So I have changed the way I take a patient history and I’m interested in others experiences.
Now that I have a mobile clinical workstation when I meet a patient with information at the bedside (After an intro obviously) I start with a bit of a ‘I see that you have told the nurse/ambulance officer x,y, z. Is that correct? I can see that your medical problems include a,b,c is that correct? Any missing? The last time you saw the chemist you were taking d,e,f is that correct? Anything else? Now can you tell me more about what the problem is today and how I can help?
I’m always amazed at how often the documented history may not be correct (at least in the patients eyes) or relevant information missing and I find this is a really rapid way of illiciting discrepancies and gauging the patients understanding of their illness as well as an opportunity to fill any information gaps they may have.
This also seems to be a much easier style of conversation and I have cut down on the number of ‘But I just told ambo/other doctor/nurse etc that’.
Should we be teaching a new approach to history taking to our clinical graduates? Maybe we are already? Am I right in my approach? Is everyone now doing this? It’s certainly not the way I was taught and I know that some consider it ‘cheating’…
Hi Ruth, I salute your attitude and approach. I would say that this approach creates a much more valuable interaction with the patient and also sends the message that information gathered to this point is valued and important. If you are then entering that new information into a system that will build that data up to a point of completeness to then be used again all the better. Then then next person in your patients journey could pick up where you left off and continue on. Great work.
Hi Ruth,
This certainly mirrors the approach we’ve been using for the last 5 years or so, we’ve also included this ‘training’ and reminders to staff with every digital or documentation upgrade I’ve helped work through, and alongside the training or comms material that gets released with a change to help it stick.
More recently the success in this area has been when we’ve had forms that pre-populate key data from one area to another, so we can see the last time someone edited it and can check through with the patient what’s altered. That seems to really prompt the clinicians to keep in this mindset.
I think the long standing practices are hard to crack but tying it up with a physical change process has helped it to start to stick better.
It has been my approach as long as I can remember. The only time that I have abandoned it was when preparing for our Anaesthesia Part 2 clinical exam, where we have 9 minutes to assess a patient with minimal prior information.
The frustration with systems that I have used to date (mostly modeled on ‘paper’ workflows) is that it is usually jolly difficult to correct an incorrect record. We are a long way from a ‘Wikipedia’ model of medical records, but I really think that we need to go in that direction.
Count me in as converted as well - I sometimes listen outside the curtains when the RMOs have gone in to do the consent - it’s a teaching hospital after all - and can’t believe it when they start from the beginning - when I ask them why they tend to look at me a bit horrified - have not had a good answer to the question yet. Totally believe we should be teaching how to work with an electronic record in medical school, how to sort through and then how to document is a skill that is different when it’s electronic to when it was on paper. Also believe we should use the electronic information in simulations as well - again interacting with the computer in a way that is beneficial and not detrimental to patient care is again a skill you have to learn it’s not actually intuitive - things like not being distracted by the machine to interacting with the machine with good infection control principles being enacted.
That exams have not kept pace with this - well yes that is a problem and I guess is a good reason for the juniors to practice history taking before doing their exams
Speaking as a GP, so usually first-encounter-contact, I’d advocate an open-ended start to the conversation . . just in case everyone else has got it wrong prior (medical students just talking about how Intimate Partner Violence (IPV) often not disclosed until the provider who’s got best rapport is involved). The way we teach in GP-land (happy to post references if you are interested), is to start ‘What’s brought you in today?’ (generally, don’t get ‘the bus’ responses). In your context, perhaps, ‘I have information from GP/ambulance/etc that I’d like to verify with you, but to start, in your own words, what’s brought you in?’ Evidence for this open-ended approach, if you let the person then talk with no interruptions (very hard to do . . . had to train myself to look at clock and not talk for at least 1 minute), is that this approach shortens history taken and elicits the most important symptoms most efficiently. Truly, if you actually don’t do anything but non-verbal encouragement and leave time for a pause, patients will keep going and give you 90% of what you need to know, in 1-2 mins. Often, they run out after about 1 min, so I say, ‘is there anything else’ at this point . . . last opportunity for ‘something else’! If someone keeps going beyond the 5min mark, it’s often a clinical sign (e.g., mental health, etc). The trick is to not say anything for 1-4mins. After this, the approach you are doing would be awesome. In my ideal world, my consultations in GP or ED would be 1) what’s brought you in; 2) Hold my tongue for 5mins +/- ‘is there anything else’; then, 3) ‘You’ve told me a, b, and c. Before I ask you more about those, do you have a patient portal on your phone? Can we please verify the information I have?’
Hey Ruth
I take a history the same way as you do… and find it more productive. On occasion I want to actually get the history from the patient (it changes over time!) and preface it with “I’ve had a chance to read the notes, but can you tell me about…”
I find this works well - you get some of benefits of the unstructured question, but can pretty quickly hone in on areas which the patient may have neglected to mention or of interest.
You point re making a change to how we train history taking is well made. I agree with you.
Mat
For people using a patient portal, the number of characters allowed is very small (about 50) to state reason for apt (i.e. I don’t
get this far in my pre-apt notes and have to restate my reason for apt more succinctly). At beginning of apt, GP asks ‘what brought you in’ or if my note is clear, cuts to the chase about what I wrote by rephrasing in such a way that I’m sent into the 4min
description of what’s wrong, as described by @emily.gill.
@KarenDay that’s why I introduced a 150 character minimum limit (you can technically write an essay if you choose) and standardise the reason for visit system on Vensa’s patient portal appointment system. We can now codify and change workflows for GPs when patients book appointments rather than only at the time of the consultation and the 5 minutes of getting them to warm up with the doctor.
New innovations are coming to streamline patient clinical and service triage needs to help GPs plan better.
I wonder what this does to learning the basic discipline of taking a history. We know that students move from a checklist type history to one that within 3 questions has started to have hypotheses of what is going on and then carry’s at least 3 (and experts at least 7) posibnle diagnoses and many questions directed by those hypotheses.
Students would be forced to this more sophisticated thinking early if they have so much prior information. I would worry that they would not establish the core history taking skills that I always go back to when I am stuck.
taking an effective history when for whatever reason there isn’t much prior info.
communicating effectively with patients when (sometimes overwhelming) information is available beforehand
We are currently teaching medical students to do the 1st one well (and have done for a long time), but I believe that they generally learn the 2nd one ‘on the job’. The pain that this causes is being felt more acutely now as we get the informatics sorted.
@barry.taylor@NathanK totally agree. It’s a combination and maybe one learned on the floor but I’m not sure it is actually taught. I confess that I am relatively new to this approach, only really practising it since I got ‘mobile’ and could verify with the patient. I do however see so much duplication and I wonder if this is something we are reinforcing at ward rounds for instance where the whole 2 pages of admission must be in your own hand?
It’s certainly common for patients to get cross if they are asked the same thing twice and they seem rather horrified if we admit to not having access to GP notes!
Totally, I think it’s the combination of the two isn’t it? The old school establishment of rapport and then the ‘let me verify/check’?
I have been trying to introduce certain health informatics concepts to the people to teach in/manage the medical curriculum at the University of Auckland for several years. Robyn Whitaker and I some time ago tried together. Now a colleague has a three-hour slot to pack some informatics content in, but what can one achieve that’s meaningful in such a short period? In the end I was given a 4 hour self-study module that is optional for Year 5 students to do online. It can’t cover much more than what the EHR is and why it’s important to clinical practice. Informatics should be a thread in the curriculum rather than an optional self-study module, or a three hour workshop.
I suspect that if the medical community were to demand that students learn how to leverage electronic data and other informatics concepts in practice, you might have a better result than I have had. It might be worth considering how CiLN can influence the medical curriculum, and make a case to the medical schools, and participate in co-design in some instances.
Ruth, absolutely.
This is the model that I have been teaching and it was one of those changes that I never thought of the value there is in discussing it - thank you.
We need to bring out these small but significant changes that clearly are impactful changes for the patient as we embrace digital records.
Even more so do we need to train those coming into our services, a conversation with tertiary providers is key is the near future.
One of the complaints patients often make (according to the disability services specifically) is that every time they speak to a new healthcare professional they have to repeat themselves. Teaching this method of taking a history ensures that the patient is at the centre of the assessment and means that we are verifying data rather than having to ask for it all over again. It will be quite a change but with joined up health information comes the need to teach new methods of effectively using it and this will be difference to traditional methods. Great idea!
After having HealthOne in the south island for years, when I am off silo, that is the way I take a history at my hospital clinic and have done so for the 5yrs we have had the south Island health system.
One of the biggest complaints from patients in the past is every HCP pre HealthOne starts from base zero. Starting from HealthOne gives a patient reassurance that the HCP has at least read the record.
