Entire books can be written on obtaining the medical history. The paradox associated with such writings is that they tend to make maximal sense only to readers who are experienced enough to no longer need them. For practical advice, I would like to highlight seven rules. Regardless of your level of training or cognitive preparation, these rules can help you obtain a better, more complete medical history.
- Introduce yourself
- Wash your hands
- Sit down
- After inviting the patient to speak, commit yourself to listen without interruption for at least 90 seconds
- Find out what the patient wants
- The patient is not always right
- Collect pearls
If you find yourself rushed while seeing patients, don’t blame the system. Yes, there have been changes. Managed care asks doctors to move faster; there is more to know than ever before; and people are living longer, with greater expectations from health care systems. But on some level, this explanation is shallow: all generations will have their own explanations why physicians are more harried and hurried than ever before. (Hard to believe though it may be, the year 2054 will one day be the “good old days”.) Time pressure on physicians is an eternal and I would say inherent problem: because patients’ appetite for your attention can border on insatiable, you can never spend “enough” time with them. You will always feel pressured to move on.
You need a method that helps fight this sense of tumult– not only to keep patients happy but indeed, to obtain an accurate medical history. Rules #1 and #3 offer such a method. By introducing yourself, you introduce a needed and necessary human dimension. It matters little whether you introduce yourself as John Smith, student Smith, student Doctor Smith or any other variation on this theme. What matters is that your remind yourself and the patient that this encounter is a personal one.
Finding a seat is also important. Even if you are in a rush, you will seem less eager to run out of the door if you are seated, and the patient will perceive this. Beyond that, I also believe that the act of sitting transforms you; it actually makes you less rushed. As the novelist Kurt Vonnegurt noted, you become who you pretend to be. If you pretend not to be in a rush, you magically become less rushed.
Rule #2, namely the commandment to wash your hands should need no comment here. When Semmelweiss introduced the notion that doctors must wash their hands between the anatomy lab and the obstetrical ward, he was ridiculed and shunned. Today, we of course understand why hand washing is medically necessary. But it is necessary also in the realm of obtaining a history, as washing your hands in the presence of the patient will help establish patient trust: assume that patients always notice if you do or do not wash your hands.
The fourth rule may be the hardest to follow. If you are an avid history taker, you will want details and you would be right for wanting them: often an experienced clinician can make a complete diagnosis on the basis of the history. The irony is that the best way to insure that the patient offers the details is for you not to extract them. Let the patient tell you the story. Do not interrupt. Again, this is not so much about manners as it is about effectiveness. If you think of some pressing question and you are afraid you will forget it, scribble a short note to yourself. If you do interrupt, it is likely that you will spend more time getting less information.
The first 4 rules are of course applicable to all practice. The 5th may be somewhat particular to Musculoskeletal Medicine. When dealing with complaints of bones and joints, it is very important to ask the patient what he or she wants from the encounter with the physician. The human body is a mechanical device and one that is subjected to wear and tear. Thus, it is unlikely that a middle-aged person has a pristine musculoskeletal system. “Abnormalities” will be lurking everywhere. Your job as the medical historian is to discern between abnormalities that are mere incidental findings and those which are a source of distress and disability for the patient. You are also charged to discover whether the patient deems the “abnormality” sufficiently bothersome that it would merit the cost, risk, and hassle of treatment.
Obviously, if the patient’s problem is likely to progress if ignored but improve if cared for, you must at the least offer treatment. On the other hand, if the condition is one whose only cost is that it may produce symptoms (that is, it is possibly “hurtful” but not “harmful”) a more passive approach may be in order. Don’t try to cure what is not bothering the patient. For example, many adults have herniated spinal disks. Your job as the diagnostician is to discover not only if there are symptoms attributable to that disc, but to find out if these symptoms are severe enough to warrant treatment. (It is possible that a patient will come to the doctor for the evaluation of back pain only to be reassured that “it’s not cancer”. Recommending surgery for incidentally discovered disc abnormalities is probably fatuous in such cases.)
And one more caveat: The patient is not always right. It is true that in a vast majority of cases, patients’ stories will tell the perceptive listening exactly what is wrong. Still, you must remain cognizant of the fact that musculoskeletal disease often produces so-called referred pain. That is, the area in which the patient reports symptoms is not necessarily the area harboring the pathology. For instance, hip disease can cause knee area pain; likewise a proximal nerve injury may be reported as pain in the distal area where that nerve terminates. And of course, visceral organs can produce musculoskeletal symptoms: the patient may complain about left shoulder pain, but what he needs is a cardiologist, not an orthopedist.
These six rules should help you from the outset, but you will not be expert with them alone. Your skills will evolve, and improve with time—especially in terms of recognizing patterns and making connections between seemingly unrelated facts. You will find your share of the many pearls relating to the musculoskeletal history. The best way to find them, of course, is to actively collect them. To do that, see as many patients that you can on your rotations. For instance, the one history pearl that I recall from medical school –“Posterior shoulder dislocations are associated with seizures and isolated lesser tuberosity fractures of the humerus”– sticks in my mind not because I memorized it from a list, but because I saw a patient whose subtle tuberosity fracture was discovered because of that rule. Patients will be your teachers. But until you have collected the experience with patients that is the beginning of wisdom, use these rules. They won’t let you down.