Table of Contents
Taking Medical History
Taking the medical history is the start of any examination. If possible, it is aimed at the patients themselves. Exceptions include small children or people who have problems expressing themselves. Possibly, caregivers or family members must take on the task and describe their personal impressions.
Doctors have to make sure that the person is truly able to describe the patient and their symptoms. It is also important that the accompanying person leaves out their personal opinions and describes everything objectively. The assessment is the responsibility of the physician. If necessary, he must check how well the accompanying person can actually assess the patient by asking skillful questions. For this purpose, questions about everyday life, aiming to determine how well the patient can accomplish certain things, are well suited.
Structure of Medical History
Anamnesis must be taken systematically. It is divided into somatic anamnesis, mental anamnesis, social anamnesis and family anamnesis. The somatic history involves a physical examination; the mental history is concerned with the patient’s psyche, while the social history also involves the patient’s environment. Taking history is a dynamic process that requires special concentration, as well as personal skills.
The importance of experienced anamnesis
The experienced anamnesis is also referred to as special anamnesis. It factors in prior knowledge of the patient. Therefore, the experienced anamnesis is especially important for the family doctor. A doctor who knows his patients, and possibly other close relatives, can incorporate this knowledge in the diagnosis and has a significantly higher chance of identifying the disease, even with unclear symptoms.
The model of the family doctor who looks after his patients for a lifetime is of a particular advantage. But in order to make experienced anamnesis possible, some requirements must be met. But they are not a privilege of long-established practices and can also be implemented by young doctors. However, commitment is a major prerequisite.
Only a doctor who actively listens to his patients will learn the things he/she needs to know. Inquiries should never turn into a sort of interrogation, but always maintain the form of a conversation. The time constraints in any medical practice are a major disruptive factor. Patients especially appreciate doctors who are closely listening to them and take their time. Such patients tend to remain in the doctor’s care.
On the other hand, it may happen that a patient with a great desire to talk might interfere with the daily activities in the practice. The physician must therefore be able to recognize for which patient he has to take the time or not. According to Dahmer & Dahmer, one has to understand the spoken word but also be able to read between the lines and understand nuances. The English technical term for this is attending behavior. The four prerequisites are:
- Willingness to listen
- Ability to listen
- Be completely present
The interest has to be genuine; otherwise the other three points cannot be implemented. This means that the dialogue partner also has to realize that he has his interlocutor’s full attention. If possible, the patient should not be interrupted. This is also important because the patient will act subjectively while describing his symptoms and list things that are particularly burdensome for him. Of course, these points are important, but perhaps it is the inconsistencies that he is not aware of and that are only mentioned in the course of the conversation. Thus, any interruption could destroy the conversation.
Empathy is sensitive understanding. This has nothing to do with sympathy and nothing to do with compassion. The goal is not for the doctor to identify with the patient. The physician has the difficult task not to be judgmental. In addition, empathy must be felt for his patient. In very insecure patients, it may therefore be necessary to make this clear through words.
Another challenge for physicians is, to preserve his/her inner distance. It actually requires some routine to be polite, honestly intensive, and empathic while not letting the plight of the patient become your own. In addition, a certain degree of dominance is required. This is necessary, so that confidence in the doctor’s expertise is not lost. The behavior is dependent on the nature of the patient and also on the medical history.
This once again shows us how helpful it is to know the patient’s environment. By getting to know the patient, experienced anamnesis is easier and makes it possible to help the patient more quickly and more efficiently. This works better the more secure the physician himself feels in his/her role. Of course, the behavior must always be appropriate. This also means that a relationship of mutual trust is necessary.
One example for this is that the doctor makes himself accessible in his free time. Such offers are especially helpful for patients in difficult phases of life. However, it goes without saying that such an offer must not be exploited. It is the obligation of the physician to make this clear to the patient.
Opportunities through experienced anamnesis
The experienced anamnesis expands the diagnostic possibilities. This is especially helpful when it comes to unclear symptoms. These include insomnia, headaches, recurrent colds or vague abdominal pain. Thanks to experienced anamnesis, the general practitioner can eliminate many factors and ask even more precise questions. There could have been, for example, a death in the family. The patient himself would not necessarily describe such an event; if the doctor knows about this however, it can steer him in the right direction with his suspicions.
If a child in the family often suffers from a cold, this is usually followed with the question whether there are pets in the home, with the assumption that it could be an allergy. That way, it can be clarified in advance whether or not an allergy test should be administered. However, there might not be a pet present. But if the family doctor knows, for example, that the sister or mother is an enthusiastic equestrian because she herself is a patient of his, he will know that the child comes into contact with horsehair (clothes and car). With this background knowledge from the experienced anamnesis the doctor can express a suspicion.
With a few precautions, the stimulus can be eliminated without needing extensive tests and countless questions. Another example is the last vacation. Patients who know their family doctor well might also talk about vacation trips. The doctor does not run the risk of misinterpreting a malaria illness for example, and thus losing valuable time, if he knows that the family has taken a vacation in an infested region.
Likewise, it appears that diseases repeat themselves through generations. It’s important to remember that patients without medical knowledge may not realize the importance of having a family member with a hereditary condition. They run the risk of forgetting important diagnoses from their family environment. But it is also possible that they have lost contact with their relatives, be it for reasons of conflict or because the relatives are no longer alive. A family doctor who has cared for his patients for generations has knowledge and can express important diagnoses faster. In certain circumstances, this can even be lifesaving, e.g. when it comes to rare diseases.
Limitations of experienced anamnesis
Of course, experienced anamnesis is not without risk, as it also has its limits. One of the risks is that the patient presents with his own diagnosis, e.g. because he is sure to have already identified the disease. Time pressure is again a risk factor here. It is also helpful to know that the patient tends to gather information on the topic.
Very anxious patients are also difficult to assess if they tend to refer to their family history when they present with unclear symptoms. This can sometimes cause imaginary symptoms to be described, which dissuade the doctor completely from the actual disease. This can be exacerbated when the doctor asks about symptoms of which the patient knows that they are typically part of the suspected disease (Munchausen syndrome) .
Conversely, it can also happen that the patient is afraid of a specific diagnosis and therefore conceals symptoms, once he is aware that the doctor suspects that very disease. Otherwise, certain symptoms may be alleviated if the patient fears a certain disease. This is possible especially when it comes to cancers or other serious processes. The physician must therefore take into account that similar severe and potentially fatal diseases might have left a trauma in the family. The fear of the diagnosis can be so great that the disease is, although perceived by the patient, veiled in front of the doctor.
Active contribution to experienced anamnesis
When a physician decides to include the experienced anamnesis in his diagnostic procedures, he can promote this in his practice. For this, the initial importance has to be placed on taking enough time to get to know the patients. Doctors who take their time are often recommended, especially within the family. This can be a partner, but also the parents or other relatives. It is also useful to emphasize to the patient on how valuable a trusted doctor can be for a family. Additional services, such as contact numbers for emergencies, add to the attractiveness of a medical practice.
Solutions can be found below the references.
Which one applies?
- …is an empathetic interview.
- …includes only the social background.
- …is a way of making contact.
- …is essential for the diagnosis.
- …is helpful in calming down the patient.
2. Experienced anamnesis…
- …includes the questioning of family members.
- …includes the medical history of family members.
- …includes examination of the relatives.
- …includes exchanges with other physicians.
- …is only of importance when it comes to medical records.
3. Anamnesis translates to: