General aspects of history taking

Allowing sufficient time

Consultation length varies. In UK general practice the average appointment is short, but this is usually adequate, provided the doctor knows the patient and the family and social background. In hospital, the similarly brief time allowed for returning outpatients can be challenging for new or temporary staff unfamiliar with the patient. For new and complex problems, a longer appointment is usually scheduled. In all settings, clinicians must learn the skill of managing the pace of the consultation to avoid running late, while not giving any impression that they are short of time. For students, time spent with patients learning and practising history taking is highly valuable; however, learning to communicate efficiently takes time, and patients appreciate advance discussion of the time students need.

Using different styles of question

To get the patient’s own perspective, begin with open questions that encourage them to think back and report their symptoms in order, such as ‘When did you first notice something wrong, and how did it start?’ Listen actively, and encourage the patient to talk by looking interested and making encouraging comments, such as ‘Tell me more’. Always give the impression that you have plenty of time. Allow patients to tell their story in their own words, ideally without interruption. You may occasionally need to interject to guide the patient gently back to describing their symptoms, as anxious patients commonly focus on describing the events or the reactions and opinions of others surrounding an episode of illness rather than what they were feeling. While avoiding unnecessary repetition, it may be helpful occasionally to tell patients what you think they have said and ask if your interpretation is correct (reflection).

The way you ask a question is important:

• Open questions are general invitations to talk that avoid anticipating particular answers: for example, ‘What was the first thing you noticed when you became ill?’ or ‘Can you tell me more about that?’

• Closed questions seek specific information and are used for clarification: for example, ‘Have you had a cough today?’ or ‘Did you notice any blood in your bowel motions?’

Both types of question have their place, and normally clinicians move gradually from open to closed questions as the interview progresses.

The following history illustrates the mix of question styles and responses needed to elucidate a clear story:

When did you first feel unwell, and what did you feel? (Open questioning)

Well, I’ve been getting this funny feeling in my chest over the last few months. It’s been getting worse and worse, but it was really awful this morning. My husband called 999. The ambulance came, and the nurse said I was having a heart attack. It was really scary.

It does sound scary for you. When you say a ‘funny feeling’, can you tell me more about what it felt like? (Acknowledging patient’s feelings, open questioning, steering away from events and opinions back to symptoms)

Well, it was here, across my chest. It was sort of tight, like something heavy sitting on my chest.

And did you feel it anywhere else? (Open but clarifying)

Well, maybe up here in my neck.

What were you doing when it came on? (Clarifying precipitating event)

Just sitting in the kitchen, finishing my breakfast.

How long was the tightness there? (Closed)

About an hour altogether.

So, you felt a tightness in your chest this morning that went on for about an hour and you also felt it in your neck? (Reflection)

Yes, that’s right.

Did you feel anything else at the same time? (Open, not overlooking secondary symptoms)

I felt a bit sick and sweaty.

Showing empathy when taking a history

Being empathic helps your relationship with patients and improves their health outcomes (see Chapter 1 , p. 6). Try to see the problem from their point of view and convey that to them in your responses to what they say and your subsequent questions.

Consider a young teacher who has recently had disfiguring facial surgery to remove a benign tumour from her upper jaw. Her wound has healed, but she has a drooping lower eyelid and facial swelling. She returns to work. Imagine how you would feel in this situation. Express empathy through questions that show you can relate to your patient’s experience.

So, it’s 3 weeks since your operation. How is your recovery going?

OK, but I still have to put drops in my eye.

And what about the swelling under your eye?

That gets worse during the day, and sometimes by the afternoon I can’t see out of this eye.

And how are you managing at work?

Well, it’s really difficult. You know, with the kids and everything. It’s all a bit awkward.

That must feel pretty uncomfortable and awkward, but hopefully the swelling will settle soon. How do you cope? Has it been a problem when you are with friends or colleagues too?