Do Zola’s triggers need re-evaluating for 21st century primary care?

Alex Burrell is an ST4 Academic Clinical Fellow in General Practice based in Bristol, and an Editorial Fellow at BJGP & BJGP Open

During a recent gathering of friends from medical school who now span various countries, specialties, and stages of training, we were discussing which subjects from pre-clinical training we still regularly used in our day-to-day practice. As a student I was drawn to sociology and ethics, and the teaching which immediately came to mind was on Zola’s triggers for consulting.

Described in his 1973 paper ‘Pathways to the doctor—From person to patient’,1 Zola, who was Mortimer Gryzmish Professor of Human Relations at Brandeis University in Massachusetts, argues that three academic assumptions made around healthcare-seeking behaviour are wrong. First, that ‘individuals at most times during their life are really asymptomatic’; second that it is the severity or frequency of symptoms which leads people to consult; and third that people who do not seek healthcare when experiencing symptoms are irrational. In breaking down these assumptions, Zola discerns five ‘triggers to the decision to seek medical aid’:

  1. The occurrence of an interpersonal crisis
  2. The perceived interference with social or personal relations
  3. Sanctioning – seeking help when pressured or advised by others
  4. The perceived interference with vocational or physical activity
  5. Temporalizing of symptomatology – e.g. setting a time limit before seeking advice

Despite being cognisant of these triggers, I had never previously read the paper in full to understand how they were established and how relevant they are today.

…patients whose trigger was not acknowledged or paid attention to were most likely to ‘break off treatment…’

The data were collected in three outpatient clinics (‘eye clinic’, ENT, and general medical) at Massacheusetts General Hospital in adult patients aged 18-50. These patients were either Italian, Irish Catholic or Anglo-Saxon protestants as ‘the three most populous ethnic groups’. The triggers are then discussed as being ‘clustered in such a way that we could characterise each ethic group…as favouring particular decision-making patterns in the seeking of medical aid’. For example, sanctioning is described as ‘the overwhelming favourite of the Irish’. Much of the paper is focussed on differences in triggers between the groups examined and their outcomes, with Italian patients frequently diagnosed with ‘some psychological difficulty’ and Irish and Anglo-Saxon patients given a ‘neutral diagnosis’ despite the fact they presented with similar psychological and social problems. Perhaps the most relevant conclusion which will ring true for anyone working in primary care was that patients whose trigger was not acknowledged or paid attention to were most likely to ‘break off treatment’. As Zola puts it, ‘without attention to this phenomenon the physician would have no opportunity to practice his healing art’.

Whilst the triggers identified still ring true anecdotally, this study has several significant limitations when applying the findings to modern primary care. It was conducted in one hospital centre in an outpatient specialist clinic setting with older adults excluded and the findings are now 50 years old. How much do these principles apply to remote or asynchronous consultations? Do these same triggers exist across routine, urgent, and out-of-hours settings? What is the impact of perceived or actual barriers to accessing GP appointments? “Why now?” is still a, if not the, key question we ask our patients and improving our understanding of the answers across symptoms and settings has the potential to enable us to provide better care for those who do present and develop interventions to reach those who may not.


  1. Zola IK. Pathways to the doctor—From person to patient. Social Science & Medicine (1967). 1973;7(9):677-89.

Featured photo by Towfiqu barbhuiya on Unsplash

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