Changing history: The questions you ask patients keep expanding
■ The centuries-old interview at the core of medical practice is under pressure to evolve, just as it also becomes more essential.
By Victoria Stagg Elliott — Posted April 6, 2009
After Martin Duke, MD, retired as director of medical education and chief of cardiology at Connecticut's Manchester Memorial Hospital, he found himself more often the patient than the physician. As a result, he spent more time giving his medical history than taking someone else's, and he noticed significant changes in how the task was accomplished. The time spent on it was shorter. It often was taken by an allied health worker. And, sometimes it didn't even involve a face-to-face conversation. Instead, he simply checked "yes" or "no" boxes on a questionnaire.
In a paper he authored in the November-December 2008 Connecticut Medicine, he bemoaned this shift. "If this trend were to continue, it is conceivable that one day patients and doctors may not even be speaking with each other," he wrote.
"Technology has changed the whole approach, and technology does add something," said Dr. Duke in an interview. "But it cannot stand by itself. It needs the person-to-person interaction for some direction."
Until the 19th century, the medical history was the only diagnostic tool available. Advances ranging from the stethoscope to genetic testing have since supplemented it, with more new tests rapidly becoming available. But the history -- a bedrock of health care -- is still considered incredibly valuable. After all, patients telling their stories can kick-start the healing process.
"We have to listen to everything the patient says, even the little side jokes. That may be what they're most concerned about, and bringing it to the forefront may be exactly what the patient wants," said James Nee, MD, medical director of the outpatient family practice clinic at Saint Joseph Hospital in Chicago.
Tracking the evolution
The medical history is undergoing significant change. Physicians have less time than ever to talk to patients and hear their stories, partly because appointments have gotten shorter. Social trends also have created a need for more extensive queries related to sex, intimate partner violence, substance use, occupational exposures and travel.
According to an American Medical Association ethical opinion, providing as complete a medical history as possible is one of the patient's responsibilities. The AMA also adopted policy in December 2000 encouraging physicians to routinely inquire about any history of family violence. Another resolution was passed in June 2005 encouraging medical schools to provide training in taking a complete, nonjudgmental sexual history.
And more energy than ever is being invested in ensuring that physicians know how to take a good medical history. The National Board of Medical Examiners implemented a clinical skills exam in June 2004. The AMA supports continued efforts to create validated means of assessing this area of practice but believes these tests should be administered by the medical school. They should not be used for the evaluation and licensure of those who graduate from accredited institutions.
Meanwhile, the topic continues to trigger professional discourse.
A book, Taking the Clinical History by William DeMyer, MD, a former professor of pediatric neurology at Indiana University School of Medicine, came out in late March. Dr. DeMyer wrote it in response to concerns that history-taking skills were getting lost amid an increased emphasis on technology.
"His feeling was that we cannot shortchange the history. We need to protect the patient and the dignity of the relationship," said Mark Dyken, MD, former professor and chair of neurology at Indiana. He completed the revisions after Dr. DeMyer died last year.
Diagnosis: Dispatches from the Frontline of Medical Mysteries by Lisa Sanders, MD, is due out in October.
"One of the problems that happens in medicine that leads to diagnostic error is inadequate data collection and that starts with how we take a history," said Dr. Sanders, who writes a column on the subject for The New York Times and is an assistant clinical professor at Yale University School of Medicine in Connecticut. "We take shortcuts. Most of the time we can get away with it, but sometimes we can't."
A lot of effort, in particular, is aimed toward making this process more collaborative between physician and patient. This focus is quite different from how the interaction traditionally was practiced. A pair of papers published in the Fall 2005 and 2006 issues of the Bulletin of the History of Medicine explored how textbooks from 1850 to the present taught the clinical interview. Medical students learned they were to take control of how a patient told his or her story, be paternalistic and, if need be, trick those they cared for into revealing needed information. The tale a patient told was viewed as an important but unreliable source for facts.
"Physicians absolutely need to take a history, but there's this ambivalence," said Dr. Jonathan Gillis, who authored both studies and is a senior staff specialist in intensive care at Children's Hospital at Westmead in Australia. "[The textbooks say] to control the process. You don't want the patient to be in control. Patients are incredibly jumbled, and they're very emotional."
To alter this approach, those who work on patient-physician communication are teaching and writing journal articles on "narrative medicine" and strategies to allow patients to tell their stories without being interrupted. Anecdotal evidence suggests a growing number of medical schools are adopting this tactic with the goal of making the clinical interview more patient-centered.
"There's more of a push to get the psychosocial perspective, including the patient's feelings about the illness and letting the patient just talk to us," said Gary Rull, MD, assistant professor and director of the doctoring curriculum at Southern Illinois University School of Medicine in Springfield.
Enter the EMR
But the biggest change to history taking is the increasing use of the electronic medical record. Many physicians view this instrument as both a blessing and a curse. They praise it because of the amount of information that can easily be found within it. Also, typed notes are usually easier to read than handwritten ones.
"In some ways, patients find this comforting. They feel good about doctors having all their data right in front of them," said Sharon Parish, MD, director of psychosocial training at Montefiore Medical Center in the Bronx, N.Y.
This sentiment, though, is balanced by concerns that recording information electronically may get in the way of the patient-physician relationship. Attention can be split between the patient and the computer -- which may prompt for irrelevant questions.
"The computer is a tough taskmaster," said Hanna Bloomfield, MD, MPH, co-chair of general internal medicine at the Minneapolis VA Medical Center. "You can end up staring at the computer screen more than talking to the patient."
Experts recommend that physicians find their own style but be consistent when asking questions so as not to miss anything.
Physicians should sit while taking the history, make eye contact and ask nonjudgmental open-ended questions. Sometimes how something is said can be as important as what is said. Most critically, experts say patients should be allowed to talk and create an agenda for the visit. Any issue that cannot be dealt with at the immediate time can be addressed at a subsequent visit.
"I ask them what is most important on their list to talk about today and bring them back fairly quickly to cover the other items," said Glenda Westmoreland, MD, MPH, associate professor of clinical medicine at Indiana University School of Medicine. "This really gets to what the patient wants to get out of the visit."
Those working on improving medical history taking also predict the value of this skill will increase.
"Lab tests can really send people in the wrong direction," said Dr. Parish. "And a lot of tests are expensive and lead to more tests."
The family history is expected to become even more critical as genetics become a bigger part of medical practice. Considered the original genetic test, a family history can identify, for instance, those patients who could benefit from having their genome analyzed and provide meaning to the results.
The AMA has a Web page devoted to the subject (link). Public health agencies also have created online tools and launched campaigns to encourage people to collect medical information about their relatives.