Research on communication reveals, as one might expect, that practitioners vary considerably in how they exchange information, and that outcome can be improved if information is clear and simple, and if practitioners negotiate and agree on treatment goals in a cooperative manner (Becker 1985). Although these findings are obviously useful, much of the research on compliance is based on the notion that behavior change is best ‘induced’ by the expert-driven delivery of clear information, a view we explicitly reject (see Butler et al 1996).

Of more direct relevance, has been the work on patient empowerment and the patient-centered method carried out by a number of North American research teams. Not all of this research focuses on information exchange, although a number of studies, reviewed by Stewart (1995), have looked explicitly at the process of history-taking. Four correlational studies, all of them in outpatient settings, reveal that during history-taking, activities like a full discussion of the problem, the asking of questions by the patient, providing information, and giving emotional support are all associated with better outcomes, such as the resolution of headaches and numerous other physical symptoms. Two randomized controlled trials found that practitioner training in history-taking improved levels of psychological distress in patients, and another two studies found that brief patient education (20 minutes) in how to ask questions not only improved participation but led to improved physical health such as control of blood pressure and blood glucose levels.

Of course, information exchange does not only occur during history-taking. A number of other studies of patient empowerment have involved the training of patients to be more assertive in other phases of the consultation. Thus, Innui et al (1976) found that giving patients greater control over what is talked about and encouraging them to seek personally relevant information can improve outcomes like control of blood pressure. Greenfield et al (1988) demonstrated that people with diabetes who were trained to be more involved in the consultation had better health outcomes than those who were not trained. Similarly, patients seen by health educators and coached to ask questions made better use of appointments over the following months (Roter 1977). Therefore, this approach is by no means new, conceptually. The challenge has been to translate research findings into better practice across the board.

Finally, it is worth taking note of Silverman’s (1997) observation of a feature of advice-giving which avoids being too personal and eliciting resistance: if the advice is couched in terms of information, i.e. in a broader, more neutral context, patients seem more likely to respond favorably.

In summary, there is clear evidence that if patients are more assertive during information exchange, outcomes can be improved. There is much less evidence that practitioners can be trained to improve their skills. There are clear correlations between elements of good-quality information exchange and patient outcome.

A second source of innovation comes from the work of William R. Miller on motivational interviewing in the addictions field. He found a way of training counselors to encourage curiosity, question-asking and personal reflection among clients about the meaning of information provided to them. This process, it turns out, can have a powerful effect on people’s decision-making. It appears that this is not just a matter of presenting appropriate information clearly to people, but of distinguishing between ‘facts’ and their interpretation. In these drinkers’ check-up studies (see Miller & Sovereign 1989), the counselor provided the facts in a non-judgmental, neutral manner, and then encouraged the patient, through the use of simple open questions, to arrive at a personal interpretation of them. More detail about this process can be found in Miller et al (1988). The ideal outcome would be for the patient to say or think, I see, I never thought about it like this before, I wonder if this means that…Strategy 1, outlined below, is based on this aspect of motivational interviewing. It was refined further in the development of brief motivational interviewing (Rollnick et al 1992), where a clearly defined and documented information exchange strategy was taught to a group of general healthcare workers doing health promotion work with heavy drinkers in a general hospital (Heather et al 1996). Rollnick et al (2008) devote a whole chapter to the skills of informing in the context of motivational interviewing in a healthcare setting, and note that, ‘a relationship, even if it lasts no more than a few minutes, lies at the heart of informing’ (p. 88).

What emerges from these developments is a view of information exchange as part of a delicately balanced conversation. It does not need to be a sterile, expert-driven activity. From a conceptual viewpoint, we do not adhere to the view of information exchange as a practitioner-driven process either of eliciting facts from patients (assessment) or of providing them with information (feedback). In both such activities, the patient will be driven along by the agenda of the practitioner, who will do most of the talking. Instead, we view the process in terms of the following circular elicit–provide–elicit process described below (Strategy 1).