You are sitting across from a total stranger who is presenting to you for the first time for an examination. But before you perform the examination you have to take a history. This sounds like a simple task, but taking a history is not only an art, but can be one of the most important things you do during your care of the patient.
Often, the history can tell you what the prognosis for this patient may be, can give you a hint of whether this patient might be the type to bring a frivolous malpractice suit against you, and can let you know how much relevant health information on the patient you must pay attention to -- past, present, and in some ways, possibly future! During the course of this article, we will look at the right way and wrong way to take a history and also how to interpret some of the things you take in during this procedure.
Shake a Hand, Make a Friend
Some of the finer points of history taking are much like a normal interaction with a friend or a friend to be. You enter the room, introduce yourself and make certain that you have the patient's name correct. Some people write their legal name, but have not gone by that name in years, so I usually find out what they want to be called. This places you and the patient on a more friendly basis. Of course, you want to find out what the chief complaint is, how long it has been going on, what they think may have caused it, and any history of trauma or illness. Just asking if a patient has been involved in a motor vehicle accident on a form is not enough. Just asking them once during history taking is not enough.
If a patient says that they have not had a car wreck ever and you respond, "Gee, you certainly are lucky that you have never been involved in a car wreck. Most people I've met have been involved in a wreck somewhere along the line." You will be amazed how many people will now volunteer that they have had a car wreck.
They usually add, "But I wasn't hurt!" I have had people, after I added that last observation, tell me that had a car wreck just months before they came in for exam, which were head on collisions at 60 or 70 m.p.h. These were people who told me two or three times that they had never had a car wreck! Sometimes persistence can be virtue.
Another thing about history taking is that you not only listen, but give the appearance of listening. Constantly checking your watch, not delivering eye contact, tapping your foot, nervous gestures, all detract from your the patient perceiving you as a concerned and caring doctor. Believe it or not, just perception by the patient that you are not that concerned about their problem(s) can not only affect how much they tell you about their problems (and thus directly effect how fitting your diagnosis is), but also, seriously affects whether you retain them as a patient.
I Haven't Slept a Wink in Five Months
Once, I was taking the history of a very nicely dressed, poised older lady. She revealed to me that she had not slept a wink in five months. Upon inquiring whether she even shut her eyes, she agreed that she did this for a short time, but did not sleep at all. She further described going to a hospital and being monitored during a sleep study and the doctors being "amazed" that she never slept.
This patient also described having had "eight strokes, one right after the other." In the past, I have heard patients allege (and seen it written in the progress notes), that among other things, on a certain date, they were "breathing out of their ears." The fact is that most doctors hear patients describe situations or experiences that are bizarre or similarly beyond belief, but a good historian (as you become as the doctor taking the history), will copy down those things the patients tell you, even if they seem unbelievable. You may be surprised how important those notes may turn out to be at a future date.
Every Doctor I've Seen Has Been Awful, but You ...
Often, a patient's possible prognosis in your office may be given to you in the history. For example, a patient may be a "doctor hopper" and has seen many MDs, DOs, and DCs in the past and reports to you that none of them have helped and all of them were incompetent. But they have faith that you will be able to help them. Well, you may indeed may be able to help them, but their past usually indicates that the cards are stacked against you. Another important point that often comes out during the history involves any ongoing malpractice litigations, either against past doctors or past attorneys. This is not to say that just because a patient has sued or is suing a past doctor or lawyer that they will sue you. It does however indicate that they are not adverse to bring a suit if they think that they did not get fair treatment. This is something that you can write down, especially as it regards any treatment or representation for the problem you will be treating them.
As a part of their history, and thus as a part of their legal records, these facts may be important if you ever become the object of their litigious angst! And, though most doctors are aware that there is a legal duty for them to do a decent exam and provide an acceptable standard of care, part of your duty is to take a professionally competent history; failure to do that, could be a reason for malpractice just as much as administering a poor adjustment. Let's say that you fail to take down the family history of a certain disease and they just happen to have thinly masked symptoms which you might have found if you were looking for that disease. To fail to inquire about the family history and thus to miss the presence of that pathological entity, could very well lead to a missed diagnosis and could land you in court defending WHY you failed to inquire about family history of illness. But above and beyond that, we should not have to have the fear of a malpractice suit hanging over our head to get us to do something that is a normal part of being a doctor. But, sadly to say, there are some doctors who will avoid doing something unless the fear of litigation forces them to do it.
Dr. Jones Fixed Me in One Adjustment
A good history can also alert you to the expectations of the patient from treatment, as well as alert you to those who may be poor at complying with your treatment plan and who may need a few extra minutes of explanation during the report of findings. If they gauged when chiropractic care should terminate in the past as being the point they were out of pain, then you have your job cut out for you if you want to keep them past the point of being asymptomatic.
I Hated That Kind of Adjustment! Never Went Back!
Taking a good history will also let you benefit from the past mistakes of other doctors they have seen and help you to avoid these pitfalls. If a doctor said a certain thing to the patient that upset them and they didn't return, you know what not to say (or at least, how to say it differently!). Also, if there is a certain technique they just will not tolerate, taking a good history can help you learn from past mistakes of other doctors and may help improve your chances of helping and retaining that patient. Also, if a patient did not take enough time with the patient and they tell you that is why they left, this will help you to know that you probably need to schedule this patient when you are not as busy and have a few extra minutes to show then extra attention. This is especially true with older patients who may move slower, having more complaints, and in general, demand extra time.
Patient, thorough history taking can be one of the most important interactions you have with a patient from initial meeting to release. It can help you avoid pitfalls, alert you to problems, help with patient retention, and even, let you know what is wrong with them! It can reveal psychological problems and secondary gains that may make returning them to a job or to their previous level of activity impossible. People tend to repeat those things which they did in the past. The essential thing, as has often been said, is that those who do not learn from history are doomed to repeat it!
John Raymond Baker, DC
Austin, Texas
