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.

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.

The clinical encounter

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.

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).

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

1.2 Triggers to consultation

• Interpersonal crisis

• 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

A

B

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.

The clinical encounter • 5

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

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,

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

6 • Managing clinical encounters with patients

or to offer additional support. When using the telephone, it is

even more important to listen actively and to check your mutual

understanding frequently.

Similarly, asynchronous communication with patients, using

email or web-based applications, has been adopted by some

doctors. This is not yet widely seen as a viable alternative

to face-to-face consultation, or as a secure way to transmit

confidential information. Despite the communication challenges

that it can bring, telemedicine (using telecommunication and other

information technologies) may be the only means of healthcare

provision for patients living in remote and rural areas and its use is

likely to increase, as it has the advantage of having the facility to

incorporate the digital collection and transmission of medical data.

Professional responsibilities

Clinical encounters take place within a very specific context

configured by the healthcare system within which they occur,

the legal, ethical and professional frameworks by which we are

bound, and by society as a whole.

From your first day as a student, you have professional

obligations placed on you by the public, the law and your

colleagues, which continue throughout your working life. Patients

must be able to trust you with their lives and health, and you

will be expected to demonstrate that your practice meets the

expected standards (Box 1.3). Furthermore, patients want more

from you than merely intellectual and technical proficiency; they

will value highly your ability to demonstrate kindness, empathy

and compassion.

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.

Alternatives to face-to-face

encounters

The use of telephone consultation as an alternative to face-toface consultation has become accepted practice in parts of

some healthcare systems, such as general practice in the UK.

However, research suggests that, compared to face-to-face

consultations, telephone consultations are shorter, cover fewer

problems and include less data gathering, counselling/advice

and rapport building. They are therefore considered to be most

suitable for uncomplicated presentations. Telephone consultation

with patients increases the chance of miscommunication, as

there are no visual cues regarding body language or demeanour.

The telephone should not be used to communicate bad news

or sensitive results, as there is no opportunity to gauge reaction Courtesy General Medical Council (UK).

1.3 The duties of a registered doctor

Knowledge, skills and performance

• Make the care of your patient your first concern

• Provide a good standard of practice and care:

• Keep your professional knowledge and skills up to date

• Recognise and work within the limits of your competence

Safety and quality

• Take prompt action if you think that patient safety, dignity or

comfort is being compromised

• Protect and promote the health of patients and the public