The Forest from the Trees: A Learner’s Insight on Developing a Patient History

Amanda FormosaAmanda Formosa
University of Toronto
Class of 2016

At the beginning of third year medical school, I envisioned the next twelve months as an immersion in the clinical world, with the personal expectation of learning everything. I never anticipated the subtleties of the patient-doctor dynamic that I would identify. One lesson I learned was about the difference between patient-doctor and patient-student communication – an exceedingly common yet rarely-spoken-about disparity that teaches medical personnel about how different approaches to history gathering can yield varied results in assessments.

The first time I clued into the issue happened on one of my emergency medicine shifts. Mrs. K, age 55, came in with abdominal pain, and so I went through my OPQRST mnemonic for pain – onset, palliative factors, quality, radiation, severity and temporal features.

“When did the pain start?” I asked Mrs. K, after I introduced myself.

“It started a few hours ago, and it’s the worst right here,” she said, pointing to her right lower quadrant. After taking the history, my physical exam showed tenderness on palpation in the right lower quadrant of her abdomen.

I presented the story as a likely case of appendicitis to my preceptor, who fixated on the timing of symptom onset. ‘Five hours’ was my answer, as we went to see Mrs. K together.

“Hello Mrs. K., I’m Dr. A. Amanda told me your story. Let me just ask you a few more questions. When did the pain begin?”

“Oh, you know, doctor, it got worse about 5 hours ago, but began several weeks ago as a crampy pain here,” she said, rubbing her entire lower abdomen. My preceptor’s physical exam showed tenderness to deep palpation in the entire lower abdomen, perhaps worse on the left.

Are you kidding me?!

As I watched my preceptor work with Mrs. K, I tried to wrap my head around the patient-doctor interaction that pointed to a diagnosis of diverticulitis, later confirmed by CT scanning. Like any medical student would, I decided that I failed to take a proper history on the circumstances surrounding the onset of symptoms.

Soon after, I faced yet another medical-student-looking-bad scenario. Mr. S, age 50, came in with sudden onset of severe constant vertigo and vomiting that started while washing dishes. The history and lack of focal neurological deficits pointed me to vestibular neuronitis. I presented the case to my preceptor, who focused on the situation surrounding the onset of vertigo, but this time I felt prepared because I had interrogated Mr. S. about what happened before he washed the dishes, how he washed the dishes, and if something happened while washing the dishes.

“So nothing happened at all?”, asked Dr. A.

“No,” was my resolute answer.

We returned to Mr. S., and Dr. A. questioned him again about what happened when the symptoms began. Mr. S. confirmed he had been washing dishes, but with a prompt, he added a tidbit of detail.

“Are you sure nothing happened that jolted your head?” asked Dr. A., as he considered the diagnosis of vertebral artery dissection.

Mr. S. stared straight ahead, knitting his eyebrows. “Actually, yes. I sneezed. Several big sneezes.”

Come on...

I realized staff physicians had a mystical manner of coaxing a patient into giving the best version of their medical history. I brought the subject up with several classmates, and invariably my conversations with them had the flavour of:

“Do you ever present a case to your preceptor, then review with the patient and something about the story changes, making you look bad?” Amidst giggling: “Oh yeah, totally.”

But what exactly contributed to the differences in history-taking between physician and student? A review of studies looking at the effect of students on patient care reassured me that my presence likely benefitted patients. According to several papers, rather than wanting to contribute to “medical student demise” in front of preceptors, most patients think positively of medical student involvement in their care (1), and in general practice students do not negatively affect the quality of a consultation (2). About half-way through my emergency medicine rotation, I told my preceptor about this issue. He thought it had to do with the style of history taking, where medical students ask questions to generate a differential diagnosis. In contrast, he approached a patient with a primary what isn’t this? versus what is this? pattern recognition point-of-view to rule out serious pathology and then pinpoint the likely diagnosis.

Dr. A’s theory gained support later in the year when I saw the 22-year-old Mr. D., who’d had a syncopal event. By this time, I had adopted the approach of ruling out serious causes first, and then generating a likely differential. I went through the red flag questions, clarifying whether or not the syncopal event occurred during physical activity. He and his friend assured me they were waiting in line to get into a nightclub. Of course, when I returned to the patient with Dr. A., the question of circumstance came up. This time, however, Mr. D. looked at me and said, “I’m sorry, Amanda, but you asked me if there was any physical activity. I forgot to tell you that a few minutes before I fainted I had been running up the street with my girlfriend on my back racing against a taxi cab.”

Redemption.

Now that third year has come to an end, I look back on how doctor-like I have become in just a year, and one of the lessons that I appreciate the most is the realisation that people change their story based on the context we create as medical professionals. The way we ask questions, how we present ourselves, and the setting we place a patient in dictate how a person presents their history. From this, I’ve appreciated the importance of gathering proper information from patients, witnesses and paramedics. Lastly, from a medical student’s perspective in the emergency department, I’ve taken on the history-taking style of questions about worst-case diagnoses first, followed by questions on the likely diagnosis. Hopefully, this approach, coupled with the “Dr.” title and experience, will be the recipe for accurate history taking and better patient care.

References

  1. Haffling ACHåkansson A. Patients consulting with students in general practice: survey of patients' satisfaction and their role in teaching (2008). Med Teach;30(6):622-9.
  2. Benson JQuince THibble AFanshawe TEmery J. Impact on patients of expanded, general practice based, student teaching: observational and qualitative study (2005). BMJ;331(7508):89.

Special thanks to Dr. Alun Ackery for his support and help in writing this reflection.

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