Working as I do in an academic medical center, I’m frequently called
upon to teach medical students. I do most of my teaching now with the
third-year medical students when they rotate through our outpatient
clinic. Usually, I’ll send them into an exam room on their own to see
my patients (after requesting my patients’ permission to do so, which
they nearly always grant) and then have them present the patient’s
history to me in front of the patient. This model is efficient and
accomplishes much: the medical students have
the opportunity to sharpen their history-gathering and
history-presenting skills, patients have the opportunity to clarify the
history the students provide me as well as to make a contribution to the
education of tomorrow’s doctors, I hear a (hopefully) concise and
accurate story that I can pick through to arrive at accurate diagnoses
of my patients’ problems, and I can evaluate and provide feedback on
students’ clinical and personal skills having watched them in action.
I typically give a small talk to the medical students who rotate with me
on the thought process I use in tackling patients’ problems in my
clinic, and I thought readers might find it interesting to know how
doctors (at least, this one) typically approach patient visits in an
outpatient clinic.
IT’S ALL ABOUT AGENDAS
The moment I enter an exam room, before my patient even has a chance
to speak, I’ve already started my assessment. This first part of the
process happens quickly and is largely unconscious. In a flash I take
in the picture I’m seeing: is my patient sitting comfortably reading a
book or fidgeting in a strained posture? Does he stand to shake my hand
when I enter the room or avoid all eye contact? What are his first
words and how are they spoken? No right or wrong answers exist to these
questions, and I’m careful to not infer too much from them. But I do
always wonder about what the answers might imply: am I seeing anxiety,
depression, impatience, anger? It matters a great deal which, if any,
are present, both to the process of gathering a history and to the
correct assessment of a patient’s problems.
Each and every time a patient comes to see me, I remind my medical students, they have an agenda and I
have an agenda. (By “agenda” I mean simply a list of things we each
want to discuss.) They may have only one thing they want to discuss or
they may have twenty. Our agendas may overlap (I may also want to talk
about their arthritis and cholesterol, for example) but often they’re
quite distinct. (Obviously, I don’t yet know what new complaints
they’ve brought with them.) What I do know patients bring with them in
variably insignificant, small, and large quantities is anxiety—not only
about what terrible malady I might end up telling them they have but
also about being prevented from communicating their concerns.
In today’s world, doctors tend to demonstrate non-verbally (and
sometimes even verbally) their sense of urgency to be elsewhere. Many
of us seem (and are) constantly distracted by the next thing we have to
do, the end result often being that we’re not only half-listening to
what our patients tell us but also are rushing through the visit,
failing to ask clarifying questions that just might reveal the key to
our patients’ problems.
To combat this problem, I deliberately spend a moment making small talk,
deliberately slowing myself down and communicating by my action that
I’m going to focus all my attention on my patients and listen to what
they have to say. Then I frequently (though not always) do the
following: I ask them to list for me everything they want to talk
about, requesting that they avoid going into any detail as they do so.
(That will come later, I reassure them.) After each item (“my ankle
hurts”) I prompt them to continue by asking, “Anything else?” When they
finally pause to consider if they have anything else left that concerns
them and at last answer, “That’s about it…” I always respond, “Are you
absolutely sure?” Usually they pause again, conduct a mental inventory
or consult a list they’ve written out beforehand (something I heartily
endorse), and tell me they’re done.
At this point, I’ve accomplished two important things (usually in under
two minutes): I’ve learned the universe of their concerns and I’ve made them feel heard.
When patients complain that their doctors rarely spend enough time with
them what they’re really irritated by isn’t the time not spent but how
little listening their provider seemed to do. In my experience, it’s
possible to spend only five minutes with a patient (depending, of
course, on the reason(s) they’ve come in) but still have them come away
completely satisfied with the visit quality. (Accomplishing this feat
in so little time isn’t the goal, of course, but the fact that it
happens proves the point.)
Having heard and understood the full extent of a patient’s concerns, I’m
now free to combine their agenda with mine and arrange them into one
large list, prioritizing them using my clinical judgment according to
their potential seriousness. Due to anxiety, for example, a patient may
have mentioned “chest pain” as their last complaint, hoping
whether consciously or unconsciously to downplay its significance.
Luckily, because they weren’t given any time to go into detail before I
gathered the entire list of their complaints, I can make their last
complaint mentioned the first complaint discussed, ensuring I have
enough time to gather those all-important details to the degree I
require. If I’d failed to obtain an exhaustive list from them at the
beginning, the complaint of chest pain might only surface at the end of
the visit (something that used to happen to me all the time). I’d then
be forced to spend an additional twenty minutes eliciting the details
around this most important complaint, making me late for my next patient
and preventing me from spending the appropriate amount of time and
appropriate amount of focus on them.
Sometimes, of course, as I mentally glance over my combined list, I find
no medically compelling reason to prioritize any one problem over
another. In that case, I turn to the patient and ask them which
complaints they want to discuss first.
IT’S ALL IN THE HISTORY
Once I’ve had my patient list their complaints, we start discussing
the details of each. The medical history, I teach medical students,
remains the most powerful diagnostic tool we have. Most students are
skeptical of this for a long time, thinking diagnoses are mostly made
with technology. Certainly, I acknowledge when they say this,
technology has dramatically increased our ability to make many
diagnoses. But with it has come an unintended consequence: an
increased likelihood that providers will exhibit lazy thinking. Why
bother to consider the diagnostic possibilities past a certain level of
detail, after all, if you can simply order a test to get the right
answer?
The reason, it turns out, is that if you apply technology with
insufficient forethought, not only will you order a plethora of
unnecessary tests on the way to the diagnosis, you may very well miss
the diagnosis entirely. As just one example, consider pain—something
that often has a functional cause rather than an anatomic cause,
rendering the all-too-often mindlessly ordered CT scan useless.
Unfortunately, I’ve lost count of the number of times I’ve had medical
students suggest ordering abdominal CT scans without knowledge of a
single qualifying detail of a patient’s abdominal pain.
This thought
error may be forgivable in medical students (it’s my job, after all, to
train them), but I’ve seen many medical residents commit the same kind
of error. I’ve come to believe it doesn’t happen just because ordering a
CT scan is easier than thinking, or even that residents are terribly
rushed (which they are), but rather because many newly minted doctors
simply haven’t yet learned to trust the data the medical history offers
them. It’s a trust that seems only to develop gradually with
experience.
Nevertheless, each fact a health care provider gathers in the taking of a
medical history is, in fact, a test itself. When I ask a 55-year-old
man complaining of chest pain if he gets it with exertion and he says
yes, in the right clinical setting that positive result carries as much
prognostic value as a stress test. With each subsequent question, I
adjust up or down the likelihood of the various diagnoses I’m
considering until I arrive at a final “pretest” probability for each.
The term “pretest” probability is used to indicate the probability of a
disease being present that’s been calculated from the history alone,
before more traditional tests are ordered. But it’s a misleading term
in one sense because the testing has long since already begun—with the
first question I asked.
Interestingly, the amazing advances in technology we’ve enjoyed in the
last fifty years have added far more to our ability to treat than to
diagnose. Which is why training medical students to take a thorough
medical history will always remain relevant: no matter how much better
our diagnostic tests become, we only know to order them in the first
place because the history we gather first leads us to consider the
diagnosis they’re able to make. Medicine, it turns out, isn’t a science
at all, but rather the art of applying science to symptoms in such a
way that yields us a diagnosis.
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| Photo : Diana Pryde |
Note :
Alex Lickerman is a physician, former Assistant Professor of Medicine
and Director of Primary Care, and current Assistant Vice President for
Student Health and Counseling Services at the University of Chicago. Alex writes in www.happinessinthisworld.com to share his views on topics relating to health,
happiness, and personal development. His principal aim is to explore
spirituality from a scientific point of view and help people think about
life, happiness, and themselves in ways they never have before. His first book, The Undefeated Mind, will be published in Fall of 2012.
Source :
http://www.happinessinthisworld.com
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