Handling sensitive information and third parties 5
Showing cultural sensitivity 6
Alternatives to face-to-face encounters 6
Professional responsibilities 6
4 • Managing clinical encounters with patients
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.
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
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
The clinical encounter between a patient and doctor lies at the
heart of most medical practice. At its simplest, it is the means by
which people who are ill, or believe themselves to be ill, seek the
advice of a doctor whom they trust. Traditionally, and still most
often, the clinical encounter is conducted face to face, although
non-face-to-face or remote consultation using the telephone or
digital technology is possible and increasingly common. This
chapter describes the general principles that underpin interactions
with patients in a clinical environment.
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).
1.1 Deciding to consult a doctor
• Perceived susceptibility or vulnerability to illness
• Perceived severity of symptoms
• Perceived costs of consulting
• Perceived benefits of consulting
• Interference with social or personal relations
• Sanctioning or pressure from family or friends
• Interference with work or physical activity
• Reaching the limit of tolerance of symptoms
Fig. 1.1 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.
1 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
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.
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.
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,
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
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