This article deals with one form of interactional asymmetry in doctor–patient consultations, that of initiative: Doctors primarily initiate actions and solicit responses, whereas patients primarily respond to doctors' initiatives. This article argues that the variable of initiative actually contains two dimensions: speaker initiative and utterance constraint. It then reviews and critically evaluates prior accounts for these asymmetries. These accounts are almost exclusively ‘professional’ in nature, relying upon features of the social organization of the profession of medicine, medical contexts, or institutionalized medical activities. This article argues that asymmetries of initiative can and should initially be accounted for in terms of the everyday social organization of action. The primary organizing sequential structure for action is the adjacency-pair sequence, which embodies an intersubjective set of normative standards for producing and understanding behavior. This article supports a ‘mundane’ account of asymmetry with a conversation analytic, single-case analysis of a patient request for a renewal of a prescription.