Wednesday, September 14, 2016
Teaching the history of present illness
Students (and interns and residents) provide important insights into their skills and understanding with their oral presentation of the history of present illness (HPI). The history of present illness provides the key to diagnosis in a great majority of patients. A recitation of the history of present illness shows us how the learner has thought through the patient's problem and their skill at asking the best follow-up questions.
Several years ago I heard this great description of the process of reporting the HPI. The first paragraph recounts the patient's story in depth. This includes the patient's chief complaint, as well as the answers to questions that the interviewer has asked. The first paragraph often contains relevant past medical history and medications.
The second paragraph includes the answers to questions that flesh out the differential diagnosis. The second paragraph anticipates the questions that the listener might ask.
That framework starts our conversation. As attending physicians we can use the HPI presentation to teach history taking, differential diagnosis, and the cognitive process.
A common trope in medical education suggests that we should not interrupt the presenter. Here I will agree and disagree. At the end of the HPI we should stop the presentation and teach. We have the opportunity to provide feedback and show provide that feedback immediately. Delayed feedback does not work as well. We should provide positive as well as constructive feedback.
I focus my teaching on the HPI. Each presentation led to the following question: ”What did the HPI not include?” Potential examples:
1. Stating that the patient has diarrhea and not describing the diarrhea.
2. The patient complains of chest pain, but the HPI does not systematically go through a thorough description of the pain, inciting and relieving features, previous chest pain history, associated symptoms, etc.
3. Present medical history includes type 2 diabetes mellitus, but does not report duration and complications.
I could continue, but you likely get the point.
We have a wonderful opportunity to teach our learners how to think through the HPI. We know that the best physicians obtain very complete histories. As we ask these questions of our learners, and as we retake the history at the bedside and get more information, our learners grow, especially when we discuss the rationale for the information.
Recently we had a patient admitted to our service for dyspnea. The patient had a history of chronic obstructive pulmonary disease (COPD) and already used home oxygen. The presenting learner gave a complete history of the COPD and when the oxygen requirement increased. So I had the opportunity to provide very positive feedback.
The referring physician had prescribed antibiotics and steroids but the learner gave a clear history that the patient did not have acute bronchitis. This history allowed us to discuss the differential of worsening dyspnea in a COPD patient. Again the learners did an excellent job.
Routine labs revealed severe anemia, and thus the presenter gave a history of melena.
The HPI did not include a complete history of dyspepsia. At the bedside the patient gave a history of early satiety for the past month or two. The patient had started taking a PPI.
Because the COPD “exacerbation” occurred secondary to acute anemia (Hgb<6), the dyspepsia history belonged in the HPI.
Spending time on presenting can greatly help our learners. So let the learner complete the HPI, but then discuss the HPI prior to hearing the rest of the data. Doing so can help the learners refine their HPI. Doing so allows us to give the feedback necessary for deliberate practice.
Focus on the HPI and our learners will benefit.
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.
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