MEDICAL HISTORY-TAKING IN THE MODERN ERA

PART 2 of 3

Medical schools seem to teach history-taking as if physicians were still in the 19th century. In the 19th, and much of the 20th century, practically everything you needed to know about the patient was obtainable from the patient, or if necessary from the patient's family. Thus the time course and nature of the patient's symptoms, as embodied in the "history of present illness," has long been taught as paramount. And so it is.

But there's a problem. History-taking, as traditionally taught in medical schools, presupposes a worried but alert and oriented patient sitting before you, ready to reveal all if you but ask the right questions and spend enough time. But what if the patient is confused, comatose, disoriented, or simply medically unaware and unsophisticated? What if the patient has already seen four other doctors and hasn't a clue as to what she was told by any of them? What if the patient is in some distress and simply can't get her breath to talk for longer than a monosyllable? What history-taking skills are necessary in these situations, which are very common (particularly in hospitalized patients)?

Unfortunately, the house officer's response in many situations is all too often, "The patient is a poor historian," a response that suggests it is the patient's obligation to render a well-organized, coherent history! In fact, labeling the patient a poor historian often signifies one thing only: the physician is not trained to assemble a comprehensive history.

Instead of blaming the patient for an inadequate history, emphasis should be on the vitally important "verifiable past medical history." Verifiable PMH covers events one can document, usually meaning specific past medical contacts (doctor, emergency room, pharmacy, laboratory, radiology department, etc.). Pity the poor house officer who, after spending an hour with a patient eliciting every nuance of her vague symptoms, has failed to learn of a recent complete evaluation at another hospital for the same complaints! (Oh? Then why didn't the patient say so? Simple: because the house officer didn't ask.)

It is amazingly common that patients we see in the hospital, the ER, or the outpatient clinic, have verifiable, recent medical history pertinent to their current problem(s): lab tests; x-rays; office visits to other physicians; pharmacy prescriptions; hospital discharge summaries; workers' compensation records; operative reports. It is also amazingly common how often this verifiable history goes undetected by the treating house officer. Here are some true stories.

1) A slightly demented man was admitted to the ward with a complaint of shortness of breath. No family accompanied him. His chest x-ray showed a large right pleural effusion. Although the patient had an old medical record number, his previous records could not be found and he could not give any verifiable past medical history. A thoracentesis was performed and the results were non-diagnostic; cytology was negative for malignancy. On the third hospital day an infectious disease consultant was called; she observed that his hospital x-ray folder contained chest x-rays two months old, although chart records for that period were still not available. She went to the medical records department and demanded that the patient's old records be found. After a 10-minute search they were found in another physician's dictation box! These two-month old records revealed a hospital admission at that time for the same problem: shortness of breath and a right pleural effusion. While in the hospital a fiberoptic bronchoscopy had been performed, which revealed far advanced, inoperable lung cancer. The patient had been started on radiotherapy in the hospital, then discharged and lost to followup until readmitted two months later.

2) A 35-year-old woman was in the hospital for four days for workup of anemia, elevated sedimentation rate and joint discomfort. A series of tests had so far failed to elicit a unifying diagnosis. On the fourth day a medical student, just assigned to the case, talked to the patient and learned that she had been in another hospital a year earlier for the same complaints! To the student's surprise, no one else had elicited this bit of information. Later that day the other hospital's discharge summary was faxed over; it revealed a workup and diagnosis of lupus erythematosus. The patient had been lost to followup after discharge, only to reappear a year later when she was re-admitted to the second hospital.

3) A 67-year-old man was scheduled for thoracotomy for a suspicious lesion. The surgical note stated that there were "no old films." Indeed, in the hospital at the time there were no old films. But there were plenty of old films in another hospital, going back six years. They were obtained by a consultant and reviewed. The "suspicious lesion" was old and it had not changed. Radiologically it was clearly benign and did not need to be removed.

* * *

The reason verifiable information is so often overlooked is because the physician a) doesn't know it exists (as in the above three cases) or b) doesn't work hard to obtain it. Given most hospitals' 19th century record-keeping systems, it may be difficult to obtain old information. But you surely won't succeed if you don't even know old records exist. To find out if they exist, the box below lists some of the questions you need to ask (and sometimes re-ask) of patients or family.

You will be amazed how often your patients have been treated and evaluated for the same problems you are treating them for; or how often they are taking medications pertinent to their current problem which they "forgot" to tell you about. When you learn that important verifiable information exists, take advantage of those modern medical tools the phone and fax machine and work to get the information.

The task may not be easy. Say you've learned that verifiable information does exist, and you've requested it be sent via fax. How long should you wait for it to arrive? Not long. You can minimize delays by remembering three rules, listed below. (And when you do obtain fax'd records, treat them like found gold. Place them in the chart, note the principal findings in a progress note, and make other caregivers aware of their existence.)