Taking a True History

It is thought that, on average, around 75% of the information you need to make a diagnosis can be derived from the patient's history. To get a true account of a patient's perceptions and experiences of illness requires a friendly, open-minded and flexible approach. In fact, there are many conditions where this is the only route by which to attain the diagnosis, as examination and investigations are unlikely to yield anything useful. For example, cluster headache should be diagnosed on the grounds of a classical story of a youngish man with episodic, exruciating, sudden-onset headache, affecting one side of the head, with reddening and weeping of the eye, and pain so severe that he is at a loss for what to do with himself, possibly resorting to banging his head against a wall. Examination and investigations will tell you nothing in this situation, as the patient is unlikely to present during an attack, and there will be nothing to see on the CT. But how satisfying, having got the right story, to make the diagnosis, start the appropriate therapy and see the patient's life turned around, without having to resort to any 'fancy tests'.
To get a true, representative account of what is troubling a patient, and how it has evolved over time, is not an easy task. It takes practice, patience, understanding and an ability to ignore how busy you are so that you may provide sufficient time and a suitable environment for the story to be told as it is remembered. Also, the history is not just a means to the diagnosis, it is a sharing of experience between patient and doctor. Sometimes a consultation may not be aiming to arrive at a diagnosis, but merely allow the patient to unburden themselves of the frustrations of living with themselves and their condition. It is important to allow patients to 'have a good moan' or lament their situation. The importance of the lament, and how it may be transformed from the grumbles of a heartsink patient, to a useful diagnostic and therapeutic tool for both patient and physician, has been discussed in an excellent recent paper.¹

Setting

Take care to do the simple stuff, like greeting people warmly with a smile to put them at ease, making eye contact, shaking hands, not having the patient sat over the other side of a gargantuan desk, having a warm, bright and relaxing consultation space and a manner that promotes trust and relaxation in the consultee. Nowadays we are blessed with brilliant technology that provides us with an account of the patient's recent consultations, history and medication, but it may be best to leave looking at the screen until the patient has had a chance to divulge their tale. This avoids the danger of preconception based on records of previous consultations and past history. All this information is useful in the final formulation of an illness and diagnosis, but is perhaps best left till after taking the initial historical details. It also avoids the danger of there being a three-way consultation between doctor, patient and hard-drive. I know that I have occasionally felt, as a patient seeing my GP, that their attention was more focused on serving the needs of their IT system than mine as their patient. Be prepared to see each consultation afresh and don't carry your own or your colleagues' diagnostic baggage with you into the consultation. A failure to change diagnoses where it is staring you in the face that the current tack is wrong is at the root of many medicolegal claims.

Listening is as important as questioning

Think back to when you weren't a medic and had to consult a doctor. It's likely that, like I did and most people do, you constructed a narrative in your head of what had happened. First there was the rash, then the night of fever and sweating, then the headache and muscle aches and the terrible cough which started this morning. Such a tale, if you can get it from your patients is invaluable and the quickest route to the diagnosis. There is an oft-quoted maxim in medical circles² that runs, roughly,

Open questions

These are seen as the gold-standard of historical inquiry. They do not suggest a 'right' answer to the patient and give them a chance to express what is on their mind. The most open of questions, and often a good gambit at the start of the consultation is 'How are you?'. Alternatives include 'What seems to be the trouble?', 'What can I do for you today?' and 'What's the problem?'. They can still be used to get specific information about a particular symptom. For example 'Tell me about your cough' or 'How are your waterworks bothering you?'. Open questions cannot always be used, as sometimes you will need to delve deeper and obtain discriminating features that the patient would not be aware of. However, they should be kept foremost in the mind as a way to broach a subject or unexplored symptom.

Questions with options

Sometimes it is necessary to 'pin down' exactly what a patient means by a particular statement. In this case, if the information you are after cannot be obtained through open questioning, then give the patient some options to indicate what information you need. For instance if a male patient complains of 'passing blood' and it is difficult to tell what he means, even after being given a chance to expand on the subject, you could ask 'Is that in your water or your motions?'. This technique must be used with care as there is a danger of getting the answer you wanted rather than what the patient meant (he might be having nosebleeds). Try to avoid using specific medical terms such as 'coffee-grounds' (one of the options you might give if trying to find out if a patient is vomiting blood). If you can use an open question such as 'What colour was the vomit?', rather than suggesting options, it is more likely to give you a true picture of what the patient has experienced, but sometimes questions suggesting possible answers cannot be avoided.

Leading questions

These are best avoided if at all possible. They tend to lead the patient down an avenue that is framed by your own assumptions. For instance, a patient presents with episodic chest pain. You know he is a smoker and overweight so you start asking questions that would help you to decide if it's angina. So you ask 'Is it worse when you're walking?', 'Is it worse in cold or windy weather?'. The patient is not sure of the answer, not having thought of the influence of exercise or the weather on his pain, but answers yes because he remembers a cold day when he walked the dog and his pain was bad. You may be off on the wrong track and find it hard to get back from there. Much better to ask an open question such as 'Have you noticed that anything makes your pain worse?'. When he answers 'pork pies' you are on firmer ground in suspecting that this may be chest pain of gastrointestinal origin.

After taking the history it's useful to give the patient a rundown of what they've told you as you understand it. For example, 'So Michael, from what I understand you've been losing weight, feeling sick, had trouble swallowing, particularly meat, and the whole thing's been getting you down. Is that right?'. If there is a nod of approval or expressed agreement with the story then it's fairly certain you're getting what the patient wanted to tell you. If not, then you may need to try another approach. This technique often picks up the little assumptions that are made by doctors, upon which can be built a whole heap of misinformation.

It's always a good idea to ask the patient if there's anything they want to ask you at the end of a consultation. This can help you to impart further information if there's something they haven't understood, and can reveal something that's been troubling them that hasn't been touched upon or got to the bottom of.

• Try and let patients tell you their story freely
• When you use questions try and keep them as open as possible
• Use all of your senses to 'listen'
• Check that what you think is wrong, is what your patient thinks is wrong
• Keep an open mind and always ask yourself if you're making assumptions
• Be prepared to reconsider the causes of symptoms that you or a colleague have decided upon.