The waning art of history taking
Medical Rants May 5th. 2008, 2:56pm
I remember having senior clinicians tell me the value of a complete history. As I recall, they told me that at least 90% of diagnoses would come from the history alone.
Of course in the 1970s we had access to automated lab tests and radiologic studies. We could order tests.
As my career has progressed those medical giants (here I refer fondly to the senior clinicians who taught me during medical school and residency) have become even smarter. I now know the importance of a good history.
All medical schools have a course which teaches students the art (and science) of the history and physical exam. Students learn a long list of questions.
This course is important, but 1st and 2nd year medical students do not know enough medicine to properly learn how to take a good history. Taking a history may seem simple, but it requires broad medical knowledge. Master clinicians alter their history taking in response to the patient’s answers, their body language and observation. As one performs the physical exam, more questions occur to the clinician.
The history does not end with the admission. As one collects laboratory results, imaging studies, and clinical changes, more questions become relevant. History taking represents an ongoing activity, designed to help both the diagnostic and therapeutic process.
How does one become better at history taking? First, you must take many histories. You must critique yourself as more information becomes available. Second, you must think about the process of history taking.
The stimulus for this rant occurred as I was listening to a mystery book. I love a mystery in which the detective carefully questions witnesses and suspects. I pay attention to the rhythm and pacing of a good interrogation.
One thing that I notice in these books is the manner in which the key question is surrounded. While I know this is the key question, I will get a more honest answer if the patient is not aware of the questions import.
Perhaps history taking just takes time. Perhaps physicians older than 50 have superior history taking skills to those below 40, just because of experience.
Even if these postulates are true, I would submit that history taking has such importance that we should invest in helping our students and residents learn these skills more completely than they currently do.
May 5th, 2008 at 3:07 pm
Ugh. I remember my 1st year standardized patient examinations — we had to memorize a full history and ROS and what to do on a full physical while having absolutely no concept what the point of it all was. This is all so the school can say you get “simulated patient exposure” during year 1. What a waste.
Student 1:”Hey what is the JVD supposed to show?”
Student 2:”I have no clue. I just know you lean them back on the table, look at the neck, pull out a ruler and say “the JVD appears to be 7 or 8 cm”. Oh, and you have to look at it kinda sideways…something about transverse lighting and shadows.”
May 5th, 2008 at 3:51 pm
As a nurse, and previously as a medical assistant, I’d often extract major clues from patients on intake forms simply because I wasn’t “The Doctor”. Sadly, many doctors would fail to read my notes and then be surprised later, while they were scratching their heads and digging through books, when I’d point out to them what the patients told me. It would please me to no end when I’d get medical students (or that rare totally thorough doc) at the hospital who’d actually read through ALL my notes and pick up on the clues strewn about.
Just as it’s essential for docs to get a history, so too is it important that nurses glean as much information from our patients. Nurses aren’t nearly as intimidating and can often approach patients in a more conversational manner that elicits much more candid responses.
May 5th, 2008 at 4:33 pm
To “Da Goddess” nurse [the screen name says a lot about your ego. Sorry Madam, Ego, RN]
What a surprise!… Another nurse, previously ‘a medical assistant’ feeling the urge to tell the world that nurses know better –more than MDs, are able to communicate better than them, yadda, yadda…
Thank you to “Da Goddess, RN” we all have learned that when having a stroke, a heart attack, cancer, etc. we must immediately summon a nurse [even better, a nurse who previously was a 'Medical Assistant'] for the best treatment and ultimate return to great health –not a trained physician, mind you…
Get a grip on reality, you fool!!!
Holly M. Wagner, M.D.
May 5th, 2008 at 6:25 pm
Wow, Holly, a bit much on the hostility front! I actually agree with “Da Goddess” (it is a bit of an healthy-ego name, but who am I to talk about ego…). I don’t think she was saying that she is better than an MD, but rather that she brings something else to the table. I think she has a point that some patients will open up more to a nurse–doctors can be intimidating (you intimidate me, and I’m a fellow MD!) and patients don’t want to say something that they believe may disappoint their physician. Also, some doctors can seem a bit judgmental (ahem).
DB–If I may ask, what was the mystery book? I’m always looking for a good audiobook, and if it can help me take better histories, all the better!
May 7th, 2008 at 5:17 am
i don’t think disagree that nurses can elicit things that doctors don’t, but frequently the nurses have more direct contact with the patients, allowing them time. i totally disagree that it is apporpriate for her to hide information in notes that she realizes they are not being read. way to go team! is there anyone else who thinks that is a conducive to good delivery of care?
May 7th, 2008 at 5:22 pm
Solution: Read the intake notes? Seems to me that a thorough, forget clever, diagnostician would catch on.
May 7th, 2008 at 7:11 pm
Having had rheumatoid arthritis for 31 years (just to denote that I am practically a “professional” patient) I feel
the opposite on this nurse vs. doctor thing. I rarely feel
confident enough in the office/clinical nurse and just
humor them through the ritual ROS so that I can finally
have access to the dr. to discuss a problem. Although it
would be ideal to feel confidence in both professionals
I would way rather have the doctor be on the ball than
feel that the nurse was the one that would “represent” me.
May 10th, 2008 at 2:30 pm
ck is exactly right; in my first year we had to take turns taking a history on a standardized patient in front of a small group of our classmates a month or so into school. We were supposed to memorize the exact order (CC, HPI, PMH, etc.,) and where each piece of information was supposed to go (smoking goes in social hx, cousin Frank’s dilated cardiomyopathy - what was that, again? goes in family hx, etc.) even though we had had exactly one lecture on taking a hx and none of us had ever taken one. We weren’t allowed to take a progess note into the room with us, either. Like so much of clinical medicine in the first two years, we were supposed to just “receive” it like magic, I guess…