Blog | Wednesday, August 10, 2016

On taking an excellent history

The art of eliciting the medical history requires medical knowledge, cultural knowledge, and many people skills. History taking is not science, but rather art, because it requires interpretation and clarification. Patients with the same symptoms express them differently. A major feature of the art of medicine involves learning how to interpret different descriptions of the same phenomenon.

A few examples might clarify these concepts.

The patient tells you that they have chest pain. At this point you really know very little. What are they really describing? How might they characterize the pain?

A patient comes to urgent care complaining of a sore throat. The nurse invokes a protocol, gets a rapid strep test that is negative. The physician reassures the patient. A week later the patient still has a sore throat. A careful family physician asks the patient to describe the pain. The patient then puts her had on a small bulge anteriorly. The patient actually has thyroiditis. She did have a sore throat, but not the same sore throat that usually attends an urgent care clinic.

The patient tells you that they have diarrhea. What do they mean using that term: loose stools, frequent stools, watery stools?

These examples should help us all reflect on careful history taking. As we read mystery novels, the detective often has to reexamine the subjective information. What did the witness really say; what did the witness really mean?

We must have the same mindset. We are detectives and the patient (and family and friends) are the witnesses. If we ask the proper questions and make certain that we really understand what the patient has experienced, we are much more likely to arrive at the correct diagnosis quickly. We must not put our interpretation on the words the patient uses, but rather elucidate their meaning. When we learn to do so, we become artists of the best kind.

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.