Reasons for the encounter

The majority of people who experience symptoms of ill health do not seek professional advice. For the minority who do seek help, the decision to consult is usually based on a complex interplay of physical, psychological and social factors ( Box 1.1 ). The perceived seriousness of the symptoms and the severity of the illness experience are very important influences on whether patients seek help. The anticipated severity of symptoms is determined by their intensity, the patient’s familiarity with them, and their duration and frequency. Beyond this, patients try to make sense of their symptoms within the context of their lives. They observe and evaluate their symptoms based on evidence from their own experience and from information they have gathered from a range of sources, including family and friends, print and broadcast media, and the internet. Patients who present with a symptom are significantly more likely to believe or worry that their symptom indicates a serious or fatal condition than non-consulters with similar symptoms; for example, a family history of sudden death from heart disease may affect how a person interprets an episode of chest pain. Patients also weigh up the relative costs (financial or other, such as inconvenience) and benefits of consulting a doctor. The expectation of benefit from a consultation – for example, in terms of symptom relief or legitimisation of time off work – is a powerful predictor of consultation. There may also be times when other priorities in patients’ lives are more important than their symptoms of ill health and deter or delay consultation. It is important to consider the timing of the consultation. Why has the patient presented now? Sometimes it is not the experience of symptoms themselves that provokes consultation but something else in the patients’ lives that triggers them to seek help ( Box 1.2 ).

A range of cultural factors may also influence help-seeking behaviour. Examples of person-specific factors that reduce the propensity to consult include stoicism, self-reliance, guilt, unwillingness to acknowledge psychological distress, and embarrassment about lifestyle factors such as addictions. These factors may vary between patients and also in the same person in different circumstances, and may be influenced by gender, education, social class and ethnicity.

The clinical environment

You should take all reasonable steps to ensure that the consultation is conducted in a calm, private environment. The layout of the consulting room is important and furniture should be arranged to put the patient at ease ( Fig. 1.1A ) by avoiding face-to-face, confrontational positioning across a table and the incursion of computer screens between patient and doctor ( Fig. 1.1B ). Personal mobile devices can also be intrusive if not used judiciously.

Seating arrangements.

A In this friendly seating arrangement the doctor sits next to the patient, at an angle. B Barriers to communication are set up by an oppositional/confrontational seating arrangement. The desk acts as a barrier, and the doctor is distracted by looking at a computer screen that is not easily viewable by the patient.

For hospital inpatients the environment is a challenge, yet privacy and dignity are always important. There may only be curtains around the bed space, which afford very little by way of privacy for a conversation. If your patient is mobile, try to use a side room or interview room. If there is no alternative to speaking to patients at their bedside, let them know that you understand your conversation may be overheard and give them permission not to answer sensitive questions about which they feel uncomfortable.

Opening the encounter

At the beginning of any encounter it is important to start to establish a rapport with the patient. Rapport helps to relax and engage the person in a useful dialogue. This involves greeting the patient and introducing yourself and describing your role clearly. A good reminder is to start any encounter with ‘Hello, my name is … .’ You should wear a name badge that can be read easily. A friendly smile helps to put your patient at ease. The way you dress is important; your dress style and demeanour should never make your patients uncomfortable or distract them. Smart, sensitive and modest dress is appropriate. Wear short sleeves or roll long sleeves up, away from your wrists and forearms, particularly before examining patients or carrying out procedures. Avoid hand jewellery to allow effective hand washing and reduce the risk of cross-infection (see Fig. 3.1 ). Tie back long hair. You should ensure that the patient is physically comfortable and at ease.

How you address and speak to a patient depends on the person’s age, background and cultural environment. Some older people prefer not to be called by their first name and it is best to ask patients how they would prefer to be addressed. Go on to establish the reason for the encounter: in particular, the problems or issues the patient wishes to address or be addressed. Ask an open question to start with to encourage the patient to talk, such as ‘How can I help you today?’ or ‘What has brought you along to see me today?’

Gathering information

The next task of the doctor in the clinical encounter is to understand what is causing the patient to be ill: that is, to reach a diagnosis. To do this you need to establish whether or not the patient is suffering from an identifiable disease or condition, and this requires further evaluation of the patient by history taking, physical examination and investigation where appropriate. Chapters 2 and 3 will help you develop a general approach to history taking and physical examination; detailed guidance on history taking and physical examination in specific systems and circumstances is offered in Sections 2 and 3.

Fear of the unknown, and of potentially serious illness, accompanies many patients as they enter the consulting room. Reactions to this vary widely but it can certainly impede clear recall and description. Plain language is essential for all encounters. The use of medical jargon is rarely appropriate because the risk of the doctor and the patient having a different understanding of the same words is simply too great. This also applies to words the patient may use that have multiple possible meanings (such as ‘indigestion’ or ‘dizziness’); these terms must always be defined precisely in the course of the discussion.

Active listening is a key strategy in clinical encounters, as it encourages patients to tell their story. Doctors who fill every pause with another specific question will miss the patient’s revealing calm reflection, or the hesitant question that reveals an inner concern. Instead, encourage the patient to talk freely by making encouraging comments or noises, such as ‘Tell me a bit more’ or ‘Uhuh’. Clarify that you understand the meaning of what patients have articulated by reflecting back statements and summarising what you think they have said.

Non-verbal communication is equally important. Look for non-verbal cues indicating the patient’s level of distress and mood. Changes in your patients’ demeanour and body language during the consultation can be clues to difficulties that they cannot express verbally. If the their body language becomes ‘closed’ – for example, if they cross their arms and legs, turn away or avoid eye contact – this may indicate discomfort.

Handling sensitive information and third parties

Confidentiality is your top priority. Ask your patient’s permission if you need to obtain information from someone else: usually a relative but sometimes a friend or a carer. If the patient cannot communicate, you may have to rely on family and carers to understand what has happened to the patient. Third parties may approach you without your patient’s knowledge. Find out who they are, their relationship to the patient, and whether your patient knows the third party is talking to you. Tell third parties that you can listen to them but cannot divulge any clinical information without the patient’s explicit permission. They may tell you about sensitive matters, such as mental illness, sexual abuse or drug or alcohol addiction. This information needs to be sensitively explored with your patient to confirm the truth.

Managing patient concerns

Patients are not simply the embodiment of disease but individuals who experience illness in their own unique way. Identifying their disease alone is rarely sufficient to permit full understanding of an individual patient’s problems. In each encounter you should therefore also seek a clear understanding of the patient’s personal experience of illness. This involves exploring the patients’ feelings and ideas about their illness, its impact on their lifestyle and functioning, and their expectations of its treatment and course.

Patients may even be so fearful of a serious diagnosis that they conceal their concerns; the only sign that a patient fears cancer may be sitting with crossed fingers while the history is taken, hoping inwardly that cancer is not mentioned. Conversely, do not assume that the medical diagnosis is always a patient’s main concern; anxiety about an inability to continue to work or to care for a dependent relative may be equally distressing.

The ideas, concerns and expectations that patients have about their illness often derive from their personal belief system, as well as from more widespread social and cultural understandings of illness. These beliefs can influence which symptoms patients choose to present to doctors and when. In some cultures, people derive much of their prior knowledge about health, illness and disease from the media and the internet. Indeed, patients have often sought explanations for their symptoms from the internet (or from other trusted sources) prior to consulting a doctor, and may return to these for a second opinion once they have seen a doctor. It is therefore important to establish what a patient already understands about the problem. This allows you and the patient to move towards a mutual understanding of the illness.

Showing empathy

Being empathic is a powerful way to build your relationship with patients. Empathy is the ability to identify with and understand patients’ experiences, thoughts and feelings and to see the world as they do. Being empathic also involves being able to convey that understanding to the patient by making statements such as ‘I can understand you must be feeling quite worried about what this might mean.’ Empathy is not the same as sympathy, which is about the doctor’s own feelings of compassion for or sorrow about the difficulties that the patient is experiencing.

Showing cultural sensitivity

Patients from a culture that is not your own may have different social rules regarding eye contact, touch and personal space. In some cultures, it is normal to maintain eye contact for long periods; in most of the world, however, this is seen as confrontational or rude. Shaking hands with the opposite sex is strictly forbidden in certain cultures. Death may be dealt with differently in terms of what the family expectations of physicians may be, which family members will expect information to be shared with them and what rites will be followed. Appreciate and accept differences in your patients’ cultures and beliefs. When in doubt, ask them. This lets them know that you are aware of, and sensitive to, these issues.

Addressing the problem

Communicating your understanding of the patient’s problem to them is crucial. It is good practice to ensure privacy for this, particularly if imparting bad news. Ask the patient who else they would like to be present – this may be a relative or partner – and offer a nurse. Check patients’ current level of understanding and try to establish what further information they would like. Information should be provided in small chunks and be tailored to the patient’s needs. Try to acknowledge and address the patient’s ideas, concerns and expectations. Check the patient’s understanding and recall of what you have said and encourage questions. After this, you should agree a management plan together. This might involve discussing and exploring the patient’s understanding of the options for their treatment, including the evidence of benefit and risk for particular treatments and the uncertainties around it, or offering recommendations for treatment.

Concluding the encounter

Closing the consultation usually involves summarising the important points that have been discussed during the consultation. This aids patient recall and facilitates adherence to treatment. Any remaining questions that the patient may have should be addressed, and finally you should check that you have agreed a plan of action together with the patient and confirmed arrangements for follow-up.