When first seeing patients in clinics and on the wards, the learning curve is steep. During these early encounters, it is often a struggle to ask the right questions, follow up on the answers, and sort the information into the appropriate categories. On the other hand, when watching a seasoned clinician take a medical history, it all seems natural and effortless. The interview flows smoothly and the medical history falls seamlessly into place. Over time, clinicians develop a personal interview style, integrating the information in this book and experience with patients. The following guidelines are some “tricks of the trade” that may help the student—at whatever stage of training or practice—to dodge some of the usual obstacles to efficient, effective medical history taking.
The initial interview with your patient is a unique opportunity to lay a solid foundation in the patient–physician relationship. Spending extra time and paying special attention to patient concerns up front will save time in the long run and lead to better medical care.
In the course of everyday clinical care, there are occasions when you are pressed for time. There are several patients to see, laboratory results to check, and a presentation to rehearse for morning rounds. Patients are very perceptive and sense when you are in a hurry. When rushed, it is especially important to be completely present for the patient. Greet the patient by name. Sit down rather than stand. Maintain eye contact as much as possible, looking up at the patient frequently as you jot down notes or make an occasional entry into the electronic medical record (EMR). All of these things will help the patient feel heard, nurtured, and cared for, and will generally not require extra time.
There is a wealth of information in the chart, and it makes sense to use it. It takes much less time to extract dates of past surgeries from the medical record than to ask a typical patient to develop the list de novo. Making use of secondary sources does not release you from the obligation to confirm key points directly (eg, “I see from your record you were hospitalized in 1966 for kidney disease. Can you tell me more about that?”). Additionally, in patients with poor cognitive function or organizational skills, it is helpful to expand secondary sources and verify information with friends, family, and other physicians. Finally, beware of “chart lore” (eg, the patient who carries a diagnosis of “lupus” passed down from one discharge summary to the next but who has no corroborating physical or laboratory evidence of the disease). Recognizing these caveats, it is always appropriate and usually necessary to “interview the chart” as well as the patient.
EMRs are increasingly available, and many clinics have installed computers in every examining room. The potential benefits of EMRs are numerous. However, if not used judiciously, computers can intrude upon and distort the physician–patient relationship. When accessing the ...