Medical students are taught to take a careful history because in most cases therein lies the patient's diagnosis.
When I was in medical school, we were taught how to "take a history." This included the history of the present illness (the presenting problem, when it began and the details of the patient's symptoms), the review of systems (an inquiry into all the major organ systems), the patient's past medical history (including allergies, operations and significant illnesses and hospitalizations) and family medical history.
As students, we tended to focus on getting specific details from the patient, and this often resulted in what must seem like a barrage of questions. These are intended to rule in or rule out particular medical conditions.
Particular conditions often follow a predictable pattern of presentation. For example, gallstone pain is often described as crampy right upper abdominal pain radiating into the back following a heavy or fatty meal.
The classical symptoms of high blood sugars from uncontrolled diabetes are excessive thirst, hunger, urination and weight loss.
Sometimes, in the search for the diagnosis, we get caught up in the questions and try to fit the patient into a recognizable pattern. Physicians trained in this way, may fall into a pattern of asking many close-ended questions. The problem with this is that we limit the information we get in response, and some of the missed information may be crucial to the correct diagnosis.
I'm happy to report that medical school has evolved since then. Students are learning early to listen better, to ask more open-ended questions and to invite patients to share more information.
We know that patients put a lot of thought into how they are going to explain their problems to their physicians. They might be rehearsing what they're going to say on the way to the clinic or hospital and again just before they meet with their doctors.
When I teach med students and residents, I remind them that the old adage that the diagnosis is in the history really means the patient will tell us the diagnosis but we have to listen. After making the patient feel at ease, I encourage my students to let a patient talk about their symptoms without interruption. Studies have shown that most doctors interrupt patients within two minutes, and when this happens, they lose their train of thought and crucial information is missed.
By taking time to listen first, we gain more than launching in the typical medical inquisition. Students are now taught to ask more open-ended questions that invite more elaboration from the patient as opposed to the yes or no responses to closeended questions.
Medical students throughout Canada are taught to attend to more than the physical symptoms of illness. They learn the acronym, FIFE. This reminds them to ask patients about their feelings (fears and other feelings related to the experience of their illness), ideas (the patients' own ideas about their condition), function (how the illness affects their daily lives) and expectations (what they expect from the doctor and from their condition).
Though old habits are difficult to change, I'm optimistic that doctors will continue to improve the way they communicate and relate to their patients. You could help.
Send questions or suggestions to davidicuswong. wordpress.com. The Burnaby Division of Family Practice is working on a major project to transform the patient-doctor relationship.
Dr. Davidicus Wong is a family physician.
