One of the first aphorisms you’ll hear during your medical training is that ‘a careful history will lead to a diagnosis 80% of the time’ [1]. While this obviously depends on the context, your ability to take a precise and relevant history is the most powerful diagnostic tool in your armamentarium as a doctor. Even as I’m writing this during the COVID pandemic, where clinical encounters are replaced by telehealth consultations, getting the history right has never been more important for our patients.
The ‘history’ is essential to most fields of medicine (yes, even in radiology the number one complaint is not being provided enough clinical history with the imaging request!). In my particular training specialty of neurology, an accurate history can be the difference between a syncopal episode or a seizure; between being admitted to hospital to undergo unnecessary and invasive tests or being able to go home with the correct treatment. I’ve seen too many patients re-present with catastrophic outcomes as a result of missed diagnoses that could have been avoided with more diligent history-taking at an earlier clinical encounter.
Taking a history is a skill that you will continue to refine throughout your career as you constantly juggle the seemingly competing priorities of exactitude and efficiency. To help guide you on this journey, I’ve included 10 key tips for that next time you’re asked to see that patient in the emergency department, on the ward or in the clinic.
First impressions matter and can influence the trajectory of the history and consultation. Introduce yourself including both name and position. Smile and try to communicate warmth and attentiveness. Ensure the patient is comfortable – offer a pillow or blanket if they need one. Just as importantly, make sure you are comfortable. Pull over a chair and get down to eye level with the patient if possible. These small gestures tend to tell patients that you have time for them which encourages them to volunteer important information. I personally find I am less likely to rush through the history if I am sitting down.
Tell the patient the purpose of your being there: “I’m here to get some information about your chest pain”. If you anticipate you will get calls or get paged, let them know upfront: “I want to let you know in advance that I am on call for emergencies in the hospital and may have to answer my phone/pager during our discussion”. It is incredible how much more tolerant your patients can be of these interruptions when you warn them in advance.
Although rapport will depend on the entirety of your interaction with the patient, I take a minute or so at the beginning to connect to the patient at a human level. This may sound daunting to some, but in fact can be quite simple. A good place to start usually involves just taking some of the social history first. For example: “What do you do for work?” or “What did you used to do for work?” Such information is very useful in establishing a cognitive and educational baseline (which can help you pitch the rest of the discussion) but importantly it might reveal shared interests. At the very least it serves as a reminder that you are speaking to a human being with their own set of skills, knowledge, and life experiences.
In a landmark study analysing 74 doctor visits, Beckman and Frankel (1984) found that interrupting a patient early in their opening statement and reverting rapidly to closed questioning often prevented the patient from disclosing relevant information [2]. On the other hand, they found that if a doctor allowed the patient to finish their opening statement, more medical issues were raised and there was a reduction in late-rising problems.
For those who are time-pressed, it’s worthwhile noting that patients allowed to complete their opening statement without interruptions often took less than a minute, and none took longer than 150 seconds. Giving patients this time gives them the sense that they have been heard, after which you can direct the patient to the relevant aspects of the history. This is also the time when you should be keeping a checklist of those issues that you need to make sure you cover in your history and is an opportunity to ask the patient which issue is their major priority so that you make sure you address this.
By the end of the first year of medical school, most of you would have memorised the important headings: Past medical history, allergies, medications, etc. However, you’d be surprised how easy it is to get lazy especially when you’re feeling tired. You may forget to ask an important heading (smoking, alcohol, recreational drug use, etc). As you become more senior, you’ll also add more subheadings to these major headings.
For instance, for background medical issues (e.g. Type 2 Diabetes) subheadings can include the treating physician, when they were last seen and how well the condition is controlled (e.g. HBA1c) and complications of the condition (e.g. nephropathy). There are also special components of the history which might give important clues to the diagnosis but often get missed such as ethnicity, travel history, developmental history, pregnancy and fertility, and consanguinity. I always make a conscious effort to try to remember and ask about them if the context is appropriate.
You will notice that medical students when starting out often take long, linear histories. But one thing you’ll quickly notice watching more senior clinicians is that they rarely ever follow the original order that we learn in the first year of medical school. Instead, they change up the order of the headings to suit the clinical context.
Generally, I will often start with social history and past medical history before leaping into the history of presenting complaint. These earlier aspects of the history are important for establishing the pre-test probability of a condition, can help to direct questioning of the presenting symptom later, and help decide on investigations and discharge disposition (e.g. atypical chest pain in a 50-year-old healthy non-smoking female versus the 50-year-old female diabetic with a history of hypertension, hypercholesterolaemia and ischaemic heart disease).
On the other hand, if I am in a time-pressed situation with a sick patient, the history of presenting symptom is often more important to establish upfront to help me focus the remainder of the history and identify any immediate investigation or therapies that need to be initiated.
Throughout the history it is important to stop every now and again and reflect back a summary of what the patient has told you. This is important both to aid your memory and to make sure you’ve understood the information and sequence of events correctly. A summary is also a good time to clarify ambiguities or missing pieces in the history and pinning down patients’ understandings of specific terms.
There are certain words that you should never leave up in the air – for example, when patients say they felt ‘dizzy’ or ‘sick’, or had a ‘funny turn’ – they should always be followed by a reflex of rapid-fire questions to help differentiate what they actually mean. It is worthwhile also noting that specific words you say may have different connotations depending on cultural context and educational background so always be sure to check-in with a patient to see if they’ve understood what you’ve told them as well.
If you are dealing with a patient from a non-English speaking background, the safest position is to assume that there will be miscommunication. Always make an effort to arrange an interpreter (even over the phone) to clarify the history directly from the patient rather than relying purely on collateral history or translation from family and friends. Of course in situations when you are dealing with the disoriented or incapacitated patient the collateral history is everything, but even then make sure to seize the opportunity at a later stage to confirm the history with different informants and the patient themself if possible.
When you first start off as a medical student, the primary motive for taking a history is information gathering. But as you transition to fully-fledged doctor history-taking is no longer a rigid process but a dynamic one which involves a complex interplay between obtaining and synthesising information to increase or decrease the pre-test probabilities of a set of differential diagnoses. This latter version of history-taking is highly shaped by experience and knowledge and is what allows certain physicians to become very efficient. However, this is also the very thing that makes our history-taking vulnerable to cognitive traps (or biases) that can lead to medical error [3,4].
These biases include:
The literature suggests the first step to overcoming these biases is to be consciously aware of them. For a great introduction on cognitive bias and medical error – check out our podcast series on medical error and this blog on cognitive bias in medical decision-making.
Don’t be mistaken, you cannot be an efficient and balanced history-taker without knowledge. An understanding of different conditions allows you to know what aspects of the history are relevant and which questions to ask. You will not be able to distinguish migraine from meningitis if you do not know the defining qualities of each condition. A deep understanding of all conditions is impossible, especially when starting out. However, there are some things you can do to help.
When in doubt, remember the goal is to get enough information to allow your supervisor or the specialist to extract the relevant information, and you can just fall back to your basic structure (SOCRATES – Site, Onset, Character…works for any symptom). Try to read around your cases and if you happen to refer the patient to a senior colleague or specialist team – learn from them. Over time you will start to build your own bank of useful phrases and direct questions for undifferentiated symptoms e.g. diarrhoea (colour, chronicity, pain, fevers, travel, etc).
Sometimes there is important information contained in the body language of a patient. Watch them carefully. A subtle change in eye contact or the timbre of a patient’s voice at just the right instant is sometimes the only clue to an otherwise missed diagnosis of depression, suicidality, domestic violence or abuse. If a partner or family member is present, watch their interactions. Sometimes the additional person provides important information (facial expressions, a subtle nodding or shaking of the head) that may be at odds to what the patient is indicating. Often, I find this is due to lack of insight on a sensitive issue (e.g. medication adherence, excessive alcohol use, driving ability, independence). A patient that frequently turns to their partner for the answer to a question can often be a clue to underlying cognitive impairment.
You will spend a lot of your career taking histories from patients and for some, it may be your only interaction with them. If there is one thing we’ve come to appreciate from the COVID-19 pandemic is that we are social beings. Learning to enjoy the process by taking that little extra time to make a connection with your patient will not only lead to better clinical outcomes but will also lead to a greater sense of fulfilment and satisfaction in your professional life.
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Derek Louey
January 8, 2021 at 3:51 pmRemember that a history is a timeline of events
http://emedsa.org.au/CoreMed/2018/03/06/disentangling-the-history/