Byrne and Long on the Consultation
Publication: ‘Doctors Talking to Patients’, Byrne & Long (1976)
The book is as fascinating to read now, as it was when it was first published in 1976. They
spent three-and-a-half years examining doctors’ consultations. The final analysis not only
provided detailed descriptions of actual consultations but also 'a set of instruments with
which the solo learner could provide himself with feedback to facilitate his self-learning'
(p132). One single instrument they suggested was for the doctor to ensure that he always used
the following 6 phases which form a logical structure to the consultation:
The 6 Phases of the Consultation
Phase I
The doctor establishes a relationship with the patient.
Phase II
The doctor either attempts or actually discovers the reason for the patient’s attendance.
Phase III
The doctor conducts a verbal or physical examination or both.
Phase IV
The doctor, doctor and patient, or the patient (in that order) consider the condition.
Phase V
The doctor, and occasionally the patient, detail further treatment or further investigation.
Phase VI
The consultation is terminated usually by the doctor.
They then divided the analysis of the 'consultation' into consultation and prescribing phases,
and discovered that there were
 4 distinct styles of consultation and 7 distinct prescribing styles.
 a range of verbal behaviours doctors used when talking to their patients.
 a spectrum ranging from a heavily doctor-dominated consultation, with any
contribution from the patient as good as excluded, to a virtual monologue by the
patient untrammelled by any input from the doctor.
 Between these extremes, they described a graduation of styles from closed
information-gathering to non-directive counselling, depending on whether the doctor
was more interested in developing his own line of thought or the patient’s.
Robin Beaumont, 2010
Behaviours – doctor-centred, patient-centred and the negative
Bryne & Long provide several checklists
('instruments') that the doctor can use to help access
her/his degree of patient/doctor centeredness as well
as their use of negative behaviours (p146). We have
provided the lists of items below :
Doctor Centered Behaviour
 Offering self
 Relating to some previous experience
 Directing
 Direct question
 Closed question
 Self-answering question (rhetorical)
 Placing events in time or sequence or
place
 Correlational question
 Clarifying
 Doubting
 Chastising
 Justifying other agencies
 Criticising other agencies
 Challenging
 Summarising to close off
 Repeating what patient said to
affirmation
 Giving information or opinion
 Advising
 Terminating (direct)
 Suggesting
 Apologising
 Misc. Prof. Noises
 Suggesting or accepting collaboration
Patient Centered Behaviour
 Giving or seeking recognition
 Offering observation
 Broad question or opening
 Concealed question
 Encouraging
 Reflecting
 Exploring
 Answering patient question
 Accepting patient ideas
 Using patient ideas
 Offering of feeling
 Accepting of feeling
 Using silence
 Summarising to open up
 Seeking patient ideas
 Reassuring
 Terminating (indirect)
 Indicating understanding
 Pre-directional probing
Negative Behaviour
 Rejecting patient offer
 Reinforcing self-position (justifying
self)
 Denying Patient
 Refusing patient ideas
 Evading patient questions
 Refusing to respond to feeling
 Not listening
 Confused noise
Robin Beaumont, 2010
Prescribing Styles
Byrne & Long 1976 devote a whole chapter to the various approaches taken by UK GP's to delivering a
diagnosis and treatment (they called it 'prescribing') to patients. They identified seven different styles, on a
continuum from being extremely doctor-centred to patient- centred:
'Prescribing' styles
(Byne & long 1976 p106)
Incidence
in sample
Example
Additional information
(definitions in Bryne & Long
1976)
N=1965(p106)
The doctor makes a
decision about the
patient and his
treatment and then
instructs the patient to
seek some service.
[Style 1]
The doctor makes his
decision and
announces it.
[Style 2]
The doctor sells his
decision to the patient.
[Style 3]
624
"I want you to take these tablets and
come back in two weeks, Bye-bye"
680
"This is an infection of the lung. I want
you to go upstairs and have an X-ray
now. When you have had that come
back here and I will detail the treatment"
Now then, I would like you to take this to
the chemist. . . .don't worry it is no more
serious than last time . . .right then off
you go. Cheerio"
The doctor presents a
tentative decision
subject to change.
[Style 4]
279
57 on its
own
70 as a bac
up strategy
=127
". . .I think you need a long rest. Now
then, how do you think you can cope
with that?"
Afterwards there is a discussion on
length and time of rest
agreed.
The doctor presents the
problems, seeks
suggestions and makes
decisions. [Style 5]
159
Similar to the previous style but the
doctor directs the patient to come up
with suggestions which he takes up.
The doctor defines the
limits and requests the
patient to make a
decision.
[Style 6]
35 primary
strategy
39
secondary
strategy
after
failing with
styles 1 and
2
=74
". . .this condition is no more than a
simple appendicitis. It can be quickly
treated by surgery, although at this
stage that is not the best possible
answer. I can also treat you at home
with some drugs. This treatment will
take a short time if you rest. If you have
to keep working then the treatment will
take rather longer, and may not be so
effective. The choice is yours."
The doctor permits the
patient to make his own
decision.
[Style 7]
22
Typical behaviours
". . . .Well you know medical opinion can
be a terribly fickle thing. Years ago we
would have had it out by now . . .Given
what you have , I don't think I would
advise an operation . . ."
". . . what I want you to think about is
what we should do next . . ."
Notice no mention of a
diagnosis
Directing
Direct termination
Giving information
Directing
Terminating
Diagnosis, treatment and
reassurance
Diagnosis, treatment and
mutual understanding.
Danger of 'I will if you
will' game (p108)
Doctors have very
different opinions about
this style as a treatment for
hypochondriacs
[negative attitude] or
when they face a an
emotional problem and
do not know what to do
about it [more positive
attitude]
Giving information
Directing
Reassuring
Seeking patient ideas
(but not
using them)
Direct Termination
Giving information or
opinion
Directing
Advising
Answering patient
questions
Reassuring
Seeking patient ideas.
Indicating understanding
Using patient ideas
Giving information or
opinion
Advising
Clarifying
Reflecting
Exploring
Seeking patient ideas
Using patient ideas
Offering collaboration
Terminating (indirect)
Giving information
Answering patient
questions
Seeking patient ideas
Using patient ideas
Summarising to open up
Pre-directional probing
(i.e. If I said X how
would you react?)
Reflecting
Encouraging
Seeking patient ideas
Using patient ideas
Robin Beaumont, 2010
Exercise A
1. Use the following tools with some of your own video consultations or for providing
feedback through observing another colleague’s consultation directly (i.e. sitting in).
2. For the particular consultation that you have observed, now decide which of the above
prescribing styles is the most appropriate. Provide reasons.
3. Finally, in relation to what you’ve decided in 2., how could the consultation have been
improved? What might the doctor need to work on in the future?
Exercise B
Why do you think some doctors had a negative attitude to prescribing style 7? Can you think
of ways this attitude might be modified? Is it still the case today?
Closing statement
The above description of how doctors describe various treatment strategies to patients is
fascinating and I recommend anyone to read Bryne & Long's 1976 report although it is an
academic paper it is written in such a manner as to be extremely exciting at times.
While the research of Bryne & Long, 1976 is old nothing on this scale has been repeated and
certainly nothing with such rigor in the nurse practitioner or other health care group that has
taken on the role of undertaking consultations. This is a great shame as one would like to
think things have moved on towards a more patient centred approach.
Robin Beaumont, 2010