Today I spoke at the Canadian Rocky Mountain ACP Chapter meeting. As usual I spoke on clinical reasoning. A colleague asked me about how learners should start their presentations. The questioner complained about hearing a long previous medical history (PMH) prior to knowing the chief complaint.
I almost salivated at the question. This question frames 1 of my pet peeves.
When did the presentation initiation switch from the chief complain to the PMH? Who made this decision? Why do I care so passionately?
We should use context to interpret the history, physical and tests. The PMH represents a part of the history, but not necessarily the most important part.
How can the PMH help me with the new chief symptom without knowing that symptom? How do we think through diagnostic possibilities?
As we hear the chief complaint we start developing our thought process. We then continuously modify our thoughts as the history develops, including knowing the past medical history.
Hearing the PMH prior to knowing the chief complaint seems very unnatural. What am I missing here?
Likewise, when we call our consultant, we should lead with our request. For example, we might call a pulmonologist to consider doing a bronchial alveolar lavage. The first sentence makes that clear: We would like you to consider a bronchial alveolar lavage for our patient. She is a ….
Too often I have heard interns and residents start telling the consultant an abbreviated history and physical without framing the information.
Good speaking and good writing follows from great initiation. We should learn this during medical school and residency. Too often we do not, and our thought processes may get muddled.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.