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Dealing with different types of patients

In the first of an occasional series on communication skills, Dr Peter Tate explains how to explore patients' agendas

In the first of an occasional series on communication skills, Dr Peter Tate explains how to explore patients' agendas

The health belief model is the most researched and validated description of patients' beliefs about health and related matters. One of its concepts is the 'locus of control', which is jargon for how we explain to ourselves what is likely to happen to our health. Using this idea we can divide the human race into three types of people, summarised below.

Influencing the 'locus of control'
When Mrs Arthur first went to her GP she had prepared her speech, but she did not feel in control of the situation, nor was she fatalistic. She wanted the doctor to take the lead, but she did expect a referral and an explanation. She could not be pigeonholed into any of the three categories described below but perhaps is closest to a 'powerful other' who, with support, judicious involvement and some education, can be helped to take more control over her worrying illness.

The good thing about locus of control as far as doctors are concerned is that it can be influenced. It is rather like political affiliation – most of us lean to the left or the right, but can sometimes be cajoled to vote the other way. Similarly, locus of control in most people is a tendency, not a fixed aspect of their personality.

We humans are not necessarily consistent. For example, I may be a fatalist, but I still buy big chunky cars, believing them to be safer for my family and perhaps for me.

If it is correct that the communication strategy of the medical profession should be directed towards increasing people's tendency to look after their own health and take some responsibility for their health – and I believe that it should – only the 'internal controllers' are going to accept this idea readily. The other 50-60% of patients are going to need some persuading.

However, the effort may be worthwhile for several reasons, not least because it is likely to lead to more patients following more medical advice. In a review of the literature in 2001 it was found that for five behaviours, the odds of healthy behaviour were more than 40% higher among individuals in the internal controller category. Fatalist scores were associated with a reduction of more than 20% in the likelihood of healthy options for six behaviours, whereas powerful others' scores showed more variable associations with healthy actions.

Caution on control
Now a cautionary thought about control. Consider type 1 diabetes. Many young females with diabetes quickly discover that letting their sugar levels rise produces weight loss – high sugar equals small bum. So they make a decision to put their health at risk in the long term for a short-term reward. Is this internal control or fatalism?

What works
If patients all require different styles of communication depending on their locus of control, and research suggests that we doctors have on balance pretty inflexible styles, then how are we, as doctors, going to acquire the necessary flexibility without spending all our lives at communication workshops? Heaven forbid.

The answer must be to explore our patients' agendas. If we know their beliefs, and have an inkling about their locus of control, we can try to follow at least some, if not necessarily all, of their agenda, and talk to them about what matters to them and to us. Communication will therefore become tailored to the individual.

The three types of patient

The internal controller
This type of person believes that fundamentally they are in charge of their own future health. In other words, what happens to their health is largely the result of their own actions. This is the muesli-and-brown-rice-eating, leather-sandal brigade – those diligent humans who digest every morsel of health-related news from the Guardian or Telegraph health pages.

The external controller
This type of person is the opposite of the internal controller. They do not believe that they have any control over their health. What will be will be. They are fatalists. A good example is the 'bullet with my name on' type of person who can be found down at the local pub expounding their theories as to why these dietary, high-exercise, low-fat and no-alcohol theories much loved by the medical profession are rubbish.

The powerful other
This type is quite different from the other two. They do not believe that they are in control of their own health, nor are they fatalists. They believe that you are in charge of their health. This patient will tell you: 'I have this terrible cough, doctor. I know it's not related to my smoking because I have been doing that for a long time and it has never bothered me. I'd like you to give me something to stop it.' Many heartsink patients can be found in this category.

Dr Peter Tate was a GP in Abingdon, Oxfordshire, for 30 years and is a former convenor on the RCGP's panel of examiners
This article is an adapted extract from Dr Tate's new book The Doctor's Communication Handbook, fifth edition, Radcliffe Publishing, 2007, ISBN 1-84619-138-6. To order, go to

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