Taking a Medical History John Gazewood, MD, MSPH Department of Family Medicine
Objectives Describe three characteristics of an effective interview Describe patient-centered interviewing Describe the content of the medical interview Describe the process and sequence of taking a medical history
Understanding Exactly Objectivity Precision Reproducibility
Understanding exactly Objectivity Precision Reproducibility
Understanding Exactly Respect Value an individual s traits and beliefs Genuineness Be yourself, both personally and professionally Empathy Understanding and sensitive appreciation Communicating that understanding
Patient Centered Interviewing Illness framework (Patient) Patient s ideas, concerns, expectations, feelings, understanding patient s experience of illness Disease framework (Physician) symptoms, signs, pathophysiology differential diagnosis Integration of two frameworks
Who Controls the Interview? Patientcentered Doctorcentered Time
Interview Styles Facilitators Patient Centered Silence Interruptions Doctor Centered Directive questions
Patient-centered interview improves outcomes Associated with: Patient satisfaction Better patient outcomes symptom resolution fewer follow-up visits for symptoms Patients less likely to switch physicians Lower chance of malpractice suits
Content of Medical History Chief Complaint History of Present Illness Past Medical History Family History Social History (Patient Profile) Review of Systems
Setting the Stage Common courtesies show respect for patient Knock Introduce yourself, and purpose of interview Be friendly, but formal - use the patient s name Attend to the patients comfort and privacy
46 y/o man who is not feeling well
Chief Complaint (CC) Patient s main reason to seek care Identify patient s agendas Hidden agendas Iatrotropic stimulus
Let the patient talk Use minimal facilitators, non-verbal tools Patients usually don t talk for long Most took less than 60 seconds. None took more than 150 seconds. Interrupted patients won t finish statement Order of complaints not related to importance
Chief Complaint - Defining Agendas Screening Checking with patient if there are other issues. Confirmation Confirm and clarify your understanding Negotiate agenda for session Allows patient to prioritize problems Helps to establish therapeutic partnership
Patient complains of chest pain, and trouble keeping up with son.
History of Present Illness (HPI) Patient centered interview What was happening in patient s life? Who else was involved/affected by it? What are patient s feelings about the problem? What are patient s expectations? What does the patient think is the cause?
Seven symptom characteristics Physician-centered interview Location Quality Severity Timing Setting/context Modifying factors Associated symptoms
Pain history - PQRST Provocative/Palliative factors Quality Region (location, radiation) Severity, associated Symptoms semi-quantitative or quantitative Temporal characteristics
Sequence of HPI Open ended questions Directive open-ended questions The Wh questions Laundry list/menu questions Directive or close-ended questions Avoid leading questions multiple questions
Power tools Clarify uncertainties/ambiguity Summarize Feedback to patient your understanding of story Confrontation Points out discrepancies in the story, behavior, verbal/non-verbal communication clarifies discrepancies
Transitions Summarize Allow patient to ask questions Explain to patient what will happen next
Closure Summarize Review problems and plans Have patient feed-back information Allow patient opportunity to share questions or concerns
Getting started Tell me about your illness. How has your illness affected you? Your family?