It is time to reframe patients’ medical history?

It wasn’t long into my clinical training when I realized that most patients do not convey information the way templates are designed to record it.

Instead, they tell stories — which may weave from topic to topic, progress forward or backward in time or in patterns that may not be familiar or clear.

But they are told as the patient sees fit to convey them. David, a forty-year-old man who recently presented with neck and shoulder pain, reinforced my appreciation for the value of receiving patient stories, regardless of how they are told.

I walked into David’s exam room and saw him sitting nervously on the edge of his chair. When I asked what prompted his visit, he began to speak with urgency and sounded like he was instantaneously in the middle of his story.

“So this pain in my neck has gotten so much worse, I’m not sure if I take much more of it,” he said.

As I sat quietly and waited for him to continue, I found myself leaning toward him in anticipation of what would come next.

“It hurts when I turn my head and goes into my left arm. Am I too late?” he asked with concern that seemed mismatched to his clinical presentation.

Before viewing the history as a story to receive, this is a juncture at which time I might have said, “David, how about if you back up a little and tell me how this all started.” After listening a little more, I may have asked a flurry of closed-ended questions in order to refine my diagnostic thought process. In other words, I would have tried to force his narrative into a form that was easier for me to digest, one that moves from beginning to middle to end. This is not necessarily wrong and may have helped me establish the correct physical diagnosis, but possibly at the cost of missing the essential concern that motivated his visit to a physician. Here’s how it actually went.

“Too late for what?” I asked.

“To prevent a heart attack!” he replied with alarm.

As it happened, this is what worried David most about his left arm pain. Once I was able to reassure him that his symptoms were not cardiac in nature, he calmed down significantly. In fact, he was impatient to conclude the visit after my examination and did not want to take any medicine for his pain, once I explained that he was probably suffering from a pinched nerve in his neck.

While some patient stories have a traditional story arc, others can be non-linear. Many start with an “action scene” and fill in the background details later. The variety of story patterns is endless. I have learned not to chime in too soon, because — as muddled as story may seem — it is my patient’s way of expressing their concern. Often patients are more interested in making sure of what they do not have, as in David’s case, than in their actual diagnosis. Listening carefully to the unique way a story is expressed offers a better chance of understanding what is truly prompting the visit.

Historically, we have not been effective at receiving patient stories in their unaltered form, with studies showing that physicians interrupt patients on average, within 18 seconds after beginning a medical interview. In today’s time-constrained office visit, it is understandable that many of us may fear being inundated with a never-ending filibuster unless we quickly intervene and establish control. This is unfortunate, because further study has shown that: when allowed to speak without interruption, patients speak for substantially less time than anticipated. Further, the first complaint mentioned by a patient is often not their chief concern, nor is it the most worrisome. Many of us can probably recall a “doorknob” question about chest tightness, as an example.

The fact that we have coined and become comfortable with the phrase “taking the history” speaks volumes. When I think of other interview types which are “taken”, the deposition comes immediately to mind. This is less an interview than an interrogation, which usually consists of closed-ended questions strategically designed to build a story which is helpful to the client of the attorney who “takes” it. Reflecting honestly, I’m sure that I have, especially when unaware and pressed for time, slipped into almost deposing patients in order to find out what I thought I needed to know. All interviews are performed in an effort to gather information, but the medical interview is unique in that it commonly involves intimate information a person would never divulge elsewhere and is an invaluable opportunity to build trust and connection — the crucial underpinnings of a therapeutic relationship. Without this foundation, we may still make diagnoses, but we may not learn of our patients’ deepest concerns. This is, after all, what is most human about doctoring.

So how can we move toward a more consistently generous, relationship-centered receiving of the medical history? First, we must become more skilled communicators. Improving communication has been associated with improved patient outcomes, lower malpractice rates and improved physician and patient satisfaction. Next, we should lead efforts to create a work environment more conducive to close listening, with a more fully realized EHR and support staff working at the top of their licenses. Last, those of us in a teaching role should stop asking students and trainees to “take” the history. Instead, we should encourage them to listen and conduct an interview. Neither of these is an easy task, but the potential payoff for our patients’ experience and our own professional reward is enormous.

It is time to reframe the medical history not as something to be taken or extracted, but as an offering, a story which should be humbly accepted in the way our patient needs to convey it before we set out to refine it for our diagnostic purpose. The history is more than a diagnostic tool — it is a vital part of establishing a trusting connection and conveying empathy. It may also be foundational to appreciating the total picture of what the patient is seeking from their visit. Embracing this interview paradigm gives us the best chance to, paraphrasing Osler: Treat not only the disease but the patient who has it.

Jeffrey H. Millstein is an internal medicine physician.

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