More recently, Stewart & Roter re-classified the three models of the DPR to four: paternalistic (equivalent to active-passive), mutuality (corresponding to mutual participation), default (corresponding more loosely to something between the active-passive and co-operation-guidance) and consumerist, which had equivalent in Szasz & Hollender’s model. The consumerist perspective acknowledges the fact that patients increasingly have a choice and means to object or complain if dissatisfied - this may be professionally or, increasingly, through litigation (suing the doctor).

However, all of these models suffer frm the problem of being “state” models - they fail to acknowledge that DPRs are not static states of being but dynamic exchanges which may vary as the needs of the situation vary - at certain times a paternalistic approach is needed - such as when the patient is unconscious in the A&E after an accident, while a week later there is a mutuality or negotiated relationship when the orthopaedic surgeon offers a choice of methods for fixing a damaged limb.

The state models were then, superceded by models which tried to accommodate this dynamic element of the DPR.