Medical history taking – 3 top tips
It’s all about African elephants
Taking a medical history is a skill. In fact it is a doctor’s most important skill. Unfortunately it takes a long (long) time to develop this skill.
Why is it so important? It’s because 80% of the diagnosis is in the history (+10% examination, +10% investigations). Or it can be entirely in the history. This is why experienced GPs etc often don’t need to examine the patient or request tests.
However for a medical student, taking a history can be a laborious, time consuming process; with long, meandering conversations including the weather, the recent form of the local football team, stories of Doris next door who has a young Labrador, and the state of the local park.
(“So, what’s this to do with African elephants?” Stay with us, dear reader. MyHSN Ed)
Then, irritatingly, a consultant or GP can waltz past, ask four questions in under 30 seconds, and then tell you the diagnosis.
But don’t worry, you will get better! And all it takes is a little knowledge, and alot (we mean alot) of practice. It’s all about knowing what questions are relevant in a given situation. And that can only come with experience.
So. Here are our three top tips on how to take a good medical history.
1. Almost nobody is a classical presentation
Annoying isn’t it. You spend five years at medical school reading about classical presentations, then, when you get out there in the real world, nobody really fits.
If they did, it would be easy. But they don’t. And it isn’t. That’s what makes it fun and interesting (not such fun with an exam looming we know). So you end up having to ‘best match’ them into a diagnosis.
And you’ll get it wrong. Even consultants get it wrong. Not often, but they do. So don’t beat yourself up about it. Try to learn what symptoms will almost rule out a particular diagnosis, and which symptoms just make it more or less likely.
For example, diarrhoea in a patient with abdominal pain doesn’t rule out appendicitis. But it makes it less likely. But now say, that they have bloody diarrhoea, which has been going on for 3 months, now appendicitis is now very unlikely – almost ruled out (but remember nothing is every 100% certain in medicine!).
This is not surprising. We mean, do African elephants look exactly the same? Do they ALL have big ears .. and yes, ALL live in Africa?
2. Don’t decide on your diagnosis too early
Getting to your diagnosis is not a race. In fact, it’s not even the goal of your history taking. That’s right. The purpose of taking a history is NOT to get to the diagnosis immediately – unless you can, i.e. “this is Laurence-Moon-Bardet-Biedl Syndrome” (let’s call it an African elephant)”. Why? I’ve seen it before and this is another barn door case – yawn – next patient please Dr.
Enough of elephants (or 🦛). The goal of your history taking is to make a list of differential diagnoses so that you can focus your examination and investigations. This is the process of clinical reasoning.
History taking is an important part of clinical reasoning, but it isn’t the whole story.
It’s very, very easy to fall into the trap of only asking questions to cover one diagnosis. You hear the first two or three symptoms, and you think ‘Aha I know what this is! I’m a bloody genius!
Can’t wait to show off to my Consultant’, and you quickly think of questions to ask that confirm your hypothesis, they fit, and then.. boom! “Yes! I’m a genius!” I’ve done it. I think we’ve all done it.
Then you go and present to your Consultant. Expecting a pat on the head and a box of Quality Street. Then he (or she) says ‘and have they had any diarrhoea?’. And your heart sinks. Oh blast. I don’t know. What shall I say? Do I guess?! Do I admit it?
Do I quickly pull a ‘lightbulb moment face’, turn around with my Belgian detective ‘ah ha’ finger raised, march back to the patient, ask them the right question (that I neglected to ask earlier), and then return with the answer?!
Then it dawns on you. You haven’t even attempted to rule out if Mr. Jones has had any symptoms of diverticulitis, because you were far too busy congratulating yourself on being the next House.
3. Let the patient talk (but not too much)
I don’t know about you, but at medical school we had this very firmly drummed into us. Start with ‘open questions’. E.g. you are taught to start with something quite vague, like: “So, Mr. Bond, tell me what the problem is”.
Mini Top Tip 1. Don’t call all your patients ‘Mr. Bond’
Often, then the patient will give you lots of relevant information in their opening few sentences. In fact ..
Mini Top Tip 2. The clue to the diagnosis is usually in the very first words the patient says (whether it’s Mr Bond or Miss Moneypenny) ..
.. in their opening sentence. Listen very (very) carefully to those words.
So let them get it all out (especially the elderly, they don’t like being rushed and you should show them respect). And write much of it down, especially the start.
But resist the temptation to shut them up! Let them talk. At least for the first minute or two.
But don’t let them get off topic too much. A little is fine. Build a rapport. But if you’re losing control, bring them back to the matter at hand.
It’s all about pattern recognition. You don’t have to know why it’s an African elephant (big ears and lives in Africa) .. or how it evolved into an African elephant .. just that it looks like an African elephant, as you have seen one before (remember? Yes . . big ears ang lives in Africa).
Note. There is a reason for starting with open questions. If you start with “Madam, have you had low abdominal pain associated with frequency of urination and dysuria?”, a. they will have no idea what you are talking about, and b. you will persuade to them to say ‘sort of’; and yes you will brilliantly (and incorrectly) diagnose a UTI and give them antibiotics (for being pregnant!).
Other stuff
You are a machine.
You are trained to obtain and retain information. Like an encyclopaedia. Like an elephant spotting machine (or will be one day).
You are trained how to extract information from a patient. And you are trained how to compare this information with the encyclopedia stored in your head, and to find the best match. That is your job. That is your skill.
So. Don’t be too clever and change the machine’s gears every time. It gets confused. You will get confused. The elephants will go to India. The hippos will go on strike.
Be consistent, even if it’s dull. Good history taking is not meant to be exiting. Hence MyHSN also advises ..
Mini Top Tip 3. Ask the same questions, in the same way, in the same order .. every time
Mini Top Tip 4. And do not skip the drug, social and family history – especially the drug history
Why? 30% of hospital admissions are wholly or partly due to prescribing issues (not necessarily errors). You cannot be s good doctor if you are not a good clinical pharmacologist. Full stop.
If you do all this (not easy we know), you will rarely go wrong. Doesn’t mean you will get the diagnosis right every time. But a machine like repetitive process gives you the best chance of getting it right. And the 🦛 will call off their strike. The Belgian detective comes back to help you.
But just because your job description is best suited to a machine, doesn’t mean you have to be like a cold machine. Be a warm cuddly machine with a ❤️ and compassion.
And finally
So there we have it. Be a well oiled and loving machine. And .. practice, practice and practice a bit more .. and good luck!
And finally finally
Be nice to the patient. And they will be nice to you. And tell you the diagnosis.
A good opening gambit to set the tone is ..
Thankyou for coming to see me today”
And finally finally finally
MyHSN hopes you are not a splitter and separate Laurence-Moon AND Bardet-Beidl syndromes. No way hose ..
Summary
We have given you our 3 top tips for taking a medical history. We hope it has been helpful.
Other resource
This article is derived from one by Tom Leach
