Hello history taking…

From AMSA On Call:

Post #5 of the "Back to the Wards" series focusing on the transition from research years back to the medical school and clinical rotations.

Last week I saw a real patient by myself for the first time. Granted, my actions had absolutely no bearing on his care as I was only seeing him as part of my program's official reentry clinical experiences, but nonetheless, I saw a patient by myself. It was profoundly different from every other experience I’d had conducting a history and physical examination. Unlike practicing with a friend or a standardized patient, this patient wasn’t directly evaluating my skills.  There would be no debriefing with him at the end of the afternoon to discuss whether or not he thought I had adequately checked for organomegaly on the abdominal exam (aka, enlarged liver or spleen), or how I might have more carefully guided him through a recounting of his past medical history. Unlike previous sessions where I was observed directly by an attending physician, there was no doctor present. There was no instructor correcting my percussion technique or reminding me to ask about medication allergies, or noting carefully that I should have been more diligent about screening for domestic violence. Unlike clinical examinations, and unlike many of my clinical experiences to come, there was no time limit. I had as much time as necessary to meander through a history and struggle through a physical exam. All of these differences did make the whole experience less stressful, but highlighted for me the value of having patients who are either truly performing (as my colleagues and standardized patients had done), or those who recognize that they are being watched by a doctor as part of a clinical exercise and put on their best helpful patient facade. Instead, I got a friendly and talkative gentleman (carefully selected for me by the charge nurse) who assumed I was a nurse and wound his way through a baffling series of events that proved to comprise his entire life history, occasionally touching on episodes related to his medical condition.

As a student training in public health, I firmly believe that the social determinants of health are as important as any explicitly medical issue. You’ll note that in the previous sentence, however, that I place those two things on equal grounding, indicating that a good history has to lead to a good understanding of what medical issues and interventions led the patient to the current state, as well as the social issues and interventions along the way. At this point, I can safely say that I am not a good history taker. I am excellent at establishing rapport with the patient, am careful not to interrupt too soon, aware that data suggest that responding too soon to the first things a patient says can lead the history taker astray (possibly missing more urgent problems further along in the patient’s story), and generally leave the interaction with a vast knowledge of the patient’s children, eating habits, and hospital preferences.  I am not yet excellent at knowing when to redirect a conversation in a more productive direction (say, to illuminate some aspect of the past medical history), or how to suggest that a topic of conversation may be inappropriate (for example, the patient’s perception that an outside hospital is inferior and begins listing examples). Striking the balance between empathic confidante and authoritative information-seeker is difficult, and I’m convinced that this is not made easier by small stature, female sex, and clinical inexperience, none of which is easily disguised on the wards. So what is the rusty and inexperienced clinician (dare I even call myself that at this point) to do? Fortunately, interactions with those further along in this process suggest that ultimately, clinical experience overcomes most additional barriers, and that it becomes easier to matter-of-factly state, “No, I am the medical student/doctor.” This, fortunately or unfortunately, depending on how you look at it, leaves me with only one option, and only one recommendation for you, dear readers, should you find yourselves in a similar position: practice. That’s right. As in all things, I can only hope that if I try and try again, eventually I’ll succeed.