Managing clinical encounters with patients

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 can influence whether patients seek help. The perceived severity of symptoms is determined by their intensity, the patient’s familiarity with them and their duration and frequency. Beyond this, patients try to understand their symptoms based on their own prior experience and from information they have gathered from a range of sources, including family and friends, print and broadcast media and the internet and social media. 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. The expectation of benefit from a consultation (e.g. 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. For face-to-face clinic interactions the layout of the consulting room is important and furniture should be arranged to put the patient at ease ( Fig. 1.1A ) by avoiding confrontational positioning across a table and the incursion of computer screens between patient and clinician (see 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.

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, introducing yourself and describing your role clearly. A good reminder is to start any encounter with ‘Hello, my name is … ’. In face-to-face or video encounters 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 or scrubs are appropriate. Before examining patients or carrying out procedures, roll up long sleeves, away from your wrists and forearms. 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. Enquiring about someone’s personal gender pronouns (e.g. she/her, he/him, they/them) can help them feel respected and valued and affirms their gender identity. 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 clinician in the clinical encounter is to understand what is causing the patient to be ill or to believe they are ill. To do this you need to establish whether or not the patient is suffering from an identifiable disease or condition, and this requires evaluation of the patient first by history taking and then by physical examination and investigation where appropriate. Chapter 2, Chapter 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 consult. 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 clinician 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 (e.g. ‘indigestion’ or ‘dizziness’); these terms must always be defined precisely in the course of the discussion.

Clinicians who fill every pause with another specific question will miss the patient’s revealing calm reflection, or the hesitant question or aside that reveals an inner concern. Active listening is a core skill in clinical encounters, as it encourages patients to tell their story. It is more than keeping quiet. Encourage the patient to elaborate by making encouraging comments or noises, such as ‘Tell me a bit more’ or ‘Uhuh’. Demonstrate that you understand the meaning of what patients have articulated by reflecting back statements and summarising what you think they have said. Nonverbal communication is also important. Look for nonverbal 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 their body language becomes ‘closed’ (e.g. if they cross their arms and legs, turn away or avoid eye contact), this may indicate discomfort. Remote consultation increases the chance of miscommunication as nonverbal cues are not so readily apparent (see Chapter 21 ).

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 that 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.