The Medical History

20 May

The Medical History
No two people tell a story the same way.

The ability to explore the patient’s story and then transform it into a cohe- sive narrative from which decisions about diagnosis and treatment  are made defines a good physician. When physicians interview a patient, they “take a history.” When they write it down, they “record the history.” When they inquire from a colleague about a patient’s illness, they ask, “What’s the history?” As a first step in diagnosis, taking the medical history is more im- portant than the physical examination or any tests. Only on rare occa- sion—patients who are unconscious or otherwise unable to speak reliably in their own behalf, for instance—are the other elements more important.

Previously I described a five-step process in the medical transaction: the story, the history, the issues, the doctor-patient relationship, and, the final step, the question “What did I learn?” To the extent that the history, the ed- ited and abbreviated version of the story, is accurate, valid, and complete, the issues will be comparably well defined. A sloppy history severely com- promises the whole process.

This chapter describes ways physicians encourage patients to tell their stories, how doctors transform the stories into the “medical history,” how the stories and the history become the basis for diagnosis and treatment, and how this whole process can run amok.

GENERAL HISTORY AND THE MEDICAL HISTORY

Insights from the study of history in general help us understand all the dimensions of the medical history. We speak of ancient history, modern history, and current history, of national history and local history, of cultural history, economic history and family history. There is reliable, corrobo- rated history, and history that is unreliable—fantasized, self-serving, and uncorroborated.

What actually happened is the story. History is what was recorded. Good history is the sum of many moments, what led up to those moments, what took place thereafter, the consequences for those involved, and their reac- tions. History is not simply the account of the events; it is an integration of all that is germane into a coherent account. Without that information, we squander the opportunity to learn as much as we can about the events and from them. By exploring the story, we have the opportunity to tease out causes and contributing factors, nuances, and new insights. Story is fact. History, at its best, approximates fact, but it is also inference: Did one event cause another, or was it coincidence? What can we learn?

If the story is the whole truth, then history is really the story “as told to”

or “as seen by” the historian and may represent only part of the truth. As the actual event becomes more remote from the time the historian investi- gates and records it, the account becomes less reliable. Complex events are more difficult to describe and validate, as are inferences from them. We en- hance the quality of history by getting other points of view. Bias, prejudice, preconceptions of what happened, and ignorance of what might be impor- tant or when the story really started get in the way of good history.

It is no different with the medical history. If its purpose is to aid in the di-agnosis and treatment, then we must gather all the information we can to help us in that task. Doing it well serves the patient, but it also maintains the physician’s stance as a lifelong student, not simply learning about each patient, but also learning from each patient. How to develop the history, how to talk to people, and how to listen are all dimensions of the human side of medicine.

In the medical context, like history in general, “the story” is all that hap-pened, and “the medical history” is the abbreviated, edited story. The story, by definition, is always the same. The history varies according to the skill, point of view, fund of knowledge, and perceptiveness of the physician. The credential of “physician” gives privileged access to the patient’s story. In the process of taking the history, the patient is the eyewitness, and the phy- sician is the detective; the patient, the speaker, the doctor, the listener; the patient, the narrator, the doctor, the recorder; the patient, the author, the doctor, the editor; the patient, the teacher, the doctor, the student. And so one of the ways to judge the skill and level of professional competence is the degree to which the physician is a detective, listener, recorder, editor, and student.

Specifically the medical history is the sum of

•  The “chief complaint,” in the patient’s own words, what brought the patient to the doctor.

•  The “history of the present illness,” the details of the chief complaint.

•  The “past history,” details of previous illnesses and operations, medications, and allergies.

•  The “family history,” a listing of family members’ important illnesses, which may put the patient at increased risk.

•  The “psychosocial history,” selected details of the patient’s life story.

•  The “review of systems,” an inquiry into common symptoms related to each or- gan system.

Together they provide the physician context for the problem at hand, a “sense of history” similar to that which wise statespersons use as they ap- proach a crisis. In this process, physicians question, listen, and amplify; in- terpret and validate; edit, compose, and record; critique and learn; and empathize and form a relationship. Each of these steps has potential for flaws, and so physicians need to do them well.

We question, listen, and amplify. For example,

Doctor: What brings you to the office? (This is called an “open-ended ques- tion,” one that encourages the patient to tell a story. A “closed-ended question,” such as “Do you smoke?” can be answered “yes” or “no.”)

Patient: I’ve got pain in my stomach. (In the patient’s own words, this becomes the chief complaint.)

D: Tell me about it.

P: Last night I didn’t feel so well after supper, and I started to get this pain here, around my belly button. I didn’t think too much about it, but the pain kept on. By the time I went to bed, it was a little worse, but I was able to sleep until about 6 this morning, when I woke up because the pain was worse yet. That’s when I called you.

D: What else can you tell me about it? P: I vomited just before I called you.

D: Had you ever had pain like this before? (A “closed-ended” question.) P: No, this is the first time.

D: Where is the pain now?

P: (pointing to the lower right side of his abdomen) Down here. D: When was your last bowel movement?

P: Yesterday morning.

D: Any blood in your urine?

And so on, with a series of open-ended questions, then more precise ques- tions and refinements of the answers. This exchange is enough to create a strong suspicion of acute appendicitis. The story, told spontaneously, then followed by a few questions and then an examination, points toward the di- agnosis. “I’ve got pain in my stomach” is too vague for a definitive diagno- sis; the rest of the history-taking process helps to get the answer. We repeat this routine of questioning with each new problem.

We interpret. Patients tell their stories in their own “code” or manner of speaking. Only rarely does a patient declare, “I have appendicitis,” and even then, if not validated with proper inquiry and documentation, it may be in error. The physician translates the story and “decodes” it.

We validate. We validate further by correlating one part of the story with another or with information from prior records, family, or close associates. To the extent that the history at hand does not accurately reflect the story, it is helpful to have that additional point of view. Sometimes a consultant helps.

We edit and compose. The medical history is more than a combination of words like “diabetes,” “appendicitis,” “pain,” “chest pain,” and “shortness of breath”; rather, it is an organized presentation of a great deal of informa- tion. If world history provides context to single moments in history, then the complete medical history provides the “clinical context” to the medi- cal moment. Without  knowing the context,  physicians limit what they learn about the patient and from the patient.

Think of history in photographic terms. History is not a single snapshot; it is a movie, a sequence of snapshots, a story with a time dimension. We come into the movie during one short segment. If it is a mystery, the clues accumulate and the “solution” is clearer at the end. So it is with the medi- cal history. Physicians enter at a certain moment. Early in the story, the so- lution may not be so clear; later, almost anyone could figure it out.

From an artist I learned, “No two people tell a story the same way.”1

Some ways are more effective than others. What the patient says is often a sequence of spontaneous, short narratives, connected haphazardly. As phy- sicians, our task is to recognize the connections, apply order, make sense, clarify and separate the issues, and do it in a way that does not undermine or destroy the sense of the patient’s story and cause us to draw the wrong con-clusions and take inappropriate action. How well the doctor edits the story determines how useful the material is in leading to a diagnosis, treatment plan, and prognosis. Editing takes many forms: determining when the story actually began, what is important and what is superfluous, what are data and what are inferences, and when to quote the patient directly.

We record. The physician records the history of the above interview in this way:

This 44-year-old man comes to the office with the

Chief complaint: “I’ve got pain in my stomach.”

History of the present illness: He was in good health about 7 p.m. yesterday, af- ter supper, when he noticed periumbilical [the area around the “belly button”] pain, not especially severe, which persisted and slowly worsened. By this morning,

11 hours later, the pain was localized to the right lower quadrant of the abdomen. He vomited once, after the onset of the pain. He had a normal bowel movement yesterday and has had no hematuria [blood in the urine]. He has not had previous similar pain.

We critique. When we take and record the history, we discover gaps and new connections  between events, and we look at ways to do it better. Whether the process of interviewing is good or bad can make a difference in the relationship with the patient and a difference in both the process of care and the outcome of the illness.

We learn. Our patients are our teachers. From their stories, we learn most of what we need to know about them and their diagnosis and how to ques- tion the next patient with a similar complaint.

We empathize and form a relationship. As physicians, it is our job to project ourselves into the story well enough to understand it and the patient and to express that understanding. The interaction demonstrates our interest, es- tablishes a model for further transactions, and helps to establish or rein- force the relationship. The relationship facilitates care. We cannot do that with a questionnaire.

THE PSYCHOSOCIAL HISTORY

Attending to the psychosocial history recognizes what is going on in pa- tients’ lives as an important factor in how they feel. We learn how they deal with illness and other dilemmas and how they relate to others. It tells us what it’s like to be the patient. Even in the absence of a psychological illness, the psychosocial history widens the physician’s view and the context in which the illness occurs; a simple list of illnesses too narrowly defines the patient.

The physician explores the psychosocial history in various ways. She asks, “What’s this illness been like for you?” She explores the symbolism of the ill- ness by asking, “What does this mean to you?” Patients may respond: “My ar- thritis means I’ll be disabled.” “My high blood pressure? My father had high blood pressure and he died when he was 50.” “I’m worried I have cancer.”

Questions using the BATHE2 technique help:

B Background                             “What’s going on in your life?”

A Affect (the feeling state)       “How do you feel about what is going on?”

T Trouble                                     “What about the situation troubles you the most?”

H Handle                                      “How do you handle that?”

E Empathy                                  Some statement of empathy that validates the pa- tient’s reflections and brings closure to this part of the inquiry, such as “That must have been very dif- ficult for you.”

Without this inquiry, the opportunity to help, not simply with a diagno- sis, but also with advice about what is going on in the patient’s life, is too limited. Stories of patients’ illnesses come from broader stories of their lives, and remedies have to be compatible with that story. It is folly to pro- pose treatment with an expensive blood pressure medicine, for instance, if the patient cannot afford the drug. It does not help to talk about limb am- putation if the patient has decided that life is not worth living. In the story below, prescribing more physical therapy for this patient’s back pain was not helpful; knowing more about his psychosocial history explained why his recovery from the injury had been slow.

For two years now, this 55-year-old butcher had persistent back pain, despite sev- eral careful physical examinations, multiple x-rays, and weeks of physical therapy and medication. A different physician questioned him more completely about his psychosocial history and learned that he had been a butcher for many years, happy in his work and well regarded. When a grocery chain took over his market, he felt devalued in his new position, simply one of many other employees. After a few months in his new job, he slipped and fell, striking his back. He had survived a con- centration camp during the Holocaust, when prisoners were identified by a num- ber tattooed on their forearms. “How did this new job make you feel?” his physician asked. His answer was the key to a larger story: “Like a number.”

TEACHING THE MEDICAL HISTORY PROCESS

To the extent that the process of taking and recording the clinical his- tory is faulty and the psychosocial context is ignored, subsequent diagnos-tic and therapeutic action can be misdirected or incomplete, and appropriate care can be delayed—or never provided. It is critical that phy- sicians-in-training learn good, reproducible, and valid techniques early in their careers.

How do we interview patients and get them to tell their stories? How do we teach this skill? The physician-teacher models the process. To illustrate these techniques, I use a videotaped interview of a patient with metastatic colon cancer. I explain the structure of the interview before I play the tape. My questions will be open-ended initially, I tell the students, and I will al- low her to tell her story at her own pace, without interruption. During that time, I will make only a few notes. When she is through with her spontane- ous narrative, I will go back over the story with her and ask questions to clarify and amplify what she has told me. I will draw on my experience and my curiosity to come more precisely to a diagnosis or at least a “differential diagnosis” (see chapter 10) of what her problems are. During this time, I will also explore her understanding of her illness, her reaction to it, her ways of coping, and where she gets her moral and emotional support. I will use all of this information as I plan her treatment and, more broadly, how I will help to care for her. And throughout the whole interview, I will ask my- self, “What did I learn?”

I teach these lessons.

•  Trust your patients and believe their story. Only rarely are patients dishonest.

Trust is a two-way street: Unless you trust them, they will not trust you.

•  Remember, you are learning about the patient, and if you are doing it right, you will be learning from the patient. The patient is your teacher. One of my stu- dents wrote, “The conversation should be treated at first as a lecture, where the patient is the authority on her own condition and her body.” You can start with little or no technical knowledge. A good way to develop this skill is to imagine that you are the first person ever to interview a person with colon cancer, ap- pendicitis, diabetes, shortness of breath, or any other complaint or illness, that you are going to be the first ever to describe this illness, and that your patient is your only resource. Then allow the patient to tell his story.

•  First ask open-ended questions, that is, questions allowing the patient to re- spond with a narrative. Start with, “What brings you here?” followed by “What was that like?” and “Tell me about it.” Then listen and become fascinated by what the patient says and how. Reserve questions that can be answered “Yes” or “No” until the very end.

•  Do not interrupt. Allow silence when it occurs. Silence may mean that the pa- tient is thinking, trying to organize thoughts, perhaps struggling with a difficult emotion. Intruding on that silence may fracture the sequence of thoughts and feelings. Often what follows an uninterrupted silence may be valuable informa- tion.

•  Review and revise. Tell the patient your understanding of the story. If one part of the story does not jibe with another, go over the inconsistencies.

•  Regard the initial history as neither definitive nor final. Inquire about informa- tion the patient may have forgotten or hidden. If you are stuck on the diagnosis, go back and reinterview the patient. Sometimes the physician has neglected to explore an important part of the story. Sometimes the patient has forgotten to tell an important part or has not yet developed sufficient trust in the physician to reveal an especially sensitive bit of information.

•  Ask this final question, “Is there any question I did not ask that I should have?”

•  Learn from your cumulative experience. The more histories we take, the greater our intuition becomes after hearing but one sentence, such as “I had breast can- cer in 1991.” Beyond the diagnosis, we can imagine the shock of discovering the lump, the shattering experience of first hearing the diagnosis, the anticipation of the surgery and the anesthetic, the uncertainty, and the family’s experience. “Her father was an alcoholic.” “When  she was 13, her parents divorced.” “Twelve years ago, I had coronary bypass surgery.” Even without the details, we know that these are dramatic moments and there is a complex story behind each statement. The story of a patient with coronary heart disease in chapter 1 illustrates this well.

WHAT CAN GO WRONG

The challenge is to consolidate and integrate the material from taking the history without destroying the essence of the story, in order to draw valid conclusions and take appropriate action. Sometimes physicians get in the way of a good medical history.

•  We interrupt. Interrupting prematurely disrupts the story and the association of one element to another.

•  We misunderstand. We hear things differently from how they were spoken.

When two people disagree on the “facts,” whether it is two professionals or a professional and a patient, it is usually because each has a different view or un- derstanding of the patient’s story. We must be certain that we are operating off the same story.

•  We do not take enough time. We can misjudge people because we do not take the time.

•  We miss the whole story by limiting the scope of the inquiry. Sometimes know- ing the history from its beginning provides clues for preventing recurrence of the illness. A 40-year-old woman had abdominal pain following surgery for gall- stones. Was the postoperative pain a consequence and complication of her sur- gery or part of the story that led up to the surgery and not even related to her gallstones? Did her marriage breakup have anything to do with the pain? Wise physicians look beyond the obvious events toward the real beginning of the story in order to draw the correct conclusions, fashion the best treatment, and learn the right lessons.

•  We fail to recognize that it may take more than one interview to discover a key detail that will help in the diagnosis. Sometimes patients talk about their fears, addictions, or other sensitive matters only after a relationship is well estab- lished.

•  There may be a “language barrier.” The barrier may be as obvious as that be- tween an English-speaking physician and a non-English-speaking patient. It may also be a metaphor for more subtle language difficulties, when a physician speaks in medical jargon.

When we fail to recognize the difference between primary data and in- ference, we unconsciously manufacture our own story with incomplete in- formation, and we draw incorrect conclusions. Once, when I was an intern on the psychiatry service at Minneapolis General Hospital, the physicians, nurses, and social workers spent an inordinate amount of time speculating about why a patient wore sunglasses all the time. “He’s hiding from us,” they suggested. “He’s turned inward. He’s afraid of the ‘light’ of self-recog- nition.” I finally asked the patient,  “Why?” His response: “Because my other glasses are broken.”

Describing his physician-hero, Robertson Davies wrote, “It also taught me a lesson about being a doctor: You can’t really form an opinion about somebody until you have seen the place where they live.”3 I see this obser- vation both in a literal sense and as an apt metaphor. If we literally cannot see “the place where they live,” then we must try to visualize it. The medi- cal interview and history-taking process are the best gateway to those in- sights.

There are many highs in medicine—diagnosing an elusive illness or pre- serving someone’s life with complex, meticulous care in the midst of a po- tentially catastrophic illness. But these are rare occurrences compared with the more common and consistently exciting everyday transaction of “tak- ing the history.” There is a joy in gathering and using the information, gain- ing insights, probing the essence of a patient’s life, and participating in the patient’s drama.

From that starting point, physicians can then proceed to diagnosis and a plan of care and treatment.

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