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5. Discussion

Most of the studies included in the review examined whether or not the basic building blocks for concordance, such as patients and professionals asking each other questions, were happening in practice. However, there was limited research on issues such as the exchange of views about medicines or health professionals encouraging patients to participate in decision-making, which are essential elements of a concordant interaction. Consequently it is difficult to draw conclusions about the extent to which concordance is actually happening.
Much of the research indicated that communication between patients and professionals retains the asymmetry typical of paternalistic health care professional-patient interactions. In addition, a number of potential barriers to concordance were identified which were associated with health care professionals not facilitating patient participation or with patients feeling unable to participate in the consultation or that it was not appropriate for them to do so. Therefore, the evidence examined in this review suggests it is unlikely that concordance is taking place. On a positive note though, there was evidence of the possibility of a move towards concordance if, for example, patients become more confident in their knowledge of medicines or if doctors encourage patient participation and listen attentively to patients' views and concerns. The research also suggested that such a move may lead to improved outcomes, including enhanced adherence and satisfaction.
 As the research included in the review was conducted in a range of countries and settings and involved various methodologies it was difficult to make overarching generalisations. Further research is needed to look at whether or not an exchange of views is taking place in consultations, whether patients and professionals form partnerships, and the impact of concordance on issues such as the relationship between health care practitioners and patients, patients' further use of services, and adherence.

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