John Goldie is a retired GP and medical educator
Over the last two years I have written a series of articles for BJGP Life/Life and times tentatively exploring what could be seen as a philosophy of general practice.1-23* Writing this series, a pattern gradually emerged: clinical understanding forms in practice under conditions of uncertainty. It is not applied to the consultation; it is shaped within it. By the time patients arrive, interpretation is already underway—informed by prior experience, digital tools, and shared narratives that shape what symptoms can mean.
Earlier essays explored the lived experience of illness and the moral texture of practice—empathy, suffering, continuity, attention, and the hierarchies shaping whose accounts are heard. Whether considering the boundaries of consciousness, the social framing of illness, or the diagnostic vacuum of medically unexplained symptoms, a shared issue emerged: clinical work requires us to interpret experiences that often exceed standard clinical vocabularies. In this setting, uncertainty is not a flaw but a condition of practice.
Symptoms do not arrive neutrally; they are already configured by prior understandings on both sides of the consultation.
From there, the focus shifted to how we make sense of what patients bring. Perception, expectation, and prior experience shape what is noticed as significant. The frames we inherit—from notes, training, risk tools, and accumulated encounters—make work under pressure possible, but they also define what can be seen. Symptoms do not arrive neutrally; they are already configured by prior understandings on both sides of the consultation. Clinical reasoning is therefore less a matter of discovering meaning than negotiating it.
Clinical understanding, then, is not the application of knowledge to cases but the ongoing formation and revision of meaning within a process already under way. Diagnosis becomes a provisional stabilisation rather than a final endpoint—something achieved for now rather than settled once and for all. The question shifts from what is the diagnosis? to how has this understanding come into being, and how open is it to revision? This reframing places the clinician within, rather than outside, the interpretive process.
A patient’s “tight chest,” for example, arrived already linked to an online risk score. The symptom had been framed primarily in terms of risk, narrowing interpretation. Asking when the tightness began, and what the patient was doing at the time, returned it to lived experience, revealing a pattern of situational anxiety that had been obscured. The work here was not simply diagnostic but interpretive—loosening a prematurely narrowed frame so that alternative meanings could re-emerge.
Within this process, a further difficulty becomes visible: interpretive drift. This is not a discrete error or bias, but a gradual divergence between a patient’s experience and the clinician’s working frame. It is difficult to detect precisely because it continues to make sense on its own terms. The very structures that enable efficient reasoning—familiar patterns, prior probabilities, established narratives—can quietly become anchors, carrying understanding away from what the patient is trying to convey. Drift often becomes apparent only when something no longer fits: when a patient says, “Actually, it wasn’t the pain that worried me, it was the way it came on,” and the frame shifts. Such moments are not interruptions to reasoning but prompts for recalibration.
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nderstanding in general practice is therefore always provisional—shaped by histories, technologies, expectations, and the slow drift of interpretation.
The task, then, is not to replace one framework with another, but to work more deliberately within this movement. Interpretive openness is the disciplined capacity to hold interpretations lightly while they are being formed: to keep them provisional, to test them against what emerges, and to remain responsive to what does not fit. Its absence is premature closure, a frame hardening too quickly leaving alternative meanings unexplored. In practice, interpretive openness may amount to no more than a question that re-situates a symptom, or a moment’s hesitation before settling. Such small adjustments can alter the trajectory of a consultation and, over time, support a more adequate understanding.
The discussion so far suggests a further implication: clinical reasoning does not reside solely within the clinician. Understanding is distributed across people, records, technologies, routines, and patients themselves—for example, in prior notes, risk calculators, and referral pathways that shape what is thinkable in the moment. Judgement arises through interaction with these relatively stabilised forms of meaning. The consultation is less a discrete moment of decision than a site of coordination, where different strands are brought into provisional alignment. Yet this network is not unconstrained. It eventually meets the resistance of physical reality: biological processes that do not conform to expectation, patterns that fail to hold. It is often this resistance that prompts revision.
Understanding in general practice is therefore always provisional—shaped by histories, technologies, expectations, and the slow drift of interpretation. Each consultation joins an ongoing trajectory rather than standing alone. The task is not to force coherence too soon, but to work within this movement: to notice when meaning narrows, to reopen it when it drifts, and to revise frames when something unexpected appears. In a system that rewards speed and resolution, the greater risk may not be uncertainty, but closing the question too early. Good practice depends on keeping it open long enough for understanding to form—and staying attentive enough to recognise when it must change.
*Deputy editor’s note: We do not normally encourage this many references. However the reference list below serves as a bibliography of John Goldie’s articles in BJGP Life/Life and Times, and readers are encouraged to browse! Authors are advised to look at our guidelines prior to submission here: https://bjgplife.com/contribute/
References
- Goldie J. Information exchange: consciousness and different worldviews in the consultation. BJGP Life 2025; 24 September. Available from: https://bjgplife.com/information-exchange-consciousness-and-different-worldviews-in-the-consultation
- Goldie J. The consciousness conundrum. BJGP Life 2025; 16 October. Available from: https://bjgplife.com/the-consciousness-conundrum
- Goldie J. How do we know if what we know is true. BJGP Life 2025; 6 November. Available from: https://bjgplife.com/how-do-we-know-if-what-we-know-is-true
- Goldie J. Sentience without borders: ethics beyond the brain. BJGP Life 2025; 27 November. Available from: https://bjgplife.com/sentience-without-borders-ethics-beyond-the-brain
- Goldie J. Becoming a doctor, becoming ourselves: socialisation, power and the hidden curriculum in medical education. BJGP Life 2025; 16 December. Available from: https://bjgplife.com/becoming-a-doctor-becoming-ourselves-socialisation-power-and-the-hidden-curriculum-in-medical-education
- Goldie J. Smarter than scores: rethinking intelligence in practice. BJGP Life 2025; 23 December. Available from: https://bjgplife.com/smarter-than-scores-rethinking-intelligence-in-practice
- Goldie J. Dwelling in uncertainty: the GP’s expertise. BJGP Life 2025; 30 December. Available from: https://bjgplife.com/dwelling-in-uncertainty-the-gps-expertise
- Goldie J. Three strikes: then we rethink — JESS rule in practice. BJGP Life 2026; 14 January. Available from: https://bjgplife.com/three-strikes-then-we-rethink-jess-rule-in-practice
- Goldie J. How doctors learn not to listen. BJGP Life 2026; 21 January. Available from: https://bjgplife.com/how-doctors-learn-not-to-listen
- Goldie J. On becoming: empathy at the deep end. BJGP Life 2026; 4 February. Available from: https://bjgplife.com/on-becoming-empathy-at-the-deep-end
- Goldie J. The consultation beneath the consultation. BJGP Life 2026; 20 February. Available from: https://bjgplife.com/the-consultation-beneath-the-consultation
- Goldie J. Time is the physics of care. BJGP Life 2026; 18 March. Available from: https://bjgplife.com/time-is-the-physics-of-care
- Goldie J. Medicines: caste system of the mind. BJGP Life 2026; 25 March. Available from: https://bjgplife.com/medicines-caste-system-of-the-mind
- Goldie J. Small acts, deep knowing. BJGP Life 2026; 1 April. Available from: https://bjgplife.com/small-acts-deep-knowing
- Goldie J. How we construct illness: premenstrual syndrome and the stories behind the illness. BJGP Life 2026; 8 April. Available from: https://bjgplife.com/how-we-construct-illness-premenstrual-syndrome-and-the-stories-behind-the-illness
- Goldie J. The first clinical decision of the day. BJGP Life 2026; 15 April. Available from: https://bjgplife.com/the-first-clinical-decision-of-the-day
- Goldie J. The myth of the autonomous clinician. BJGP Life 2026; 29 April. Available from: https://bjgplife.com/the-myth-of-the-autonomous-clinician
- Goldie J. Hesitation or humility: the consultation is already doing the theory. BJGP Life 2026; 18 May. Available from: https://bjgplife.com/hesitation-or-humility-the-consultation-is-already-doing-the-theory
- Goldie J. Against interpretive drift in the consultation. BJGP Life 2026; 3 June. Available from: https://bjgplife.com/against-interpretive-drift-in-the-consultation
- Goldie J. Making Sense Together After Algorithms. BJGP Life 2026; 22 June. Available from: http://bjgp.com/making-sense-together-after-algorithms
- Goldie J. General practice: medicine’s living philosophy. Br J Gen Pract 2026; 76(723): 2-3 DOI: 10.3399/bjgp26X744345
- Goldie J. Who decides what counts as illness? Br J Gen Pract 2026; 76(724): 78-79.DOI: 10.3399/bjgp26X744657
- Goldie J. The surgery that thinks. Br J Gen Pract 2026; 76(726): 162-163.DOI: 10.3399/bjgp26X745785
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