Since it's such an essential skill, we (and by that I mean myself and my fellow classmates) started learning how to take patient histories shortly after starting medical school. This entailed being divided into small groups of about 5 or 6 students and taking turns individually interviewing standardized patients (i.e., actors) under the guidance of a physician preceptor. For those of you who may not be aware of what a basic history includes, the following is a list of information that I, the future doctor extraordinaire, need to pry out of you, the wonderful patient:
ID (identifying data): Your name, age, gender, marital status, and any other tidbits about you that may be relevant to figuring out what ails you.
CC (chief complaint): Why you came in, basically.
HPI (history of present illness): The circumstances surrounding why you came in, basically. When you started feeling sick, how bad the pain is, and so on and so forth. (As a side note, if there's any part of the history where we want patients to ramble, this is it. The more you can tell about us about your current illness or whatever brought you in, the better).
Past Med Hx (past medical history): Any chronic or ongoing problems you may have, any past surgeries, etc.
Drugs/Allergies: This is pretty self-explanatory.
Fam Hx (family history): Any illnesses or conditions that may run in your family.
Social Hx (social history): Your occupation, diet, lifestyle, etc. Also includes things like whether you drink, smoke/use drugs, and your sexual history.
ROS (review of systems): A list of rapid-fire, seemingly random questions about the rest of your organ systems from head-to-toe. Mostly used to make sure that neither the doctor nor the patient has missed any other medical problems during the history.
While all of that doesn't seem too complex on the surface, taking a history involves much more than just an exchange of information. I actually have to do things like gain your trust, make you feel comfortable and at ease, and generally conduct myself in a way that won't make you go running off to report me to medical licensing authorities for unprofessional behavior.
Needless to say, I have trouble taking patient histories.
Don't get me wrong, I'm not a sociopath or a complete jerk. But I can be pretty socially inept, and in a casual conversation I can go from zero to "Oh shit, I can't believe I just said that" in about 10 seconds flat if I'm not careful. So I usually have to really concentrate on what I say, as I'm saying it, when I'm chatting with someone, just to make sure that I don't end up blurting out something stupid or offensive or just plain nonsensical. I have varying degrees of success with this, but for the most part I can hold my own just fine in a normal conversation. As a result, I wasn't too nervous when we started practicing taking patient histories, because I figured it would just be like a pleasant social visit. Just a normal, garden-variety, harmless conversation.
Patient histories are totally not normal, garden-variety, harmless conversations.
To illustrate this point, here's an excerpt from one of my first mock histories:
Me: "So, what brings you in today?"
Standardized patient (SP): "I have a sore throat."
Me: *waits patiently for SP to elaborate*
SP: "Yeah. Sore throat."
Me (thinking): This can't possibly be all you have to tell me.
[Room fills with a devastatingly awkward silence]
Now, in normal conversations, Person A says something, Person B responds, and things go back and forth like a game of tennis. In patient histories, Doctor A asks what's wrong and Patient B ideally gives a nice, long detailed account of what's wrong, uninterrupted by the doctor. In fact, since those first few sentences out of a patient's mouth are often key to making a diagnosis, med students are instructed to initially let the patient talk and talk, and only interject to ask for clarification on a muddy point or if the patient is getting insanely off track. This goes against the pattern of Person A talk, Person B respond, and some patients may politely give me one sentence detailing their problem while I'm expecting a paragraph. The awkward silence then ensues as I wait for the rest of their story and they wait for me to stop being a dumbass and actually reply like a normal person would in a normal conversation.
Luckily, there's a really simple solution for this that I should have figured out a lot faster than I actually did. And that's to just sit back, relax, pop the collar on my white coat and say, "Tell me more about that."
(A bit like this, but with a lot more awesome and a lot less douchebag...Wait, no, on second thought, nothing like this.)
So that's one minor and admittedly boring problem I had with taking patient histories. But where I really started having trouble was the part where you're supposed to make the patient feel at ease by essentially not conveying any emotions other than sympathy, concern, and all other things warm and fuzzy. As a patient I truly do understand the importance of this. When you're feeling sick and scared and vulnerable, the last thing you want is for your doctor to come across as hostile, judgmental, or completely shocked. But now that I've had a taste of both ends of the spectrum, I've realized that it can sometimes be as hard as hell to even appear neutral during certain parts of the history. If you read the components of the history that I outlined above, maybe you can guess which section I'm about to talk about.
Sexual history.
This will probably make me seem like an immature 12-year-old who still snickers at words like "erection" and ends every retort with "That's what SHE said!". But humor me for a minute and try to imagine how difficult taking a sexual history can potentially get. Sexuality is a sensitive subject to begin with, and I think it takes a fair bit of bravery for a patient to talk about their practices and preferences with a physician that they may just be meeting for the first time. In a normal conversation about sexuality, it may be okay for Person B to let out a bit of a laugh or maybe gape in horror at something Person A says. During a patient history, anything other than a neutral expression and a nod that says "I understand completely" on the part of the doctor may damn well ruin their chances of getting the patient's trust, and may even prompt the patient to lodge some kind of complaint. Considering how some of the sexual history portions of my mock history taking have gone, it's a good thing that I'm not an actual practicing physician yet:
Me: "If it's all right with you, I'd like to ask you some questions about your sexual history. These questions may be a bit sensitive, but we ask them of every patient in order to get a complete picture of their health."
SP: "Oh, sure, go ahead."
Me: "So, are you currently in a romantic relationship?"
SP: "Yes."
Me: "Tell me a bit about your partner."
SP: "My wife, you mean? Well, she and I have been married for about 12 years now."
Me: "Are you sexually active with your wife?"
SP: *shoots me a weird look* "Of course."
Me: "What precautions do you take during sex?"
SP: "'Precautions'? What do you mean by 'precautions'? Like, we have a 'no biting' policy, and we always use a safety word when we, you know, role play." *winks*
(Keeping in mind that standardized patients are actors, I think this one particular guy was just screwing with me to see if I would lose my composure in some way. Which I slightly did).
Me: *squeaky, strangled noise comes from my throat as I bite down on the inside of my cheeks to keep myself from laughing my ass off. It's not that he said something mind-blowingly awful, shocking or funny, but I think I'm just really sheltered. I may also have had a "Are you shitting me?" look on my face*
SP: "I'm sorry, did you say something?"
Me: "What? No! I- I'm sorry, I don't think my question was very clear. By 'precautions' I meant things like using condoms or birth control, b-because STDs are...they're bad, and you, uh, don't want to get them. Yeah."
SP: "Oh, yeah, my wife just uses the Pill. I'm clean, just so you know." *raises eyebrow and winks*
You may have noticed a few unusual things about that exchange of words. While the patient is free to be completely ballsy and blunt about what they say, I had to ease into things with neutral and non-presumptuous phrases that tend to beat around the bush. Like if a male patient says that he's married, you can't assume that his spouse is a woman. And instead of asking straightforward questions like "So...you gettin' any lately?", which would make the conversation flow so much better if the patient decides to drop a blunt, graphic bomb about his auto-erotic asphyxiation or something even more outlandish, you have to talk in terms of "romantic relationships" and whatnot. I'm all for approaching situations like this delicately, but I guess it can be a bit jarring when I'm talking as if my parents are in the room and the patient is talking as if he's bragging to his buddies about his conquests over a couple of beers. (Although bear in mind that this was just a mock history, the patient was just acting, and I'm just not good at taking sexual histories. I'm sure that real histories go much more smoothly, real patients are a lot more tactful, and real doctors are not like me at all).
So those are some of my qualms with histories thus far. I'm sure that with time and practice I'll eventually get the hang of things, and the future will hopefully see me making awesome House-like diagnoses and saving lives rather than making patients cry and getting fired.
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