• 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