Medical history taking: maximise ‘golden minute’ and listening
Sir William Osler, the Canadian physician, said,
Listen to your patient, he (or she) is telling you the diagnosis”
This article is about the start of a medical history, where this statement is especially true. It is relevant to a GP or hospital clinic assessment; but the principles can be used for an acute (A&E-like) situation, or a virtual one . It has 3 components:
- Pre-assessment: looking at the patient record, especially medication
- Introduction: a smile, and a handshake (if face-to-face assessment)
- ‘Golden minute’: open question and listen.
The history is by far and away the most important part of a medical assessment and the (‘golden’) minute at the start is the most important part of that. So listen very carefully when they speak at the start.
1. Pre-assessment
Before you start, look at the patient record for at least a minute, up and down. Then again.
This may take less than a minute bit it is perfectly feasible. Patients will often assume that you know everything in their records even though in reality you haven’t had 20 minutes to read all the letters!
But a brief look at the summary and problem list and the previous consultation is time well spent. The repeat prescription list is vital as it gives quick clues – e.g. if full of cardiac or diabetic medication then you know they have a cardiac problem or diabetes, for instance.
2. Introduction
Rapport is so important. An initial warm smile and greeting (including handshake, if F2F assessment) are crucial.
A medical diagnostic handshake is part of that and can lead to the diagnosis.
Also, have something personal ready about the patient, in a reminders section. This is usually only possible if you have seen them before.
This might be only visible to you, so you can mention the name of their spouse, if they have children, what they do for a living, what they do at other times such as sport or other hobbies, or what they are studying or hoping to do in their future career, or their favourite football team.
3. Golden minute
The golden minute is an established medical history technique, used during medical history taking to allow a patient to speak without interruption for about a minute. This technique can help to:
- Build rapport: patients feel listened to and can tell their story in their own words
- Avoid putting words in the patient’s mouth: open questions allow patients to describe their problem without being forced to answer with a yes or no
- Improve efficiency: (initial) open questions can lead to faster consultations.
Good opening questions are:
Thankyou for coming to see me/contacting me today.
How can I help you? (or) Tell me about the problem.”
Then listen carefully for the next minute, and only interrupt if you have to.
If it goes a bit quiet, you can say “please go on” or “yes, tell me more”.
The logic of the golden minute is that if you allow the patient, most of the relevant information will emerge, so long as they are not interrupted. Or will it? Actually, we generally only elicit half the patient’s complaints and concerns. And the main concern may not be the first mentioned. Either way, listening and watching carefully with full attention is key.
Listening carefully is crucial, and showing that you have listened equally so, whether for a complicated history or minor illness as subsequent reassurance will be more effective.
As we have two ears but only one mouth, we should listen twice as much as we talk”
After the golden minute
You need to record what was said in a few notes and proceed with the rest of the assessment.
Conclusion
The start of a medical assessment is vital. It sets the scene, and tone, for what is to come. Do a good pre-assessment, introduce yourself properly, and listen carefully in the golden minute.
