History Taking Through Heart

I was trying out the Daily Rounds app on Android and came across a case description "Unilateral limb swelling in a 51 year old lady. No comorbidities. KFT normal. How to proceed to diagnosis?"

This reminded me about how clueless I was about history taking during medical school. I think if I've learnt anything well by now, it is on how to take a detailed history. And looking at this question made me realize how much that helps me in coming to diagnoses. So here are some super simple tips to take detailed history while building a personal connection - which doesn't require any knowledge of pathology or medicine.

Start with the person

You might have learnt that asking for name is the way to build rapport. But that's a lie. Asking for name is so you can write it in your notes. If you want to build rapport, talk to the person in front of you (and not the patient). I've found that the question "have you had breakfast?" in their language (adjusted for the time of the day) is a super simple way to build rapport. And the reason is that this is what regular people usually ask each other casually when they are on the road.

This lets the patient relax and breathe free. With just one sentence you're telling them that you're a human like them and you respect them like another human. That their sickness is secondary to their human existence.

Move to the patient

Now you let them talk. Unless they're experienced, they will not have arranged in their mind what to tell you. For the first few minutes, let the patient speak without interruption. Let them figure out what their problem is while they're talking to you. Use only head nods, and "hmm" to communicate that you're listening. Make sure you're looking at the patient and don't give off an impression that you're not listening.

If the patient stops after describing just one symptom, just give it back to them as a question. 

"I have headache" Long pause.

"Headache?" with a puzzled, but caring face.

Awkward long pause.

"Yes. The right side of my head feels like it is exploding, since yesterday"

"Hmm. Tell me."

"That's it. I'm unable to get up from bed."

Pause.

"And everything becomes dim and dark to see"

...

Once you let the patient figure out that you're there to listen, they'll tell you everything you need to know without asking.

Get the timeline right

Once you know the presenting complaints, it's time to arrange them in the right order with dates. Ask specifically about when they were completely alright. Get as specific a date as possible about when things started. (The longer people have been having symptoms, the less specific you can get. But still.) Retrace the course of their illness from day 1 of symptom. Find out the order of symptoms. Find out the progression of illness. Find out what they've been doing (I betcha they've gone to another doctor already or tried something). Find out why they decided to come to you. (That needs a point of its own)

Find out why they came to you

There's a reason the patient has come to you. This is not the same as the chief complaints. Some are scared and are coming for reassurance. Some are tired and want relief. Some have been referred by someone else for a specific reason. Confirm the reason why the patient has come to you. This becomes super helpful when you're figuring out the management. As a bonus, it allows you to address the exact concern the patient has.

Let them know you are on their side

This is the turning point in the consultation. You have heard the patient. You have understood their concern. You now win their trust by telling them that you are there to help them. And then you start talking a bit.

Ask your questions

You should have held the questions in your mind till now. The time to start asking them is now. Start with clarification of symptoms. Ask for negative history. Ask about comorbidities. Ask about past history, family history, socioeconomic history, and so on.

Asking negative history

For asking specific negative history, you'll need to know about diseases. But there is a way to avoid that pre-requisite. Go from head to toe. (You'll need some anatomy, physiology knowledge). 

 

Look at the head and ask about all the organs that you see. Bonus point if you touch their head when talking about the head. (But that's not always appropriate. Use your gut sense). Ask how their sight has been, how their hearing, taste, smell has been. Have they had cough, cold, throat ache? Then look underneath the skull. How has their memory, sleep, thoughts, etc been? (There is hair, tongue, teeth, and so many finer details I've skipped for brevity. You will have to be careful not to ask too many questions too. This is just an algorithm to generate questions mindlessly. Filter those questions by applying your mind.)

Then go down to the chest. There are lungs, heart, esophagus, neck + thyroid. Ask questions about things that could go wrong there. Then the upper limbs.

Then the abdomen/pelvis. These have so many organs. Liver, spleen, kidneys, adrenals, pancreas (endocrine, especially), and the alimentary tract per se. And depending on your patient, uterus, ovaries, so on. It is easy to forget the back with spinal cord.

Then there are genitals and lower limbs.

 

Then there are some general things like fever, bodyache which don't really fit into this organ by organ thing but they usually come up somewhere in between.

This is only one way to generate questions. Depending on how much differential diagnoses you have in your mind based on chief complaints, you might be able to come up with questions without using this algorithm.

Other histories

The best way to take history like past history, socioeconomic history, etc is to imagine yourself in the patient's life. What is this person? Where are they coming from? Where are they going? What do they do in their daily life? How's their life like? What's their family? What do they do after getting up from their bed till they go back to bed? Do they take some medicines? Do they go to hospitals? Do they drive a tractor? Do they work in three houses?

This part of the history should ideally go like a conversation that has become really interesting and you "want to know everything about" the other person. But often we don't have a lot of time to spend here. And it is inappropriate to spend a lot of time here. Just get a fair sense of each slice of your patient's life.

What has their relationship with themselves been? Do they treat their body and mind well? Do they consume alcohol or use tobacco? Do they eat well? Do they exercise? Do they work too hard?

 

What has their relationship with their family been. Who is their caretaker? Could someone in the family be giving rise to their sickness? What's the family dynamics?

What has their relationship with the society been. Are they generally happy with life? What do they do in their life?

What has their relationship with the medical system been. Do they have any diagnoses? Do they have any other doctors? How many times have they had significant medical care in the past and why?

Summarize your idea of pressing issues back to the patient

By this time you have gone far away from chief complaints and to bring the attention (the patient's and yours) back to it, you can summarize what you think is the problem the patient is going through to them. And then after you get the patient's confirmation you can proceed to examination.

Advantages and disadvantages of this method

What I've described here, like other ways of history taking, is just a template. This one is focused on getting a whole picture of a patient's life without using a lot of knowledge about diseases. Another advantage is that you can build a lot of empathy. But it is also very time consuming. It often takes 45 minutes to an hour just with the history if done this way.

What Patients Don't Know About Medical Schools

There are people who assume that doctors who get into medical school through reservation end up as bad doctors. They have no clue how medical school works.

I won't go into the reasons why reservation (or affirmative action) exists. That is one of the easiest ways for governments to "do something" towards inequity in the society. This post is about the relationship between medical school and bad doctors.

Defining bad doctor

Let's first define a "bad" doctor. An objective way of measuring that would be - a bad doctor is someone who kills the most number of patients. There's a problem with that though. A doctor with no patients would then not be a bad doctor. And a surgeon who takes on the most difficult cases (with proportionately higher chances of deaths) would also be considered a bad doctor. So, the absolute number of patient deaths is not a very good measure of the badness of a doctor.

Maybe we can then take the subjective measure of "patient satisfaction". The doctor who gets 1-star rating for most consultations is a bad doctor. That is tricky though. The doctor cannot keep only the emotions of the patient in mind. The doctor also has to worry about the medical issues. If a patient prefers that the doctor does not examine their abdomen, a doctor who is dealing with this patient's "pain abdomen" may score poorly on patient satisfaction if the doctor does consider it important to palpate abdomen. Patients might be less satisfied if the doctor doesn't prescribe them a few medicines. 

If "patient satisfaction" is measured in a longer term wherein the formalities of a consultation are forgotten and all that remains is the satisfaction of achieving good health, maybe then it is a good measure.

People in the profession can also score doctors. I could make up a criteria for scoring doctors. I could say the doctor who practices the most rational, ethical, and cost-effective medical care is the best doctor and vice versa.

A hospital can say that the doctor who generates the most revenue for the hospital is the best doctor.

Someone can say that the doctor who works the longest hours is the best doctor.

It is thus clear that who is a good doctor and who is a bad doctor is a difficult thing to have consensus on. Let us nevertheless choose a popular vantage point.

Let us call the doctors who are irrational in their care and leads to poor health outcomes as bad doctors. (I had initially included "insensitive to their patients" in that list, but apparently many of us elites think that the fictional (or not?) "Dr House" is a good doctor. So we will first talk about these "good" doctors and later come to whether there are alternate definitions of good doctors).

Medical school training

What does a medical school train doctors in? Indian medical schools (at least the south Indian universities I know about) confer MBBS degree on someone based purely on theory exams and practical exams with theory given more weight. The whole training for 4.5 years is focused on what those exams need. And how're those exams conducted?

Theory exams are mostly single sentence questions that goes like "Write a brief note on <insert health condition name>". (You can see many question papers in the archives of this blog). There is no "Higher Order Thinking Skills" involved in MBBS theory papers. The only skill tested is that of ability to memorize a lot and write a lot more.

Practical exams are slightly better. In the clinical subjects, there would be patients called "cases" who are examined on the spot by the candidate and afterwards an examiner(s) and the candidate discuss the "case". These practical exams are not scored with an "Objective Structured Clinical Examination" pattern. Therefore, it doesn't matter how you examine your patient or if you examine them at all, all that matters is that you have the right diagnosis and that you can discuss lots of points about that diagnosis with the examiner. In reality, often the diagnosis of the patient is "leaked" to the candidate before the exam and once that is known the patient is just a prop in the act.

In summary, medical school tests you on how well you can remember the textbooks - and that alone.

Does that mean all the training in medical school is towards that? No. There are some islands (in form of an exceptional lecturer, post-graduate or peer) where other skills are focused on. But to a large extent medical school training is towards what is tested.

In reality, medical school training does not help people perform good even in these tests because medical school training is literally paid doctors who have no philosophy on teaching (let alone facilitating learning) passing their time with by wasting the valuable time of learners. If medical school professors were sent to teach 12th standard biology classes, their students would dropout and re-join 11th standard in the computer science stream.

(Of course there are some really good people. And the bar is so low that even someone who talks to their students with kindness are considered good professors in medical school. Anyhow, let's not be bogged down by exceptions)

How are doctors made then?

Doctors become doctors not because of medical schools, but in spite of medical schools. It is mostly their interaction with textbooks, peers, patients, and life in general that makes them doctors. And only because the law restricts this opportunity to the confines of medical schools, it is restricted to medical schools.

The skills involved in patient care - communication, courage, critical thinking, empathy, leadership, etc have nothing to do with medical school training.

The theoretical knowledge involved in patient care are all textbooks based.

Procedural skills are learnt by doing (on real patients) with some supervision and there are no special courses to improve or learn these skills in a setting where it is okay to make mistakes.

Where do doctors really learn their craft then?

MBBS doctors start learning real medicine towards the end of MBBS (on their own). They get really good at it only after MBBS - either by working as a postgraduate student or by working in hospitals.

And these opportunities to learn after MBBS are really diverse and heterogeneous. Some work as residents in certain specialty departments where they learn a lot about those specialties (and a bit about medical care in general). Some do this with a gap of a few years (spent in PG entrance preparation).

From then on they keep getting better at it. Because every new patient they're responsible for teaches them something new.

In essence, the 5 years in MBBS has little to do with how good/bad your doctor is. Medical school is a place where doctors learn about the outline and the syllabus of MBBS. After graduating is where they learn to treat people - and that is what decides how good your doctor turns out to be.

What makes a good doctor?

Privilege plays a role. If one has the privilege to get trained abroad (or in India) in medical schools that are interested in pedagogy, ethics, and rationality, there is a good chance that they learn to become better doctors. Also if one has the privilege to afford to work with lesser known good doctors within India, again there is a good chance that they learn to become better doctors.

Scientific temper and critical thinking plays a role. I'm not really certain how one gains these skills. Life experiences that makes one skeptic may help, perhaps? Or reading about science might help too.

Empathy and emotional intelligence plays a role. Understanding one's patient and their context is critical to be able to understand what they're saying. Often the patient is telling the doctor the diagnosis, but the doctor can't hear because they cannot connect.

If you're under the impression that performance in an entrance test is what makes a good doctor, you've gotten it completely wrong.

Want to Predict COVID? Ask the medical officers or lab managers

From the beginning of this pandemic I've had very accurate predictions of COVID surge, lull, and fall from two kinds of people - PHC medical officers and lab managers.

The PHC medical officers see anywhere upwards of 200 sick people per day and they get to see how many people are coming in with COVID like symptoms and notice patterns before they are even tested.

The lab managers keep a track of test positivity rate (and test rate) and can sense that it is getting overwhelming vs underwhelming.

The only kind of people who haven't particularly been helpful are the people who draw graphs based on numbers from government sources.