Doctor and patient: General principles of history taking

Beginning the history

The process of gathering information about a patient often begins by reading any referral documentation and with the immediate introduction of doctor and patient. However, once the social introductions are achieved, the doctor usually will begin with a single opening question. Broadly, there are two ways to do this.

A single open-ended question along the lines of ‘Tell me about what has led up to you coming here today’ gives the opportunity for the patient to begin with what he feels to be most important to him and avoids any prejudgement of issues or exclusion of what at first hearing may seem less important. However, at this stage the patient may be very anxious and nervous and still making his own assessment of how he will react to the doctor as a person. A beginning that focuses on issues which may be more factual and less emotive can be more rewarding and lead to a more satisfactory consultation. Box 1.1 lists some of the areas of questioning that can be usefully included at the beginning of the history. It is important to inform the patient that this is going to be the order of things so that he does not feel that his pressing problems are being ignored. A statement along the lines of ‘Before we discuss why you have come today, I want to ask you some background questions’ should be sufficient to inform the patient satisfactorily.

A particular logic exists in taking the past medical history at this stage. For many conditions, the distinction as to what is a current problem and what is past history is unclear and arbitrary in the patient’s mind. A patient presenting with an acute exacerbation of chronic obstructive pulmonary disease may have a history of respiratory problems going back many years. Therefore, taking the history along a ‘timeline’ will often build up a much better picture of all of the patient’s problems, how they have developed and how they now interact with life and work.

Once these preliminaries have been completed, the doctor should use a simple and open-ended question to encourage the patient to give a full and free account of the current issues. This could be something along the lines of ‘Tell me what has led up to you coming here today’. This wording leaves as open as possible any question about the cause of the patient’s problems and why he is seeing a doctor, and could give rise to an initial answer beginning with such varied phrases as ‘I have this pain …’, ‘I feel depressed …’, ‘I am extremely worried about …’, ‘I don’t know but my family doctor thought …’, ‘My wife insisted …’ or even ‘I thought you would already know from the letter my family doctor wrote to you’. All of these answers are perfectly valid, but each gives a different clue as to what are the real issues for the patient, and how to develop the history-taking process further for that individual.

This part of history taking is probably the most important and the most dependent on the skill of the doctor. It is always tempting to interrupt too early and, once interrupted, the patient rarely completes what he was intending to say. Even when he appears to have finished giving his reasons for the consultation, always ask if there are any more broad areas that need discussion before beginning to discuss each in more detail.

Developing themes

This stage of the history is likely to see the patient talking much more than the doctor, but it remains vital for the doctor to steer and mould the process so that the information gathered is complete, coherent and, if possible, logical. Some patients will present a clear, concise and chronologically perfect history with little prompting, although they are in the minority. For most patients, the doctor needs to do a substantial amount of clarifying and summarizing with statements such as ‘You mean that …’, ‘Can I go back to when …’, ‘Can I check I have understood …’, ‘So up to that point you …’, ‘I am afraid I am not at all clear about …’ and ‘I really do not understand, can we go over that again?’ If a patient clearly indicates that he does not wish to discuss particular aspects of the history, then this wish must be respected and the diagnosis based on what information is available, although it is also important to explain to the patient the limitations that may be imposed by this lack of information.

Non-verbal communication

Within any consultation, non-verbal communication is as important as what the patient says. There may be contradictions, such as a patient who does not admit to any worries or anxieties but who clearly looks as if he has many. Particular gestures during the description of pain symptoms can give vital clinical clues ( Box 1.2 ). While concentrating on the conversation with the patient, the doctor should keep a wide awareness of all other clues that can be gleaned from the consultation. These include the patient’s demeanour, dress and appearance, any walking aids, the interaction between the patient and any accompanying people and the way that the patient reacts to the developing consultation.

Vocabulary

It is very important to use vocabulary that the patient will understand and use appropriately. This understanding needs to be on two levels: he must understand the basic words used, and his interpretation of those words must be understood and clarified by the doctor. Box 1.3 lists words and phrases that may be used in the consultation that the doctor needs to be very careful to clarify with the patient. If the patient uses one of the ordinary English words listed, its meaning must be clarified. A patient who says he is dizzy could be describing actual vertigo, but could just mean light-headedness or a feeling that he is going to faint. A patient who says that he has diarrhoea could mean liquid stools passed hourly throughout the day and night or could mean a couple of urgent soft stools passed first thing in the morning only. Therefore, the doctor needs to use words that are almost certainly going to be clearly understood by the patient, and the doctor must clarify any word or phrase that the patient uses to avoid any possibility of ambiguity.

Indirect and direct questions

Broadly, questions asked by the doctor can be divided into indirect or open-ended and direct or closed. Indirect or open-ended questions can be regarded as an invitation for the patient to talk about the general area that the doctor indicates to be of interest. These questions will often start with phrases such as ‘Tell me more about …’, ‘What do you think about …’, ‘How does that make you feel …’, ‘What happened next …’ or ‘Is there anything else you would like to tell me?’ These questions inform the patient that the agenda is very much with him, that he can talk about whatever is important and that the doctor has not prejudged any issues. If skilfully used, and if the doctor is sensitive to the clues presented in the answers, a series of such questions should allow the doctor to understand the issues that are most important from the patient’s point of view. The patient will also be allowed to describe things in his own words.

Many patients are in awe of doctors and have some conscious or subconscious need to please them and go along with what they say. If the doctor prejudges the patient’s problems and tends to ‘railroad’ the conversation to fit his assumed diagnosis too early in the process, then the patient can easily go along with this and give simple answers that do not fully describe his situation. Box 1.4 illustrates this extremely simple, common and important pitfall of history taking.

Judging the severity of symptoms

Many symptoms are subjective and the degree of severity expressed by the patient will depend on his own personal reaction and also on how the symptoms interact with his life. A tiny alteration in the neurological function of the hands and fingers will make a huge impression on a professional musician, whereas most others might hardly notice the same dysfunction. A mild skin complaint might be devastating for a professional model but cause little worry in others.

Assessing how the symptoms interact with the patient’s life is an important skill of history taking. A simple question such as ‘How much does this bother you?’ might suffice. It may be helpful to ask specific questions about how the patient’s daily life is affected, with comparison to events that many patients will experience. Box 1.5 illustrates some of the relevant areas. Patients do not want exaggerated or ‘fake’ sympathy, but occasional interjections such as ‘That must be difficult, given your work’ will provide reassurance that you are assessing their symptoms against the backdrop of their lives.

Medical symptomatology often involves pain, which is more subjective than almost any other symptom. Many patients are stoical and bear severe pain uncomplainingly, whereas others seem to complain much more about apparently less severe pain. A simple pain scale can be very helpful in assessing pain severity. The patient is asked to rate his pain on a scale from 1 to 10, with 1 being a pain that is barely noticeable and 10 the worst pain he can imagine or the worst pain he has ever experienced. It is also useful to clarify what the reference point is for ‘10,’ which for many women will be the pain of labour. The pain scale assessment is useful in diagnosis and in monitoring disease, treatment and analgesia. Assessing a patient with pain is discussed in more detail in Chapter 11 .

A schematic history

A suggested schematic history is detailed in Box 1.6 . In many clinical situations it will be clear that a different scheme should be followed. An important part of learning about history taking is that each doctor develops his own personal scheme that works for him in the situations that he generally comes across. Nevertheless, it is useful to start with a basic outline in mind.