People from socioeconomic groups 1 and 2 are more likely to seek medical assistance than those from socioeconomic groups 4 and 5 (Bygren 2001, Townsend & Davidson 1982). People who work are also less likely to seek medical attention, and there are also differences between ethnic groups. There is also growing evidence that white middle-class men are less likely to seek medical treatment for illness probably due to ‘traditional masculine behaviour’ and a belief that the problem will go away (Galdas et al 2005). Variation is also seen in the type of healthcare accessed. Delay in utilisation of emergency medicine is more common in people who infrequently see their general practitioner (GP) (Rucker et al 2001), whereas there is little if any difference in people seeking palliative care for cancer (Kessler et al 2005).

It is important that the practitioner allows the patient to describe the problem in their own words. This should enable the practitioner to determine the ‘needs’ of the patient and the significance of the concern or problem. The practitioner’s perception of the problem is not always the same as that of the patient. For example, a mother may be concerned that her 3-year-old child has flat feet. The practitioner considers this to be normal for a child of that age. However, during the consultation, the practitioner notices a small verruca on the apex of the right second toe and suggests that it is treated. The mother accepts the treatment but leaves the clinic still concerned about her child’s flat feet, as the practitioner failed to alleviate the mother’s main concern. An effective solution would have consisted of advice and reassurance regarding the flat feet as well as treatment of the verruca.

Encouraging the patient to tell you about concerns and problems

How can you encourage patients to tell you why they have sought your help? A whole range of factors can make it difficult for the patient to articulate the problem in words. Some patients may be frightened or embarrassed, others may be concerned that they are wasting your time and yet others may be worried that you will think they are silly to be concerned about a minor problem. It is essential that patients are made to feel that they are not wasting your time and that you are genuinely interested in their concerns and problems.

Most patients present with discomfort or pain. For example, a patient may present with discomfort from a bunion rubbing on footwear. The patient may also be concerned about the appearance of the bunion and scared that she will develop a deformity similar to her grandmother’s. A skilled practitioner will identify all the anxieties the patient is experiencing: the problems with the current discomfort, the difficulty in finding appropriate shoes to wear, the worry about the unsightly appearance of the bunion and the fear that it may get worse.

It is important that you consider how best to start the conversation. Asking the patient ‘What are you complaining of?’, ‘What’s the problem?’ or ‘What is it that’s wrong with you?’ are probably not the best ways to start. The last question may result in the patient responding ‘That’s what I’ve come here for you to find out’. ‘How can I help you?’ or ‘Would you like to tell me about what concerns you?’ may be preferable. Open questions should be used (see Ch. 2). The patient should not feel rushed; avoid interrupting and putting words into the patient’s mouth. Record in the patient’s own words what they are concerned about and what they see as a problem. Avoid medical jargon wherever possible.

Having obtained an idea of the patient’s concerns, it may help to find out if they have any thoughts about the cause. Ask the reason for such conclusions as this may help determine the aetiology of the condition and could help guide management. The answers to these questions may also reveal whether the patient and practitioner share the same views.

When patients do reveal what is worrying them, avoid being judgemental and making comments such as ‘Oh, that’s nothing!’ or ‘I don’t know why you are so worried!’. Remember it is a problem to the patient even if it is relatively innocuous matter for you. Patients may not reveal their real reason for coming to see you until they are just about to leave. This can be a source of annoyance to the busy practitioner. Do try to give the patient time even if it is at the end of the consultation. Patients may also not tell you the real reason for seeking treatment if they think it may affect your decision to offer treatment. An example of this is a foot deformity for which the patient would like surgical correction for cosmetic reasons rather than for any disability or pain the deformity may cause. Conversely, if a patient does not like the treatment offered, they may play down the significance of the problem.

Patients with special needs

Some patients may find it hard to tell you about their concerns and problems. This may be more than simply having poor powers of description. The patient may be deaf, dumb, have suffered a stroke, have a speech impediment, or have learning or language difficulties. It is important you give these patients extra time. Avoid jumping to too many conclusions. If the patient can write, ask them to write down the nature of the complaint. Friends, relatives, or carers may be able to provide valuable details and information or act as interpreters.

Why did the patient seek your help?

A variety of factors can influence why a patient has chosen to visit your practice. Box 3.2 gives the usual reasons for a patient choosing a particular practitioner. It is important to find out what made the patient choose you. For example, a patient who has been referred by a friend or relative may find it easy to disclose her concerns to you. The friend/relative might have been complimentary about your abilities. On the other hand, a patient who is seeking a second opinion may want you to give a different diagnosis from the one given by the previous practitioner. As a result they may not disclose all the salient features of the problem. It is important to remember that legal claims associated with a patient’s problem may affect the patient’s perspective.

Box 3.2 Reasons for a patient choosing a practitioner