HELPING THE DOCTOR HELP YOU
A simple omission can be disastrous is what I learned when Sateesh Reddy explained me how his brother in-in law got into coma stage. Past eight months, Prabhakar is lying in a coma stage in a hospital. Prior to his unconsciousness, he consulted three doctors complaining about neck pain radiating to shoulders. All the doctors prescribed him analgesics and some pain balms and could not find anything suspicious. Prabhakar overlooked his fall from bike few months ago and never mentioned it to the doctors who he consulted. Untreated cervical hairline fracture due to the fall resulted in the coma. The information (history of fall) was crucial for the doctors for further investigations, and this omission is in one way resulted in the mishap. It is widely taught that diagnosis is revealed in the patient's history. Above mentioned scenario involving inadequate history taking leads to serious consequences illustrate the importance of medical histories in diagnosis and here Prabhakar’s case is the classic example of the value of history.
Recently I interacted with three retired consultants, two physicians and a surgeon on the sidelines of a conference and when I broached the subject of the value of history taking, with no dissent, all of them expressed their dismay at their denigration of the importance of proper history taking in clinical practice. Modern day doctors, mostly nudged by managements give preference to ‘investigations’, and happy to go with figures rather facts. As champions of evidence based medicine can they produce evidence that taking a proper history is "unhelpful"?
Extracting a proper history means listening carefully to what the patient has to say, followed by relevant systematic and constructive questions. As examples of clinical situations in which this discipline yields rich rewards we would cite the elucidation of chest pain or the recognition of da Costa's syndrome, where a proper history could save expensive and anxiety-producing investigations.
The foundation of a true history is nothing but a smooth communication between doctor and patient. Here patient should not show any inhibitions and the doctor is a good listener. Listening is at the heart of good history taking. The patient may not be looking for a diagnosis when giving their history and may even have irrelevant aspects and the doctor's search for one under such circumstances is likely to be fruitless. The patient's problem, whether it has a medical diagnosis attached or not, needs to be identified. Without the patient's perspective, the history is likely to be much less revealing and less useful to the doctor who is attempting to help the patient.
There was a time not long ago; often the history alone does reveal a diagnosis. Sometimes it is all that is required to make the diagnosis. A classic example is with the complaint of headache where the diagnosis can be made from the narration of the headache and perhaps some further questions. For example, in cluster headache the history is very characteristic and reveals the diagnosis without the need for examination or investigations for an experienced consultant.
To acquire a plausible, representative account of what is troubling a patient and how it has evolved over time, is definitely not an easy task. It takes practice, patience, understanding and concentration. The history as told in the beginning is a sharing of experience between patient and doctor and certainly time consuming. A consultation can allow a patient to pour out his agony. They may be upset about their condition or with the frustrations of many other aspects of life other than the present affliction and it is important to allow patients to give vent to these feelings. Ultimately how it may be transformed from the grumbles of a heartsink patient, to a useful diagnostic and therapeutic tool is what matters.
The traditional method of detailed history taking and physical examination and thinking about what tests to be ordered, (if any) are needed may take somewhat longer time with the patient, but must remain the cornerstone of clinical practice. The content of the history involved in primary care consultations is very variable and will depend on the presenting symptoms, patient concerns and the past medical, psychological and social history.
However the general framework for history taking is as follows:
• First is the presenting complaint.
• History of presenting complaint, including investigations, treatment and referrals already done and provided.
• Significant past diseases/illnesses, surgery, including complications, trauma.
• Medications now and past, prescribed and over-the-counter, allergies.
• Family history must be enquired to especially parents, siblings and children.
• Social history also matters. Here we find many habits and his addictions like smoking, alcohol, drugs, accommodation and living arrangements, marital status, baseline functioning, occupation, pets and hobbies.
• Finally, the systems review: cardiovascular system, respiratory system, gastrointestinal system, nervous system, musculoskeletal system, genitourinary system.
Let’s go back to the coma patient Prabhakar. Prabhakar, who went and consulted three doctors but never mentioned his fall from the bike, thinking that it is insignificant. He thought the presenting complaint; neck pain is not even remotely connected with the fall, which happened three months back. None of the doctors have any leading questions to this effect like, ‘did you have any fall in the past?’ sometimes you may have to ask some wild questions when you as a doctor have no other suspecting reasons. The doctors set no agenda in this case and they missed the vital clue, which finally ended in a tragedy.
After taking the history, it's useful to give the patient a run-down of what they've told. For example: 'So, Prabhakar, from what I understand you've been getting this pain since one month and you are sure no incident worth mentioning like any fall in the recent past. Is that right?'. This summarizing or leading question could have helped Prabhakar mentioning the history fall, which he felt trivial.
It is vital to remember that a good elicitation of the patient’s history, in his own words coupled with few leading questions from the doctor can help the latter to arrive into ‘provisional diagnosis’. This does no suggest the patient doesn’t need any detailed evaluation. History alone cannot lead into a definitive diagnosis unless until validated by other pertinent tests. Having said that, history taking has an integral and irreplaceable role in the appropriate diagnosis. 'Listen to your patient; they are telling you the diagnosis' is oft quoted aphorism. In olden days, it is widely taught that diagnosis is revealed in the patient's history. It is true even today, provided the doctor is willing to listen.