A Perspective on Doctor-Patient Interaction

I recently came across a doctor-patient interaction on a case of low back pain in a 24-year-old man. John (not real name) had been experiencing this pain for a week before his presentation. This was his first episode of back pain. John had no numbness in his legs, bladder or bowel symptoms. He had not lost any weight. Although he was otherwise fit and healthy, he had to avoid his regular gym sessions due to the pain. He denied any history of trauma. However, he was concerned because his uncle had also experienced back pain and was later diagnosed with cancer. Based on some reading online, he was hoping for the doctor to do an MRI and give him some advice about pain medications.  

The clinician may find it puzzling that John was worried about cancer as a potential cause of his symptoms. However, comprehending John’s thought process is a crucial first step to as managing his concerns. This discussion highlights the importance of teaching consultation techniques in the GPVTS.

Below is a conversation with an anonymous patient advocate about the patients’ expectations when visiting a GP. 

Exploring Patients’ Health Belief

Moderator: In this conversation, I would like you to provide some insight into why a patient might draw correlations between their physical symptoms and certain diseases. For instance, in the case of a 24-year-old with back pain, how did he go from being a young man with back pain for one week to worrying about cancer? What factors could have influenced him to make such a connection? It might seem like an extreme possibility to a clinician, do you think so?

Guest: When someone expresses “extreme” concern about their health, they have likely researched online, which may have reinforced their worries about diseases like cancer. Additionally, if they have a relatable scenario where a close relative has died from cancer, it’s understandable that they may experience increased health anxiety. Although it may seem puzzling to the clinician. However, from the patient’s perspective, they may be thinking: “I have a family history of a serious illness, and I’ve had this back pain for a week. If it was just simple back pain, it should have eased by now. Something must be wrong with me. I hope it’s not cancer”

Moderator: I understand, do you think he may have self-diagnosed based on his knowledge of his family history? 

Guest: That’s right, and that’s where the professional can step in to provide factual information, conduct tests and provide additional information to alleviate any fears. It may seem unlikely, but you can’t jump to any conclusion without knowing the type of cancer that the uncle had. It’s important to understand why he may have felt that way.  

This scenario also applies to a situation in which a child has been diagnosed with a rare disease and their nephew or niece begins showing a few related, albeit temporary, symptoms. When the parents discuss this, they are advised to consult their GP. Having this firsthand experience within the family will make the parents more cautious due to their increased awareness of their family history.

Given that it is such a rare condition, the clinician might say, “I don’t think that’s likely in this case, as these symptoms were for example transient.” However, it’s important not to dismiss the family history. It might seem unlikely because you’re not in their position, but it’s not unusual for a parent to be concerned about something so rare or extreme. It’s not unusual for them to consider such possibilities

Varying Degrees of Health Anxiety

Moderator: That’s right. It’s common for trained clinicians to understand people’s health beliefs. They learn about disease progression, pattern recognition, cause and effect. In primary care, there’s more focus on the psychosocial aspects. It’s important to understand the patient’s situation, why their current condition is relevant, and how it might influence the pattern of disease. These are essential elements of history taking, but it’s not always a crystal-clear scenario. Clinicians don’t often jump to far-reaching symptom-disease correlations because they have a sorting mechanism called “common things occur commonly.”.

Patients do not intuitively have this same mindset.  Is that right? or do you think generating “extreme health beliefs” is a normal human behaviour.  

Guest: I think my view would be yes. Patients do not intuitively have same mind set, otherwise, there wouldn’t be doctor-patient relationships. Patients rely on the clinicians’ training to help them sort their health concerns and navigate the health system to get them the right solution. Granted, there may be people with higher health anxiety than others, and that’s also influenced by a lot of factors. I’ve heard a story of woman who said her mum was always having breast pains. When encouraged to visit the doctor, she would decline and say “Oh don’t worry, it is my bra”. Her children who were adults and didn’t live with her, kept calling her saying “ go and check out your breasts”. As an older person, let’s say an immigrant, who is not accustomed to seeking professional help, would sometimes say that she forbids herself having such experience and believed there was nothing going on. Unfortunately, when she eventually did see a doctor, it turned out that she had breast cancer.  

In her own words, she said, “Well, I’m not used to going to the hospital. I don’t see any reason why I should get such a thing”. This highlights a crucial point about the different levels of health anxiety or health awareness. In this scenario, she had a very low health anxiety and you could see how that is not also a good thing.  

Some people experience high health anxiety, causing them to worry about even the smallest health issues and prompting them to search for answers online. On the other hand, those with low health anxiety may not pay much attention to minor symptoms. Those with high health consciousness tend to monitor their health regularly and may be more likely to visit a doctor for reassurance.

I also think that there are things that could surround that decision to be anxious about one’s health. To the clinician, instead of maybe seeing such presentation with a closed mindset, or from a negative connotation, learn to explore the things that surrounded that concern. For example, a special needs parent of a child with a rare disease, who worries about being alive to care for their child, may be prone to having a higher health anxiety due to their unique life situation. 

A parent of a child with a unique medical history, which nobody else in their life has, would likely be told that it’s so rare that it’s probably something benign. This situation could make the parent prone to experiencing high health anxiety. Even if they had lower health anxiety in the past, such a significant change in their life would put them on high alert.

Moreover, when someone has experienced a situation where they were told that a symptom was probably not serious, but it later turned out to be serious, they are more likely to have a broader perspective when it comes to their health. This may seem extreme if their story is not considered in context.

Exploring Doctors’ Health Belief

Moderator: That is quite detailed and insightful.   

Guest: I believe the clinician should take the time to understand why the person is concerned, rather than dismissing them based on how often they visit the surgery.

Understanding someone’s concerns in context helps make sense of why a person might seek assessment while others with similar concerns may not worry as much. Sometimes, individuals with high health anxiety end up getting their lives saved because of their vigilance. For example, I recently watched a TikTok video in which a 27-year-old girl noticed a lump on her leg. Despite people telling her it was nothing to worry about, she didn’t dismiss her concerns when the lump didn’t go away after a few weeks. Eventually, she went to a doctor, who referred her for a biopsy test. The results revealed that the lump was cancerous, not benign. This is the kind of symptom that a person with low anxiety might not even notice until it’s too late. In her case, because she acted on her worry, she was able to start treatment on time. I hope this clarifies things. 

Moderator:  It’s incredibly important, because what you’re trying to convey is that clinicians are essentially on the receiving end of people’s experiences or perceptions of illness. Primary care clinicians, as the gatekeepers, should be mindful of where a person is coming from and make an effort to understand their real concerns. The clinician should strive to clearly and quickly understand the patient’s perspective during the doctor-patient interaction, combining this with their medical expertise to assess disease patterns, risk factors, and epidemiology of the disease. By doing so, they can empower the patient to develop a management plan, which could involve options such as waiting, immediate action, or recognising life-threatening situations.  

Exploring medico-legal aspects of doctor-patient interaction

Moderator: Who would be responsible in cases where a clinician fails to recognise the early stages of a disease, such as certain difficult-to-differentiate moles? Patients who were initially told that their symptoms were not a big deal, only to later find out that they were significant, might wonder about the evolving nature of the patient-clinician relationship in such cases. What factors might have led to the mistaken advice, and how would you, as a patient, perceive this situation? 

Guest:  I believe that a patient’s overall experience is key here. When a patient feels that their doctor truly listened to them and provided attentive care, it can significantly impact their mindset and response to the treatment. Patients who feel heard and understood by their doctor may be less likely to harbour resentment compared to those who feel dismissed or unheard. This highlights the importance of building a strong and empathetic doctor-patient relationship. The best approach involves understanding the patient’s perspective on their illness or symptoms, addressing their concerns, and being sensitive to their emotions. If a diagnosis turns out to be serious, it’s essential to have a backup plan and be open to acknowledging and learning from any mistakes or missed opportunities in the patient’s care. 

When patients visit a doctor, they often hope the doctor has all the answers. However, in reality, nobody knows everything, so there may be some uncertainty. It’s important to remember that being a patient isn’t always easy, as they are the ones facing the situation. This is an opportunity for the clinician to showcase empathy and build a successful patient-doctor interaction.

Consider a scenario where a mother repeatedly visits her GP with concerns about her baby appearing to be tired and listless in the mornings. By the second or third visit, the healthcare provider should be attentive and consider the possibility that something may be wrong. It’s important for the healthcare provider to approach the situation with an open mind, listen to the patient, and not dismiss the concerns by attributing them to factors such as new parent anxiety. This kind of response can make the patient feel like their concerns are being overlooked.

It’s important to recognise that while some people may seem to call the doctor’s office for seemingly random reasons, there are also individuals who would prefer not to seek medical attention because it disrupts their daily activities. When a person visits a clinician multiple times for the same symptom, the clinician should make an effort to address their concerns and provide reassurance. This could involve ordering tests or making referrals to specialists to provide concrete evidence of their assessment. 

Moderator: Here are your receipts.  

Guest: Thats right. I know it is important for primary care clinicians to be mindful of working within the NHS system and using resources effectively. It can be helpful to advise patients that if they have concerns or notice any changes, they should come back to the doctor, especially if they have visited multiple times.” 

Moderator: There is a term for that: Safety netting!

Guest: That’s a great term. This is why the art of developing an empathetic patient–doctor relation should be emphasised. If someone comes to a clinician once, and clinically you could not see why that symptom is happening. The second time give them a bit more thought. Even if your were not the clinician the patient met at the first presentation, they return to you and say this is my second time for this symptom. Give it a bit more thought. What could be beneath the surface? Reflect as if you were a patient in the same scenario. What you would like done for yourself? Or as a clinician, be aware that rarities happen. Be open and empathetic. You might be a recipient of eternal gratitude from patients. While as a clinician you don’t live for these moments, when given, it does spice up your career and empower you to keep doing the good work.  

Moderator:  I think that every primary care doctor or clinician should have the basic skill of inquiring about patient ideas, concerns, expectations, and the impact of illness. This is crucial for a successful doctor-patient interaction. We are incredibly grateful for the NHS, as it allows clinicians to explore solutions to health problems without being limited by upfront costs. General practitioners have various systems in place, including referral systems, 2-week wait pathways, local formularies, algorithms, and NICE guidelines. These resources are available to clinicians to help understand people’s problems and guide them toward better health..

Thank you so much for that insight.

To learn more about communication skills in primary care consultations, watch this video.  

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