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Obtaining an accurate history is the critical first step in determining the etiology of a patient’s concern or defining their risk for developing specific disorders. A large percentage of the time, clinicians will be able to make diagnoses based on history alone. The value of the history, of course, depends on the ability to elicit relevant information. This requires being thorough and systematic when interviewing a patient.
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In obtaining the history, the doctor functions like a sculptor. The tools are not a hammer or chisel; they are the words and questions used to gather information (Figure 1-1). You take a block of marble (ie, a nonspecific symptom) and shape it into something that is recognizable, a diagnostic possibility.
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Being thorough and organized enables clinicians to generate a historical foundation that is solid and accurate and will serve as a great backbone for the care that will be provided. The patient’s answers are the construction material, the bricks of the history-taking trade. The goal is to build a “historical structure” that is substantial, not a house of cards that is incomplete and/or weakened by inaccuracies (Figure 1-2).
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The first part of this chapter focuses on key approaches to optimizing interactions with patients. This is followed by a description of how to obtain the history of present illness (HPI). The patient initiates the HPI by describing a symptom, and it is the clinician’s responsibility to take this information and use it as a springboard for additional questioning that will help to identify the root cause of the patient’s concern. Details for obtaining the rest of a comprehensive history are described after the section on the HPI.
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OPTIMIZING YOUR CLINICAL INTERACTIONS
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Communicating Effectively
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Effectively interacting with a patient requires excellent communication skills. This entails speaking clearly and using terminology that is easily understood. It also requires that the clinician slow down and listen well, providing adequate time for the patient to ask and answer questions, as well as clarifying points when there is confusion. Responding to nonverbal cues (eg, sadness, hesitation indicating reluctance to answer questions) is also critical in order to communicate well and set up a relationship that promotes engagement and trust.
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It is very easy to reduce history taking to a task composed of a list of questions to be asked and answered, losing track of the fact that, at its core, this is a dialogue between 2 people. Information needs to be exchanged in ...