invitation to collaborate in general practice came as a new registrar. I was thrilled when patients returned asking for me by name. I wanted to emulate inspiring general practitioners (GPs) and reach into the heart of every medical difficulty, bringing cure and comfort. With the foundational skills needed to help ‘whoever walked in the door’, achieving Fellowship would be confirmation of mastery in my chosen field. Applying the medical sciences meaningfully and ethically remains technically challenging and ever evolving.

The second invitation, later that year, was ambivalent. A medical educator and I were analysing a consultation with a patient who wanted a knee X-ray (XR) to diagnose early osteoarthritis (OA).

Me: OA is diagnosed on history and examination, an XR doesn’t correlate with symptoms.

Educator: She still wanted it ...

Me: Don’t the guidelines say the XR is wrong?

We seemed to be working at cross purposes.

Therapeutic journeys can stall, despite good intentions. The experience of possessing requisite knowledge and an evidence base in reserve and then to have it seemingly count for little in practice has become familiar since then. One must negotiate and compromise, but on which grounds or why?

The academic concept of monologic and dialogic truth from education and literary theory may offer help.1,2 Think of a novel in which the characters are flattened stand-ins for the author’s ideology, and compare that to one in which they stand out in imagination long after the book ends. Or the teacher who intimidates with knowledge, and one who instills confidence in learning. Monologic truths are unchanging, impersonal and independent; differences may be present but are ultimately subsumed. Patients tell their symptoms or acquiesce to treatment but do not influence medical understanding of disease. Dialogic truth is open-ended and requires relational contact between multiple embodied voices that agree and disagree. In the consultation, when my patient and I were disputing truths, had I created dialogic space, we could have begun again with her explaining her reasoning to me.

Dialogic truth can also illuminate clinical and academic interactions between healthcare professionals. A child may present with recurrent periumbilical abdominal pain to a GP, emergency physician and gastroenterologist and be appropriately yet differently assessed and managed by each. Each has an expert voice distinctive to their context.

The notion that medical practitioners might seek to augment perspectives, rather than replace wrong ideas with right ones, can be troubling when significant health outcomes are at stake. Missed immunisations, medication interactions, delayed diagnoses and futile treatments are independently verifiable as generally harmful. They are also complex, interlayered and longstanding problems where different voices enhance cooperation.

Simply having multiple representatives present does not mean that dialogue will take place. Voices that disagree with the group’s ethos can be ignored or be too far apart to bridge. Power imbalances compromise the ability of others to even speak. I recollect the silence that followed one three-hour meeting, broken by a participant stage-whispering ‘computer says no’ after the leaders left.

Some observations on what seems effective: first, participants must all be able to accept an uncertain outcome for the sake of a problem they wish to solve or a point of ambivalence they agree to explore. In the dialogue, begin by taking turns so that all can speak, and speak authentically. After a while, ideas will bounce around and flow without being owned by a single person. Not every voice will be equal – some will speak more with the group’s agreement than others; some will not agree. Resist closing with the definitive, all-encompassing solution.

While GPs’ knowledge and experience primes them to be skilled at problem solving, not every solution is accepted. The idea of dialogic truth may be a concept that can help all parties move closer to thinking creatively together.

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  1. Wegerif R. Rupert Wegerif’s blog [internet]. What is ‘dialogic space?’. 5 February 2016. Available at [Accessed 26 June 2022]. Search PubMed
  2. MM Bakhtin. The dialogic imagination – Four essays. Edited by M Holquist. Austin, TX: University of Texas Press, 1981. Search PubMed

CollaborationGeneral practice

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