How do you feel or how do I feel?

The art of history taking builds the blocks of diagnosis. Time befriends neither doctor or patient

By Susan Orr-Mongeau

What's hot and what's not in doctor-patient communication: HOT: Remembering your audience -- tone down jargon and complex explanations. Saliva or even spit works better than 'sputum culture.' Learning to love lists -- grin -- don't grimace -- when your patients bring in their complaints in writing, and encourage them to do it more. Keeping quiet -- staying physically and verbally silent allows you to listen better. Leaning in -- eye contact and posture are important. Slouching can make you look bored, crossed-arms can convey defensiveness; a desk can seem like a barrier. Leaning forward a bit during the interview tells the patient you're listening and want to hear more. Slowing down -- rattling on at a mile a minute obviously makes the patient feel like they're being rushed out. Slow down and try to pay attention to your tone. Pausing for feedback -- let your patient take in the information, and ask 'Do you understand?' Get the patient to repeat instructions back to you to make sure they've got it. Never letting them see you stressed -- frustrations get the best of all of us, but try not to let your patients see it. Remember, they're probably stressed too. NOT: Dismissing a subject -- try to suppress the urge to move on to the next topic because the current one is boring or you feel it's not valid. The patient clearly doesn't. Pretending to listen -- don't even try, they can tell. Taking calls mid-interview -- enough said. Shying away from the tough stuff -- a routine ingrown toenail appointment turns up a drinking problem in your patient. You don't have time for this, right? Wrong. Staying inside the box -- facts and figures are dandy, but don't forget those feelings. Taking notes -- surprising as this may be, note taking can make patients nervous. It's best left until after the patient has finished a point; even then just key phrases or words. Formulating your response rather than listening -- stop, look and listen.

Taking a patient's history is one of the first things med students learn, and it's one of the cornerstones of all medical practice. In the coming year a "typical" GP/FP will conduct some 5,000 interviews and spend about 1,250 hours (that's 32, 40-hour weeks) talking with their patients. But that doesn't mean there's no room for improvement. One place that could use some work is physician interviewing skills -- something that both patients and communication specialists agree on. There's strong evidence that communication affects patient adherence to treatment and to outcomes, so improvements are being pushed from all sectors, and med schools are putting increasing emphasis on it for the next generation of doctors.

The majority of complaints about doctors are about communication not competence. Patients' major beefs are overuse of jargon, poor listening skills, being interrupted, lack of consultation in decision-making, and poor explanation of outcomes. One of the few things they do like is doctors who use a psychosocial approach, asking how they feel about their ailments and taking time to chat. The difficulty is, of course, the very fact that this does take time. With family practitioners up to their eyeballs, while patients seethe in the waiting room, is it a case of never the twain shall meet?

U of T's Dr Deana Midmer recently conducted a trial on the subject in which she compared history-taking by physicians and nurse with patient completed forms. The doctor version contained questions like "What changes have you experienced this year?" A matching question in the patient form might read, "Over the past year, my life has been..." with the answers provided in check-off boxes on a scale from very relaxed to very stressful. The results found that providers gleaned significantly more information using the provider form than they did from the patient-completed form though patients had a slight preference for the self-report. For the full results see the January issue of Canadian Family Physician.

WHO DOES THE TAKING
Some have suggested that the best way to solve the communication conundrum is to let the patients do more of the "talking" -- in the form of filling out self-assessment questionnaires. So are doctors ready to relinquish this hallmark of the doctor-patient relationship, and hand history-taking over to the patient? From the medical community in Canada it's pretty much a resounding 'No.'

Dr Irene Simons, a solo practitioner and family physician, has tried self-reported paper-based history questionnaires in her Montreal office, and she's not overly enthusiastic. "It just didn't work, there were lots of errors, legibility problems, misunderstandings. It just wasn't worth it," she says. "Maybe it could work for certain specialists -- like ob-gyns."

There are a lot of reasons self-reporting has never really caught on in Canada. "We don't even let patients complete medical questionnaires on their own for the third party work we do, like driver's physicals," says Linda Volkmar, clinic manager at the St James Street Medical Clinic in Winnipeg. Why not? "Because they often don't understand the question," she says. Dr Jan Ritchie, a family physician at the same clinic, has another reason. "Taking history entails more than a series of questions," says Dr Ritchie. "It's important to interpret body language and pay attention to the nuances from the patient."

Dr Togas Tulandi, McGill University professor and Chief of OB/GYN at the Jewish General Hospital in Montreal couldn't agree more. He recently submitted a response article taking exception to a study in Fertility & Sterility that concluded there was limited clinical usefulness of taking a history in the evaluation of women with tubal factor. Dr Tulandi feels that history taking is a skill, nay an art, that simply cannot be replaced by a questionnaire. He suggests a direct question may remain unanswered, whereas a similar question with a twist will get a relevant reply. Also new or enhanced meanings can come from the way symptoms are described, whether it's from a patient's tone, facial expression, gesture, or posture. "The standard questionnaire is a tool to collect information, but its validity for patient management is doubtful," he says. Dr Tulandi reminds readers that history taking is not just about obtaining information from the patient, it's also to "establish trusting relationships with the patient, and to provide information and counselling."