How much should a health professional know about a patient or client? When I consult with a patient new to me and new to the practice, I know their name, address, gender and age but typically little else. When I see these bare demographic details on the computer prior to meeting the person, I am already forming an impression particularly from the surname and where they live.
When I invite the patient into my territory (the consulting room), I appraise them in more detail: how they are dressed, their build and gait, whether they appear anxious, relaxed, ill, etc. Then, I introduce myself and note how they respond: speech, words, accent, non-verbal behaviour are informative.
As health professionals we do this quite quickly. However, we are not aiming for the level of detail of Conan Doyle’s consulting detective Sherlock Holmes, who could deduce a person’s history and lifestyle within a few minutes. And we need to be mindful that first impressions are frequently misleading. Our unconscious bias*can lead to stereotyping of certain groups and jumping to conclusions that are uninformed and potentially harmful.
Calibration is an important part of communication. Communication skills training stresses the importance of that initial meeting – eliciting and recognising cues so that the professional can judge how best to interact with the patient for an optimal outcome, while being aware of bias.
When working with students on their communication, educators may stress how important it is not to jump straight into the reason for the consultation. We advise how to exchange some pleasantries to help the patient relax and to calibrate their style of talking. This is particularly important when consulting with first nations peoples in Australia, for example, where it is important not to rush the conversation but take time to get to know one another.
Unfortunately, there is less time to do this in contemporary clinical practice where consultations are frequently limited to 10-15 minutes, leaving little time for chat. We may not have space to recalibrate those first impressions.
To mirror the realty of practice, we show clinical students how to ‘take a focused history’, concentrating on the ‘presenting complaint.’ And we reinforce this message by having assessments in which students are given 5-10 minutes to elicit histories from people they have never met before.
No wonder that health professionals frequently interrupt patients in the first few minutes of an interaction.
Speed and information gathering short cuts can lead to making value judgements about patients that are far from an accurate. A simple example from some work I did a while ago with recently qualified doctors indicated that they were less likely to involve patients in decision making if they were 65 and older. Older people are also less likely to be asked about their sexual histories and risk of sexually transmitted infections.
Even though we are increasingly aware of the importance of the social determinants of health, the non-medical factors that influence health outcomes, we may skim over the ‘social history’ of the patient. As a medical student there were only a few questions relating to social history in the patient history list such as marital status and who else is at home before moving onto lifestyle, limited to smoking and alcohol.
In a session on well-being for medical students, we were discussing the importance of their having a general practitioner/family doctor. I asked whether they would tell the doctor they were medical students. One replied no, because when he had done this before, the consultation turned into a teaching session. Another, astutely, said: of course, how can a doctor understand my problems without knowing what I do?
Employment and unemployment are major parts of a person’s life and their identity. How much time are we able to spend on really understanding our patients’ lives?
It is good for health professional students to observe the different professions’ approaches to patient histories. But all of us only have small glimpses into the lives of others. These glimpses grow over time if we develop relationships with patients, but how deeply should we try to delve into their lives?
*unconscious bias (also known as implicit bias) is a somewhat controversial term. Unconscious bias training (UBT) is big business and has become a ubiquitous aspect of organisations’ diversity initiatives. Such training typically starts with an online assessment that almost invariably shows that respondents are all biased. Critics say that, while such training may alert people to their biases, it does not necessarily lead to any change in behaviour. As is common when evaluating educational interventions, UBT tends to be evaluated over the short term though looking at change in knowledge and attitudes/perception rather than change in behaviour in the workplace in the longer term.
Moreover, such interventions tend to put the onus on individuals with little attention to, for example, institutionalised racism and gender inequity. We may agree that unconscious bias training is necessary but not sufficient in the quest for social justice.
See:
http://eprints.lse.ac.uk/109959/1/businessreview_2021_03_24_is_unconscious_bias_training_still.pdf
Health professional education and practice 