“Take a good history, do a good exam.”

I have not contributed to my treasure of quotes with this title.  No one reading the headline well hit their head and mutter, “Wow!”  Yet one can wonder about the lack of careful history taking and basic physical examination skills.

This delightful new blog post written by an internal medicine resident says it well: Defensive medicine supersedes quality medicine.

You should read the entire post and the link to the article that stimulated it.  How does a post with that title stimulate me to write about history and physical examination.

Here is the main idea.  Rather than doing a careful history and physical, many physicians resort to order expensive tests based on a complaint rather than a full history.  Physicians almost unanimously believe that other physicians do this (and some will admit that they are guilty also):

Our predecessors were able to gather essential pieces of clinical data from a physical exam. Today, in the world of overburdened emergency departments, full hospitals, and electronic ordering and note-writing systems, we are forced to spend less and less time with our patients. In an attempt to compensate for this problem, we make up in quantity what we cannot provide in quality – and we make up with money what we cannot provide in time. Although the perception is that patients benefit, by getting a myriad of lab tests and imaging studies, they do not. These tests mean very little unless they are correlated clinically. They only become significant in the setting of the patient.

Rather than realizing this, clinicians have begun to practice test-centered medicine rather than patient-centered medicine. This causes huge delays and expenses in patient care. It also places patient at risk for (1) being treated unnecessarily for incidental findings and (2) being exposed to unnecessary radiation. Furthermore, it alienates patients even further from their physicians – and this, perhaps, is the greatest cause of increased lawsuits and patient dissatisfaction, which starts the cycle of practicing defensive medicine all over again.

I would add to these insights taking the time to take a careful history.  I recently met with some new third year medical students for an hour.  We did a special student only morning report.  I spent most of the hour focusing on how to take a careful history.  We discussed the value of certain questions.  We discussed who we might construct questions.

I recommended that they all read the first chapter of Cope’s Early Diagnosis of the Acute Abdomen. This book has the best introduction of the history taking process that I have ever read.   While I am obviously not a surgeon, I have learned more by reading this chapter than any other single source for improving my history taking.

I believe that I have also learned much about history taking by reading mystery novels.  Of course, it may just be that I love reading mystery novels and want to justify that hobby.

Often in my role as a ward attending I find that a careful history helps us make a diagnosis without needing shotgun testing.  Less often, but just as important, a targeted physical examination helps us make a diagnosis.  But doing a careful H&P does take some time.  Learning to take a careful history, reading the patient, adjusting ones vocabulary to the patient are skills that need practice and cultivation.

I challenge all attending physicians to spend time teaching this important skill.  I challenge all residents to find a mentor to help them become excellent at taking a history.  It helps greatly.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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