A good history is integral to practicing good medicine

Have you ever gone to the doctor’s office and forgotten what you were going to say or felt like you didn’t have the answers to any of the doc’s questions? Have you ever gone in to an appointment thinking, “I have pain and I am sure an MRI will show the cause,” but your doctor seems to insist on asking you a million questions about your symptoms and doesn’t order that MRI you thought you needed?

Believe it or not, even though we are in the age of rapid testing and imaging, the most important part of making a diagnosis is your story about your symptoms. We call this the “history.” Getting a good history is integral to practicing good medicine, particularly in primary care.

Imagine this. A man is walking down the street and witnesses a mugging. He is standing there watching the whole thing, but is unable to get involved because the perpetrator has a gun. After the incident, he calls the cops. Pretend you are a cop. What would you ask the witness?

“Where did the incident happen?”

“What did the suspect look like?”

“What was he wearing?”

“What time did this occur?”

As a police officer, what would you do if the witness said, “I don’t know” to some answers and, “I think…” to others? It would be hard to put together the story or to feel confident about it, wouldn’t it?

The basic ideas of getting the “Who, What, When, Where, Why, and How” are important to any kind of detective work. As a physician, I am generally supposed to answer the “Why” and “How” parts. The rest is up to you. Not to put pressure on you as a patient, but because I am not going to run every test known to man in order to come up with the diagnosis, I rely on the information you give me to figure out the appropriate next step.

Here’s a tip:

Tell your story your way, but include the important details. How do you know what is important? Well, I will tell you and you will likely see that it makes a lot of sense.

Pain is a great example of a symptom that is best evaluated initially with a certain set of questions, rather than jumping to x-rays or other imaging. Let’s say that, for example, you are seeing your doctor next week for a pain in your foot. Try to remember the following for that visit (write it down if you are worried you might forget):

  • Where exactly in the foot is the pain?
  • What makes the pain worse?
  • What makes it better?
  • When did the pain start? (dates, exact or approximate help)
  • How did it happen? (after a night of dancing in heels, for example)
  • Is the pain sharp (like a knife) or dull (like an ache)?
  • How severe is the pain?
  • Is the pain constant or does it come and go?
  • What have you tried to do for it already? (medications or exercises, changing shoes, etc).

The beauty of going through these questions yourself is that it not only helps me figure out what is going on, it might even help you figure it out before you even need to see me. I am not talking about self-diagnosis, necessarily, but it may help you keep the pain from getting worse or perhaps make you realize that a certain pair of shoes is not right for you. In our busy world, we often forget to pay attention to little details. Trust me, I have seen patients come to me for help and then come up with the answer themselves as they are talking to me because it is the first time they sat down and actually thought it through.

No matter how you describe your symptoms, I am still going to do my best to put it together and come up with an accurate diagnosis with as few unnecessary tests as possible. It is my job, after all. But sometimes, how you tell your story can help me help you better .

Linda Pourmassina is an internal medicine physician who blogs at Pulsus.

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  • http://www.stampandchase.com Burl Stamp

    Dr. Pourmassina makes such important points regarding a good history. Research has shown that a thorough, well-structured patient interview is just as important as lab or imaging results in getting to the right diagnosis. Furthering Dr. Pourmassina’s analogy to a crime investigation where the police officer doesn’t get the information she needs from a witness, a physician who works without the benefit of an excellent history often wastes both time and money getting to the right answer.

    If we want patients to feel comfortable and really open up during the history interview, open-ended questions are especially important. In Robert Smith’s book “The Patient’s Story,” he encourages physicians to start with patient-directed discussion of symptoms and concerns before immediately jumping to a physician-directed interrogation. In this way, the patient tends to be more comfortable sharing details.

  • Campykid

    I’m now very careful about giving unprompted details when being interviewed for a health history. This change came after I was referred to a cardiologist to discuss 10 years of worsening palpitations, chest pain, and dizziness. Shortly into the initial consult, as I was providing background information, he interrupted me and told to be quiet to let him talk. On the way out of the appointment, one of the RNs pulled me aside and advised me to read Jerome Groopman’s “How Doctors Think” (a great book!). I took this recommendation as an apology for her “boss.”

  • Leslie

    The best diagnostic question to ask about pain is to ask for a list of descriptive words about the pain. Or give the patient a list of words to pick from. Different body parts and conditions put out unique types of pain that serve as clues to isolate what is wrong. Indeed, some conditions and injuries are described on paper by the specific feeling of their pain.

  • http://www.cadencerelations.com Matt Langan

    I’ve personally found that keeping a diary is a terrific way to track symptoms and my successes or failures to trying medications/exercises/foods/et cetera. In fact, this method was so effective for me that I have been was able to basically lead my doctor to the modality that ultimately solved my dilemma. It’s also important to note that when I shared the information with my doctor, it made me feel like I was working with him (as opposed just taking orders) to solve my complaint, which was both empowering and comforting for me.

    I think this article also speaks to the importance of a doctor keeping thorough notes on his/her patients overtime so that treatment patterns can be identified and mistakes can be avoided. In fact, I believe so strongly in the value of keeping a living history of patients that I co-founded a service that is rooted in helping doctors do just that between visits. Feel free to visit our new blog (www.cadencerelations.com/blog), if you want. I hope to cover this topic in an upcoming post. Thanks for the terrific read.

  • rich md

    …then the cardiologist ordered a holter, stress test, echo, carotid doppler,mri/mra of the brain, cardiac enzymes and when all cam back negative sent you back to thepcp who then turfed you to another specialist…

    • Campykid

      In fact a Holter caught A-Fib and I was turfed to an EP…

  • Patricia

    As an RN with greater than 20 years of clinical experience who now reviews medical records daily, I can tell you that a good patient history is a rare gem, indeed. A well-done history reads like a whodunit, replete with diagnostic clues – and red herrings – that ultimately leads you along the path of discovery. Unfortunately, history-taking seems to be a lost art. The physician is all too willing to jump to a high-tech, expensive imaging procedure that produces either negative results, or worse, an obscure unrelated finding. We all know the reasons for this. They range from time per patient to fear of a lawsuit, but it will be more difficult to justify clinical reasoning when no reasoning was done.

    What truly amazes me, though, is the number of times the physician takes the time to elicit a history and then gets it wrong! How does this happen? Is it ‘fore-thinking;’ i.e., assuming what the patient will say and not hearing what the patient actually says? I have seen this in my own nursing practice and in my experience as a patient and the mother of a patient. I will have given the history, or been in the same room while the patient gives the history, and then, when I read the history as dictated by the physician, it sounds like a different patient.

    I have seen this happen so many times and I cannot fathom an explanation. Some cases are funny, some are sad, but they all defy explanantion. In my daughter’s case, following a workup with a renowned neurosurgeon for evaluation of a Chiari I, he wrote that she was delivered by an uncomplicated, normal spontaneous vaginal delivery without complications. In fact, she was born by a scheduled C-section and was in NICU for 3 days. I would not have made that mistake in her history!

    I recommend that you take a history, listen to the patient (as hard as that may be sometimes), and take notes or dictate immediately. Waiting until the end of the day to reconstruct the visit is a recipe for disaster. I was truly impressed by a surgeon who did my history and physical and then dictated her findings while in my room, in my presence. This way, I was able to correct one minor misunderstanding immediately. I knew what was going in my record and we were both clear on her recommendations.

  • http://www.patientcommando.com Zal Press

    I’d like to suggest that the patient history is more important in a broader context of healthcare management. Not only can it provide clinical guidance but help enrich practitioner understanding of the entire illness experience.

    Initiatives such as The Program in Narrative Medicine at Columbia University fortify “clinical practice with the narrative competence to recognize, absorb, metabolize, interpret, and be moved by the stories of illness. Through narrative training, the Program in Narrative Medicine helps doctors, nurses, social workers, and therapists to improve the effectiveness of care by developing the capacity for attention, reflection, representation, and affiliation with patients and colleagues.”

    As doctors become more competent at extracting proper histories, it’s critical that patients keep pace and improve their storytelling. Unfortunately there’s no training program for patients. We’re taught reading, writing and arithmetic but receive no formal training in analytical health self-management. Instead we hear patient stories in the humanities through literature, drama, comedy, storytelling and the arts. These stories empower patients, encourage engagement, and give voice to the patient experience as a guide to practice change.

    Transferring these skills to more doctors and patients will enable improved outcomes and richer experiences for all.

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