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

Communication, partnership and teamwork

• Treat patients as individuals and respect their dignity:

• Treat patients politely and considerately

• Respect patients’ right to confidentiality

• Work in partnership with patients:

• Listen to, and respond to, their concerns and preferences

• Give patients the information they want or need in a way they

can understand

• Respect patients’ right to reach decisions with you about their

treatment and care

• Support patients in caring for themselves to improve and

maintain their health

• Work with colleagues in the ways that best serve patients’ interests

Maintenance of trust

• Be honest and open, and act with integrity

• Never discriminate unfairly against patients or colleagues

• Never abuse your patients’ trust in you or the public’s trust in the

profession

Personal responsibilities • 7

1 between countries. In the UK, follow the guidelines issued by the

General Medical Council. There are exceptions to the general

rules governing patient confidentiality, where failure to disclose

information would put the patient or someone else at risk of

death or serious harm, or where disclosure might assist in the

prevention, detection or prosecution of a serious crime. If you find

yourself in this situation, contact the senior doctor in charge of

the patient’s care immediately and inform them of the situation.

Always obtain consent before undertaking any examination or

investigation, or when providing treatment or involving patients

in teaching or research.

Social media

Through social media, we are able to create and share web-based

information. As such, social media has the potential to be a

valuable tool in communicating with patients, particularly by

facilitating access to information about health and services, and

by providing invaluable peer support for patients. However, they

also have the potential to expose doctors to risks, especially when

there is a blurring of the boundaries between their professional

and personal lives. The obligations on doctors do not change

because they are communicating through social media rather than

face to face or through other conventional media. Indeed, using

social media creates new circumstances in which the established

principles apply. If patients contact you about their care or other

professional matters through your private profile, you should

indicate that you cannot mix social and professional relationships

and, where appropriate, direct them to your professional profile.

Personal responsibilities

You should always be aware that you are in a privileged

professional position that you must not abuse. Do not pursue

an improper relationship with a patient, and do not give medical

care to anyone with whom you have a close personal relationship.

Finally, remember that, to be fit to take care of patients, you

must first take care of yourself. If you think you have a medical

condition that you could pass on to patients, or if your judgement

or performance could be affected by a condition or its treatment,

consult your general practitioner. Examples might include serious

communicable disease, significant psychiatric disease, or drug

or alcohol addiction.

Fundamentally, patients want doctors who:

• are knowledgeable

• respect people, healthy or ill, regardless of who they are

• support patients and their loved ones when and where

needed

• always ask courteous questions, let people talk and listen

to them carefully

• promote health, as well as treat disease

• give unbiased advice and assess each situation carefully

• use evidence as a tool, not as a determinant of practice

• let people participate actively in all decisions related to

their health and healthcare

• humbly accept death as an important part of life, and

help people make the best possible choices when death

is close

• work cooperatively with other members of the

healthcare team

• are advocates for their patients, as well as mentors for

other health professionals, and are ready to learn from

others, regardless of their age, role or status.

One way to reconcile these expectations with your inexperience

and incomplete knowledge or skills is to put yourself in the

situation of the patient and/or relatives. Consider how you would

wish to be cared for in the patient’s situation, acknowledging that

you are different and your preferences may not be the same.

Most clinicians approach and care for patients differently once

they have had personal experience as a patient or as a relative

of a patient. Doctors, nurses and everyone involved in caring for

patients can have profound influences on how patients experience

illness and their sense of dignity. When you are dealing with

patients, always consider your:

• A: attitude – How would I feel in this patient’s situation?