Introduction

Health threatening behaviours are the commonest cause of premature illness and death in the developed world, affecting the sustainability of our health services and society.1 Almost every healthcare worker interacting with almost every patient has an important opportunity to change health behaviour. Examples include a general practitioner talking to a patient about smoking or exercise, a health visitor engaging a mother about her child's diet, an accident and emergency house officer talking to an injured patient about alcohol, a renal nurse discussing fluid intake, and a dental hygienist discussing flossing. These consultations can be difficult to navigate, however, and practitioners often make a cursory attempt to satisfy external guidelines or end up avoiding the subject altogether. Here, we consider how the flexible use of a guiding style could make health promotion more satisfying and effective.

Skilfulness makes a difference

The challenges of changing health behaviour have parallels in everyday life. For example, the more we raise the stakes in telling a child to do something, the more likely conflict will follow. “Please get into the bath, now!” is often followed by, “But I am not dirty!” In the more polite confines of the consulting room, weariness is a common reaction.Doctors feel pressure to do more to prevent the effects of health compromising behaviourson their patients. Yet, doctors say they are not social engineers, cannot dictate the lives of their patients, and were trained primarily for diagnosing and treating medical conditions not monitoring and modifying their patients'behaviour. When they raise health behaviour, clinicians usually default to a directing style of interacting with their patients.

It is not difficult to distinguish discussions that go well from those that go …