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Image: “ US Actor Chris Pratt Didn’t Know What “Impotent” Meant” by studio tdes. License: CC BY 2.0
Taking a Medical History
Taking a medical history is the first step in every patient examination. If possible, the physician should ask questions directly to the patient. Exceptions include small children or people who have trouble expressing themselves. Caregivers or family members can also be asked to describe their personal impressions, although the physician needs to ensure that the caregiver or family member is able to accurately describe the patient and their symptoms. It is also important that physicians put aside their personal opinions and describe the patient’s condition objectively. The assessment is the responsibility of the physician. If necessary, they 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 the History
An 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, and the social history includes an analysis of the patient’s environment. Taking a patient’s history is a dynamic process that requires special concentration and good interpersonal personal skills.
The Importance of Experienced Anamnesis
An experienced anamnesis is also referred to as a special anamnesis. It factors in prior knowledge of the patient. Therefore, an experienced anamnesis is especially important for the primary care physician. A physician who knows their patient and, possibly, other close family members can incorporate this knowledge into diagnoses and will have a significantly higher chance of identifying diseases, even when symptoms are unclear.
The model of the primary care physician who looks after their patients for a lifetime is a particular advantage. In order to make an experienced anamnesis possible, however, certain prerequisites must also be met. These prerequisites are not confined to long-established practices; all physicians can meet them. Commitment to patients is the main requirement.
Active listening
Only a physician who actively listens to their patients will learn what they need to know. Inquiries should never turn into a sort of interrogation, but always maintain the form of a conversation. The time constraints inherent in any medical practice are a major disruptive factor. Patients appreciate physicians who listen closely to them and take their time. These patients tend to remain in their physician’s care for many years.
On the other hand, a patient with a great desire to talk at length may interfere with daily activities in the practice. The physician must, therefore, be able to recognize the patients with whom they need to spend more time, and the ones with whom they do not — that is, the physician must have attending behavior. According to Dahmer & Dahmer, one has to understand the spoken word but also be able to read between the lines and understand nuances.
Physician’s must also:
- Have an interest in the patient
- Be willing to listen
- Have the ability to listen
- Be completely present
A physician’s interest in their patient must be genuine, however; otherwise, the other 3 prerequisites cannot be met. If possible, the patient should not be interrupted. This is also important because the patient will subjectively describe their symptoms and list things that are particularly burdensome. Of course, these points are important, but there may also be inconsistencies that the patient is not aware of and that are only briefly mentioned in the course of the conversation. Thus, any interruption from the physician can cause them to miss these vital points.
Empathy
Empathy is sensitive understanding, not sympathy or compassion. The physician’s goal is to identify with the patient. The physician has a difficult task: to not be judgmental and to make this clear through how they speak to their patients.
Another challenge for physicians is preserving an inner distance from the patients. It takes time and practice to be actively polite, honestly interested, and empathic while not letting the plight of the patient become your own. In addition, a certain degree of control of the conversation is required, so that confidence in the physician’s expertise is maintained. The degree of control necessary depends on the nature of the patient and also on medical history.
By getting to know the patient, an 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 themself feels in their role. A relationship of mutual trust is also vital.
One way to do this is for the physician to offer to make themselves available after-hours. Such offers are especially helpful for patients going through difficult times in their lives. 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.
Image: “Nurse with patient in City Hospital Tuberculosis Division, 1927” by Seattle Municipal Archives. License: CC BY 2.0
Opportunities through experienced anamnesis
An experienced anamnesis expands the diagnostic possibilities. This is especially helpful when it comes to unclear symptoms such as insomnia, headaches, recurrent colds, or vague abdominal pain. Thanks to an 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 would not necessarily describe such an event; if the physician knows about it, however, it can steer them in the right direction in terms of a diagnosis.
Or, for example, if a child in the family often seems to suffer from a cold, a physician will usually ask whether there are pets in the home, under the assumption that the child could have an allergy. This way, it can be clarified in advance whether or not an allergy test should be administered. However, if the family does not have a pet, the primary care physician who has taken a full medical history of the patient and family will know, for example, that the child’s sister or mother is an enthusiastic equestrian because she herself is a patient in the practice. With this background knowledge from the experienced anamnesis, a doctor can more readily identify what is going on with their patient.
With a few precautions, therefore, the stimulus for the allergy in this example can be eliminated without extensive tests or countless questions. Another example is knowing where the family last went on vacation. Patients who know their primary care physician well might also talk about vacation trips with them. By knowing where the family has recently traveled, the physician will not run the risk of misinterpreting, say, symptoms of malaria, and thus losing valuable time if they know that the family has taken a vacation in an infested region.
Similarly, we know that certain diseases are hereditary. Patients without this medical knowledge may not realize what having a family member with a hereditary condition means to their own health. A primary care physician who has cared for their patients for generations, however, has the knowledge and can uncover important diagnoses faster. In certain circumstances, this can even be lifesaving, e.g., for rare diseases.
Limitations
Of course, experienced anamnesis is not without risk or limitations. One of these risks is that the patient presents with their own diagnosis. Time pressure is again a risk factor here. It is also helpful to know that patients tend to gather their own information on a variety of symptoms.
Those patients who are more anxious 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, thereby moving the physician away from a correct diagnosis. This can be exacerbated in some cases when the physician asks about symptoms that the patient knows are typically part of the suspected disease (Munchausen syndrome).
Conversely, a patient may also fear a specific diagnosis and therefore conceal symptoms once they are aware that the physician suspects that very disease. This is often the case when it comes to cancer or other serious illnesses. The physician must, therefore, take into account that similar severe and potentially fatal diseases may have left the family with trauma. The fear of the diagnosis can be so great that the patient conceals their symptoms from the physician.
Active contribution
When a physician decides to include the experienced anamnesis in their diagnostic procedures, they can promote this fact in their practice. Physicians who take the time to get to know their patients are often recommended to others, especially within a family. It is also useful to emphasize to the patient how valuable a trusted primary care physician can be for a family, including extended family. Additional services, such as contact numbers for emergencies, can also add to the attractiveness of medical practice.
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