Accurate and Efficient Patient Histories

00:01 So this lecture is entitled getting to know you.

00:05 I like the famous song from the "King and I." I've been told that absolutely positively I cannot sing.

00:11 So therefore I'm just gonna describe the title.

00:14 I just say that just like that song is one of key elements, if not the key element to that famous musical.

00:20 Getting a good patient history is the key to good patient care as well.

00:25 That's my intro.

00:26 Let's talk about it.

00:28 So why do patient histories matter.

00:32 It really is the crux of providing the right diagnosis for patient and then eventually giving the right treatment on board as well.

00:41 So this is a study of looking at internal medicine faculty and residents and they're asked, what's the most important element in making a diagnosis? Is it the physical examination? Of course, we do physical examination in every patient.

00:54 Is that really where the diagnosis gets made? Or is it an ancillary testing and that's lab, x-ray, other forms of testing that we may do.

01:03 The majority of these faculty and residents believed it was in the history.

01:08 And I believe that too.

01:09 Patients often know their diagnosis.

01:12 And it's just a question of me helping guide them to where it is.

01:18 It's really amazing to see that.

01:20 And of course when patients have a belief and an understanding of their own diagnosis, it makes enlistment in a plan of care, a heck of a lot easier.

01:30 So how do you get started with the patient? I tend to be a pretty enthusiastic guy.

01:37 I really like my job, and I love patient care.

01:40 And if I could come in there and just bounce right in and say, "Good morning. I'm Dr. Vega.

01:45 It's pleasure to meet you, today." I do.

01:48 A lot of my patients, they're sick.

01:50 They don't feel very good.

01:52 Many have depression, or other have serious stressors in their life.

01:56 So I really wanna make my entire visit about being positive and constructive, so we can do something positive together as a unit.

02:06 Patient and physician.

02:08 One question that I should ask more often, than I do is, How would you like to be addressed? That's a really nice way to open especially for a patient whom you don't know.

02:18 Ask them what they would like to be called.

02:20 For younger patients, they may wanna use their first name.

02:24 Certainly anybody under the age of 21, I tend to use their first name.

02:29 But a lot of my patients in my practice are older and I always address them as Mister or Misses and that's just the way, that's the way I was raised to be respectful like that.

02:42 But some people might like to change that paradigm.

02:45 As somehow they would like to be addressed.

02:47 It's a really nice way to open a conversation.

02:51 Very important that there's actually been a study most patients like to shake hands with their physician.

02:57 So how do you mitigate that with this imperative, that we should always keep our hands clean.

03:02 I like to shake hands and then later I'll put my hands down and then wash my hands before examining the patient.

03:09 But this is particularly important for minority patients.

03:13 Because it's a sign of respect.

03:15 It's a sign of universal respect and connection.

03:17 I'm gonna shake your hand.

03:18 And then just start with the real open question.

03:22 What brings you to clinic or emergency room or hospital today? So this slide describes, shows a physician saying, with his finger in the air for some reason, saying, "Tell me more about." And that's a really key phrase.

03:37 Because again the patient often wants to elaborate their history.

03:42 You wanna give them a space that's safe to speak.

03:45 And you wanna show that you're listening.

03:47 And just letting them tell their story, is the real key to a good history.

03:52 So say the patient says, "Oh, I've got a terrible pain in my stomach." The nice response is, "Tell me more about the pain." "It feels like a bad cramp." So it's a crampy pain.

04:05 How else can you describe the pain? Let's just dissect that statement for a second.

04:10 So first I reflected to the patient.

04:13 "Oh, so I hear you. It's a crampy pain." It also kind of puts a category in my mind.

04:18 Crampy pain.

04:19 Because I'm thinking as I'm talking to patient.

04:22 I'm starting to form my differential diagnosis.

04:24 But it's not enough, right? We wanna know more about the pain.

04:27 And we want the patient to put it in her or his own words.

04:31 So how else can you describe the pain, is a nice open way to do that.

04:35 So follow the patient's leads.

04:38 It's really terrible.

04:40 I've seen the patients who break out crying.

04:42 And physicians are still going through a review of system checklist, like and do you have fever, and do you have headache, and is your hair dry or falling out.

04:50 And the patient is crying in front.

04:52 It's really terrible.

04:53 So as the patient is going, react to the patient.

04:56 That's what empathy is all about.

04:58 But having empathy isn't enough, you have to act upon it.

05:00 Certainly also when you hear something unusual or possibly highly pertinent in a patient's history, make sure you react to that too.

05:09 So in this case of abdominal pain, the patient says, "It hurts more when I eat.

05:12 It all started when I eat some strange food." Wait a minute strange food, "What? Just tell me more about that.

05:20 What exactly are you eating out there." That's really important.

05:23 So use the patient to help navigate their own history.

05:28 And then I'm a big believer in using continuers.

05:31 Things just simple statements.

05:32 Oh, I see.

05:33 Tell me more.

05:35 Go on.

05:37 And the famous, "Mmm hmmm." Bear in that, just maybe use silence.

05:42 Just you're smiling slightly.

05:46 You're nodding.

05:49 Silence is weird, right? So a good trick to play the next time you have a family gathering is just be silent, and let people tell their story and then you're engaged.

06:00 And it's amazing how uncomfortable people get.

06:04 Or when you're out with your friends or whatever.

06:05 Silence is a great way to get more history in of itself.

06:09 And I'm the master of silence.

06:12 I've actually had people tried that on me before.

06:13 And I know what they're doing.

06:15 So therefore, I always be silent back.

06:16 And it can be turn pretty funny and I always win.

06:21 Ask directly what the patient has as well.

06:24 It's important for a couple of reasons.

06:26 As I said, sometimes they've done research online and so they have an idea what their diagnosis is.

06:32 Sometimes my patients are, have a concern that's way out there.

06:36 Like I have had abdominal pain for one day with some lose stool and feeling malaise.

06:42 And I think it's cancer.

06:45 You know, most likely not cancer, right? But it gets that issue out there, so that you can address it.

06:51 Because of course you're gonna reassure the patient at the end it's probably gastroenteritis or something related like that.

06:57 And not a terrible diagnosis like cancer.

07:00 So asking directly is a great idea.

07:02 In terms of getting all the facts, sometimes you have to ask close-ended questions, not those open-ended questions like, "Tell me more about your pain?" Or where, you know, "Give me a location for your pain?" Can you point to where it is? You have to ask specific things.

07:17 Does the pain radiate for example.

07:19 Have you tried anything to alleviate the pain? I like when we talk about palliative factors.

07:25 Which is any, you know, things that relieved symptoms like pain, is use anything.

07:31 Because patients try all kinds of things.

07:33 Certainly think about, "Okay, we try any medications." But they might also be doing some kind of massage, or using a topical treatment.

07:40 They might be jumping up and down on the stairs.

07:42 You never know.

07:43 And it's important to get all those things out there because maybe it's the jump, you know, it's the medication you prescribed isn't helping but jumping up and down on the stairs is.

07:52 Let him have jump up and down the stairs a few times.

07:55 It's gonna be better probably than the side effects that my medications can bring along.

07:59 Alright, and you can always go back to open-ended questions.

08:03 And so for example, after you've asked, does the pain radiate? Do you have any other symptoms when the pain comes? Open-ended.

08:11 No.

08:12 Well, I need to know a couple specific things here.

08:14 So I'm gonna ask the patient, "Specifically, do you feel nauseous? Or, "Have you had fever?" Notice how I separate those two questions.

08:22 Because it's very important that you don't wanna inquire into more than two symptoms with one question.

08:28 You never wanna create a law, and do this.

08:30 And if had you had fever, back pain.

08:32 Have you or have you had lose stools or numbness in your legs or feet.

08:38 I mean the patient is just, what's the answer gonna be? No.

08:42 Why? Because they can't really remember what the first or the third thing you said.

08:45 And therefore, you're not getting a very accurate history in that case.

08:48 So really just simple statements.

08:51 Try to avoid jargon.

08:52 And make it just one symptom per question.

08:55 And then, how did they ask the question is also important.

08:59 You don't wanna say something like, You don't have fever, do you? Because what's the patient's going to say to that? No. Because it sounds like they're bad, if they had fever.

09:10 Instead, "Have you had fever?" Objective, open, no matter what kinda history you're talking about.

09:14 In particularly it's more sensitive forms of history.

09:17 Say you're asking about use of substances, or you're taking a sexual history, then you really wanna maintain objectivity, and you use language that's very neutral.