Margit Kooijman

118 chronic problems 5 . In addition, facilitation of timely access to care contributes to a positive patient experience and satisfaction 7 . Factors determining referrals amongst clinicians have been expounded upon and were found to be exceedingly complex 8 . A high rate of referrals between clinicians could indicate willingness to collaborate in the patient’s best interest. In practices performing musculoskeletal ultrasound, many requests come from GPs and physiotherapists performing musculoskeletal ultrasound tend to refer more quickly and specifically for consultation with a GP in case of conflicting findings (chapter 5) . At the same time, a high rate of referrals between clinicians could also suggest insecurity on the right management including keep/refer decision-making. In patients with severe or long-lasting complaints, GPs and physiotherapists seem to start treatment and refer for other treatment at the same time (chapter 3). Previous research showed that information on the keep/refer aspect of care is lacking in most guidelines 9 . Content of care The tendency toward action rather than inaction by clinicians, is a likely reason why general practitioner and physiotherapist treatment contain a myriad of different interventions simultaneously and correspond less with each other in subgroups of patients with shoulder pain characterized by persisting complaints or when pain is prominent (chapter 3) . Also from the literature it is known that when patients report considerable hindrance, clinicians will more often consider an active treatment option 10 . Less obvious but probably not less important, commission bias can also be recognized in the finding that both clinicians indicate they do not pay too much attention to giving advice and to the psychosocial aspect(s) of the complaint, more so in patients with persisting complaints (chapter 3) . Research reveals that patient education was viewed as important by patients but not physiotherapists. This ambivalence may raise the issue of how physiotherapists see their role and scope of practice and what are considered ‘skills’ for good treatment 11 . Limitations A potential downside concerning the results presented in this paragraph is that data are partly based on clinical vignettes and partly on electronic health records. Clinical vignettes measure stated rather than actual practice with the risk of socially desirable answers. Another disadvantage is that neither method provides the possibility of in- depth questions and nuanced responses, thus sometimes withholding us the opportunity for evenly nuanced conclusions and recommendations. So where do we go from here? In the light of the results above and our aim towards positive health, I suggest that for primary care clinicians, taking the role of coach and making time for a good conversation is the first step forward. Providing knowledge is important for changing beliefs, self- efficacy and thus treatment outcomes 12 . Models on lay perspectives, i.e. how people