Repeated story syndrome: Finding the right balance for patients

The other night, a patient gave me a piece of his mind. Mr. Q was a middle-aged man debilitated by days of nausea, vomiting and intractable belly pain. That morning, his wife finally convinced him to get medical attention and drove him to our emergency department. On arrival, he sat in a cubicle in the waiting room and explained his story to a triage doctor: how he was doing well until he ate a particularly rich meal a few days ago. How he’d vomited five, maybe six times. How he hadn’t noticed any fevers. How he’d tried Tums for his symptoms with little effect. After he was escorted to a bay in the emergency room, he repeated the unpleasant details for the resident who came in to evaluate him. This time, he added that he takes a statin for his high cholesterol, that penicillin gives him a rash, and that he doesn’t smoke. Within the hour, he gave a repeat performance for the emergency room attending.

Just as he was settling into his slightly-more-permanent bed on the medicine floor, here I was, poised before a laptop on wheels and demanding yet another re-hashing of a narrative that had grown both trite and physically exhausting: “So, Mr. Q. What brought you to the hospital?”

“Doesn’t anyone write this stuff down?” He followed with a few other choice phrases.

Why do we make patients repeat their stories so many times? My standard answer is that when we assume care for a patient, we need to be sure that we understand his history so that we can take care of him properly. This is true, but it’s worth unpacking further.

Each re-telling has a unique purpose, or at least a unique point of view: In the emergency room, the questions asked of Mr. Q were necessarily brief and to the point. There, the main goal was to rule out potentially fatal causes of his belly pain and to send him either home or to an inpatient hospital bed. When I admitted Mr. Q to the general medicine unit, I needed a more detailed story so that I could continue to diagnose and treat his symptoms, and I needed to cross-check his home medication list so that I could order those drugs for him during his hospitalization. Specialists consulting on a patient would have asked him for a re-telling of his story with a shifted frame: the infectious disease doctor would want to know about him eating uncooked hamburger; the cardiologist about whether he’d ever had chest pain while resting.

Even if I had found all of the seemingly relevant details in prior notes, I might have gotten unexpectedly valuable information from a re-telling: a diagnosis-clinching clarification of the exact quality and pattern of his abdominal pain, or a teased-out recollection of blood in his vomit. Asking those questions myself also helped me understand and remember my patient’s story better than if I had read it from the chart.

So is the repeated story phenomenon a useful, error-reducing redundancy in our health care system? A necessary annoyance in an increasingly complex medical system involving multiple doctors and departments? A vestige of the Every-Man-For-Himself doctoring model in which you must re-check everything and trust no-one? Probably all of the above. But I wonder, in our slow but undeniable transition to team-based care, to what extent should we rely on the story as it has been collected? Where is the right balance between efficiency and patient comfort on the one hand, and Getting It Right on the other?

Later that night, Mr. Q stumbled out of his hospital bed to find me and apologize for his rudeness. Surprised by his gesture, I thanked him and told him it wasn’t necessary – he had every right to be frustrated and had given me something to think about.

Ishani Ganguli is a journalist and an internal medicine-primary care resident who blogs at Short White Coat on Boston.com, where this article originally appeared. 

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  • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

    Very interesting article. I found the statement about the reason for why you ask the patient about the details of the problem helps you to better remember what they are saying than if you read it in the chart to be very interesting. Thanks for sharing that. This is something I will keep in mind for whenever I go back to my doctors and they ask me why I am there even though I have just finished explaining it to the Medical Assistant.

  • http://warmsocks.wordpress.com/ WarmSocks

    I agree with your patient’s frustration. Rephrasing the question would probably go over a lot better than the current system. “I’ve read over the notes explaining why you’re here, and now I’d like you to tell me in your own words.” Add whatever details you want after that: ‘it helps me remember better,’ or ‘often patients remember new details when they tell the story again,’ or something along those lines. The current system doesn’t inspire confidence since it looks like nobody communicates with anyone else. Adding one simple phrase to the request for history could make a huge difference.

    • pj

      Great idea!!!! Thx. Will try w/my patients.

  • http://www.facebook.com/edward.stevenson Edward Stevenson

    I think there is substantial difference in retelling one’s story, and adding to and clarifying ones story. I find that repetitive telling of a story lead to leaving out pieces of information and contradiction is various versions. This unjustly calls into question the veracity of some patients story verses a suspicion of maligning. patients pick up on the fact that everyone is repeating the same work. they then start to abridge the story to what they feel the level of the interviewer is. in other words students get the brief story, leaving the significant and embarrassing parts for the attending. hopefully the attending spends enough time with the patient to get those parts of the story.

    I find it best to tell the patient what story has been documented, then let them add, subtract, and clarify. The also makes patients feel like we are working as a team and that everyone does have the patient’s best interest in mind.

    • http://warmsocks.wordpress.com/ WarmSocks

      Your approach sounds great! I’m amazed at the number of times I’ve read notes and discovered errors. It would be nice to clarify things right away.

      • pj

        Another huge issue is, a doctor must diagnose a pt with something in order for insurance/medicare to pay for the test! Coding gurus, correct me if I’m wrong, but I MUST diagnose a pt with a brain tumor if i want their insurance to cover a CT or MRI to rule out a tumor. Even if I doubt they have a tumor, i must give them that godawful diagnosis. So it becomes part of their record, leading to more confusion when the CT somes back negative,

    • pj

      In all fairness, I;ve read articles by med malpractice defense attorneys (Lee Johnson, JD I recall) saying ANY discrepancy in a record MUST be explained or reconciled. But this does not seem possible at times. Ex- oftentimes patients can’t tell me why they told the RN they’re allergic to sulfa but told me no allergies. Worse yet, I ask why they didnt take a med I rx’d or get a test I advised, and they say “Just didn’t” repeatedly, as if that explains anything.