Taking a history may seem simple, but it requires broad medical knowledge. Master clinicians alter their history taking in response to the patient’s answers, their body language and observation. As one performs the physical exam, more questions occur to the clinician.
The history does not end with the admission. As one collects laboratory results, imaging studies, and clinical changes, more questions become relevant. History
taking represents an ongoing activity, designed to help both the diagnostic and therapeutic process.
How does one become better at history taking? First, you must take many histories. You must critique yourself as more information becomes available. Second, you must think about the process of history taking.
Dr. Wes bemoans what it has become with the help of the electronic medical record (EMR):
The EMR has become not only the administrators' friend, but the proceduralists' as well. Thanks to text-generating "macros" (sometimes called "dot-phrases") the burden of the pre-op history and physical has been all but erased. If a patient has one cataract done thirty-two days ago (outside JCAHO's 30-day requirement), well then, no problem, just hit a few "dot-phrases" and presto! Away we go! "Dot phrases" can load up an empty history and physical form faster than you can say "operation."
A speaker extolling the benefits of the EMR once said that some conditions are so similar from patient to patient that one can often generate the entire H&P with just a few key strokes and little if any editing. It was an amazing demonstration but really, really sad.
The whole thing, of course, is driven by economics. The less time you have to spend on the H&P the more patients you can see, the more procedures you can do and up goes productivity.
Sooner or later we’ll all adopt the EMR. After all, it’s what everybody (except for physicians in the trenches) says will fix the patient safety problem. We’ll take advantage of its efficiencies but real effort will be needed to save the dying art of bedside diagnosis.