The art of history taking

A word about patients (a cynical perspective)

They may give a misleading answer when:

• They don't understand the question
• They don't know the answer to the question
• They use non-conventional non-medical terminology e.g. My mother was treated for 'shock'  at the scene and then sent home
• They want to make you happy
• They want to make their relatives happy
• They think it will get them what they want

Golden rules of history taking

• Don’t assume the patient understands your question
• Don’t assume patients uses words or descriptions in the way that you (or anyone else) would use them.  Be sure you know what they exactly mean.
• Always question the patient’s version or interpretation of events
• Always question any previous diagnoses the patient might have received (it might have been obtained on weak evidence)
• Translate the chain of events, causation and chronology of the problem into a plausible pathological process; not just a list of unordered diagnostic criteria.  Patients may often jump backwards and forwards in the narrative and form their own relationships between events.
• Check for contradictions in the story

Problems with style

• Asking closed ended questions too early. Just encourage the patient to speak.
• Cutting the patient off before they can finish
• Leading the patient e.g. ‘you don’t drink alcohol DO you’?

Problems with language

• Not modifying your phrases in a way that the patient can understand. Only asking the question one way. Using jargon.

Problems with interpretation

• Don’t take things at face value. Patient’s can misinterpret their own symptoms or what they think the doctor has told them. Question a patient’s diagnosis or the diagnosis they think they have been given. Question the conclusions that patient’s have drawn from previous events or information given to them.
• Re-analyse the primary data. Were the symptoms, test results or treatment consistent with the diagnosis? Any diagnosis, condition or test that a patient claims should be viewed with a healthy degree of scepticism. Ask "why do you think that?" What "did they actually do?" e.g. A patient once had a 12 lead ECG which was normal so he believes that the doctors ‘don’t think anything there is wrong with my heart’. ‘I have migraines before’ to describe an undiagnosed chronic recurrent headaches. "My doctor thinks I have stomach ulcers" (when they have never had endoscopic confirmation)
• Avoid using relatives to help interpret (multiple reasons for error).  Engage professional services.

Problems with reliability

• A patient’s history may be misleading for a variety of reasons
• If there are concerns about a person’s memory then quickly perform a mini-mental screen before proceeding – it may save you a lot of wasted time asking questions they cannot answer
• Attempt to ask questions in several ways to check for inconsistencies or contradictions

Useful phrases

• Chief complaint – ‘what was/were the main thing(s) that made you seek medical attention (especially if given a long list of symptoms), ‘which of your symptoms most concerns you’
• Character / Site / Location – ‘can you describe these symptoms further’
• Time of onset - ‘so when did you last feel well?’, ‘when did things take a turn for the worst?’, ‘when did this current problem begin?
• Onset – ‘what were you doing when you first noticed the symptoms’, ‘how did the symptoms change after that’, ‘when did they change’
• Chronology - ‘and then what happened….’ <patient answers> (repeat again and again), ‘do the symptoms ever completely go away or diminish in intensity’, ‘how long do they last’, ‘how long between symptoms’ or ‘how often do they recur’, ‘are things same, better or worse’,
• Acuity - ‘was there point where your symptoms dramatically change’, ‘what made you decide to eventually seek attention’
• Precipitant/Alleviating / Aggravating – ‘was there anything that altered the symptoms?’, ‘when or what brings it on’, ‘when or what makes it better’.
• Associated symptoms – ‘did you notice anything else’
• Severity – ‘how bad was it’, ‘did it affect what you could do’, ‘did it affect your sleep’
• To encourage further description - ‘so then what happened?’ and ‘when did this happen’? (repeat this phrase as many times as you need to), ‘tell me more about the (knee pain, swallowing problems)?’
• Determining priorities or concerns - ‘what do you think might be going on’, ‘is there a specific thing you might be worried about having’, ‘do you know of someone else who had the same symptoms as you’
• Final comments -‘is there anything else you haven’t mentioned"?

BUT......

A constant frustration and embarrassment to doctors is when the patient reveals a completely different story to a colleague or superior

You should be reassure that there are good reasons for this other than just poor history-taking technique:

• The patient's latter recollections were prompted by the initial assessment
• They required additional time to reflect on the question
• The patient is just unreliable and tries to construct a plausible narrative

Sometimes it is worth clarifying some points a little later after the patient has had time to 'digest' the questions.