Patients Lie. Why Doctors Should be Like Medical Students. A Good History is a Checklist.

The most common question first year medical students ask me is how do they become efficient at taking a patient history.  Can they skip certain parts of taking the patient history and avoid asking about a social history, whether a patient drinks, smokes, uses drugs, or is sexually active?  When can they stop asking about the review of systems, a list of questions asked about each organ system?  A comprehensive history is used in the emergency room, hospital, or during an annual physical, not in urgent care or an outpatient appointment, right?

Wrong.


Patients lie and don't even know it.  It's not that they mean to.  In fact, they are trying to be helpful when giving a history of their symptoms.  Medical students concerns about taking a fast history reflects two things.  First is the reality of the limited amount of face time with patients, which unfortunately seems to be even less than the past.  Second, more importantly, is their fascination and desire to get started on real medicine -- what are the diagnoses, treatments, and tests that must be learned to be a good doctor.


In fact, what they realize after working with me is that the most important part of being a doctor is talking to patients and listening.  Taking a good history is the essential part of being a good doctor.


Here are two examples of patients who I saw during the winter.  The practice is busy this time of year.  I'm often running late.  Like many encounters, I've never met these patients before.  In many ways, it can feel like an urgent care practice.  Which patient is lying?  Can you tell?

Young woman wanting a work note for the flu.  She was complaining of a three day history of diffuse muscle pains, headache and high fever.  That's it.  She had no other concerns.  Just anxious to get home and go to bed.


OR


A young man with an ankle injury after playing soccer.  As an aside, he also asked about stomach flu which occurred a few days prior.  He had nausea, abdominal pain, and vomiting for a day.  He still had abdominal pain.

Which one was lying?  Both.

A medical student or doctor recently out of training might have not missed the diagnosis in either patient because they are still working on how to hone down their questioning.  In other words, they haven't take the shortcuts yet and still ask comprehensive histories.  Yet, they aspire to just ask the vital questions to be efficient.  A more seasoned doctor who is stressed and busy may have taken mental shortcuts and moved on.

In other words, how do you know what is and isn't vital until you ask?

Patients also have fallen into this trap believing this tradition of talking to their doctors is simply unnecessary, worthless, and an obstacle to getting to the truth.  With increasing out of pockets costs for office visits, I'm seeing more requests from patients to simply get a MRI or blood test instead of seeing a doctor not only to address the problem, the real reason for the tests, but also if testing is usually necessary (it isn't in the vast majority of cases).

A good history is very much like the checklists pilots use and what Dr. Atul Gawande advocates in his book.  Taking a good history also slows doctors down and allows them to avoid cognitive errors (as described beautifully in the book How Doctors Think), think more clearly, and avoid jumping to premature conclusions.  Even the time honored skill of thinking through a differential diagnosis and thinking hard to make a long list of possibilities is a checklist and safeguard to consider other alternative problems that wouldn't appear when stressed.   Being a doctor requires thinking and less knee jerk responses. 

So what did the two patients have?

The first patient didn't have the flu.  She had a kidney infection known as pyelonephritis.  In taking the review of systems when asked about her urination pattern, she realized that it had changed during her illness.  Also, in asking questions, she had no other signs of having a upper respiratory illness, no cough, no runny nose, no head congestion.  Instead of simply writing a work note for a presumed virus and moving on to the next patient, this patient received antibiotics.  Untreated, pyelonephritis can be serious and require IV antibiotics or hospitalization.


The second patient didn't have stomach flu.  In fact, patients also make similar mental shortcuts by telling us what they think is going on - "stomach flu" rather than telling us specific systems.  When people refer to stomach flu, like food poisoning, often there is nausea and vomiting which then is followed by diarrhea.  He didn't have diarrhea just persistent abdominal pain.

He had gastritis, irritation of the stomach lining, due to alcohol abuse. Asking about his social history, he admitted to binging on a 12 pack of beers that day, a behavior, not uncommon for him.  Not only was he treated for this, he was also recommended to quit drinking.

So even experienced doctors can take a page from medical students.  It's the taking the history that matters.  Everything else we do, the physical exam, lab work, and imaging tests are tools and not the truth.

Want to know, one other time a patient lies?

When you see an otherwise healthy young man in the office who simply wants an annual check-up just to be safe.  These types of patients are as common as seeing the Loch Ness monster.

The real reason he's there?  His spouse, girlfriend, or significant other for a symptom he's been complaining about but didn't want to see a doctor.

If I don't get to that truth, guess who I'll be seeing next week?  The same patient again but with his spouse, girlfriend, or significant other.


Or he's asking about Viagra.

Why Doctors Talking to Patients is Better than Technology and Blood Work

The Associated Press ran a provocatively titled piece recently, "Family health history: 'best kept secret' in care", which noted how a geneticist at the Cleveland Clinic discovered that asking about family members and their history of breast, colon, or prostate cancer was better than simply doing genetic blood testing.

Surprising?  Hardly.  This is what all medical students are taught.  Talk to the patient.  Get a detailed history and physical.  Lab work and imaging studies are merely tools that can help support or refute a diagnosis.  They provide a piece of the puzzle, but always must be considered in the full context of a patient.  They alone do not provide the truth. 

A tool to help organize the family history can be found at the US Surgeon General's website.

The challenge is being able to have a candid conversation with a doctor as office visits seem to be shorter.  Filling out this simple one page "patient resume" may help.  Give it to your doctor, particularly if she is new to you, especially when having a general check-up.  That is a good time to have a robust discussion about what you must do to stay healthy and well.

Why is this important?  First year medical students often ask me how do they know what parts of taking a patient's history, a person's past medical history, surgical history, family history, and social history (smoking, alcohol, drug habits) can be safely skipped or ignored.  In other words, already early in their careers they want to hone down, eliminate unnecessary time and unneeded questioning to clinch the diagnosis.  They want to be good doctors.

They quickly discover that good doctors can't know a patient's problems or symptoms without understanding the whole story.  Good doctors get the complete story to get the best answer.  Trying to piece a problem together by ordering tests, blood work, or xrays won't get to the truth, even though we still fool ourselves into thinking they can.  As this news article demonstrates despite all of the advances in technology, there is still value and power in simply talking and listening to patients thoughtfully.

Boston Celtics' Kendrick Perkins Knee Injury and Doctor's Xray Vision

Boston Celtics' basketball player Kendrick Perkins injured his knee during the NBA Finals against the Lakers when he landed awkwardly. Unable to weightbear, he left Game 6 not to return for the following pivotal Game 7.

Based on his mechanism of injury and his physical examination, his trainer reported that he tore his medial collateral ligament (MCL) as well as the posterior cruciate ligament (PCL). More amazingly, this was done without the help of a MRI! Since Perkins was unable to play the final game, there was no urgent medical need to expedite the test as regardless of the result, his season was already done.

How do doctors know what is wrong without xray vision or an imaging test? (Note that Perkins did get a xray, but xrays generally don't show ligament injuries). Is it guessing?

It's our medical training. Getting the right diagnosis relies mostly on the doctor able to accurately understand what happened and what symptoms you noticed. This often gives us a good idea what is going on. Afterwards, we do a physical exam that helps us hone down the number of possibilities to the right answer.

If Perkins had been a regular person playing basketball, he would have told his doctor the following:

I was playing basketball. Jumped up. Landed awkwardly. "I knew something was wrong...I didn't know exactly what it was, but I couldn't get up on my own. I couldn't walk. My whole leg was hurting, and the back of my knee was in pain. I heard something pop, but I didn't know what it was. It was just painful."

The doctor examining the knee would have noticed swelling, decreased movement, as well as significant pain on the middle aspect of the knee as well as some give or laxity.

Given the mechanism of injury, the history, and the examination, the likely injury is a medial collateral ligament (MCL) and posterior cruciate ligament (PCL) of the knee.

Yet the public is enamored with technology. Simply talking to a patient, thinking about the problem, and using our hands to examine patients can't be as good as fancy MRI. Don't these imaging tests give us the truth? Isn't more imaging better?

Let's put the doctor diagnostic skills to the test and compare to what the MRI shows. Getting the right diagnosis did not require expensive solutions. It requires listening and examining. More isn't necessarily better, yet the public believes it.

To fight the temptation of doing tests just for the sake of doing it, find a stellar doctor. The most valuable doctor is the one that is genuinely interested in you, and avoids ordering tests, procedures, and interventions when not medically necessary. He talks to you to understand what your problem is and performs an examination.

Let see if doctors got Kendrick Perkins' diagnosis right. Perhaps we really do have xray vision.

Did you pass out? Felt dizzy? What you don't say can cost you.

A recent article in the Archives of Internal Medicine titled, "Yield of Diagnostic Tests in Evaluating Syncopal Episodes in Older Patients" found that patients 65 years and older are often given unnecessary tests to determine episodes of syncope which is defined as "sudden, transient loss of consciousness with spontaneous recovery". Researchers found that although the vast majority of patients received EKGs (99 percent) , were admitted to hospital beds with continuous heart monitoring (95 percent), and a significant number (63 percent) received CT scans of the head, these tools only provided doctors to the correct diagnosis 2% of the time. The results of these tests only changed their medical decisions about 5% of the time.

A far better tool was simply checking the patient's postural blood pressure. This means checking the blood pressure of a person laying down and standing up and noticing if there is a difference between the heart rates and blood pressures. This simple procedure which can be performed by doctors, nurses, or medical assistants resulted in diagnosing the correct cause of the syncope in 15% to 21% of cases, which is up to 10 times better than the fancy expensive tests listed previously. This simple procedure changed what doctors did in 18 to 26% of the time, which is 5 times better.

Unfortunately, this relatively simple and inexpensive procedure was only done 38% of the time.

What is particularly disturbing isn't these findings, but rather the fact that this is been known for 20 years. As the authors note:

Perhaps the finding in this study that causes the most concern is the extent to which unhelpful, and presumably unnecessary, testing in the evaluation of syncope continues to be performed despite the compelling evidence against the practice dating back 20 years. The current study complements earlier work by showing the high costs associated with this unnecessary testing. Extrapolating our results nationally, assuming approximately 460 000 hospitalizations per year for syncope, yearly costs associated with the most commonly obtained tests may be nearly $6 billion. Investigators have shown that easy availability of low-risk testing contributes to the overuse of resources. The frequency of syncope and wide availability of low-risk testing make its an important source of revenue for hospitals. Unnecessary testing is a substantial contributor to rising health care costs and has been proposed as a target for cost savings.

So what other tools might doctors use if the expensive tests don't provide clues in the vast majority of cases? It's the secret that good doctors know. It's the secret that medical students are taught even today. It's something you should know.

Getting a good history and doing a good physical exam is far better in determining which tests are the right tests to get to the right diagnosis.

Therefore in the case of syncope, be sure to try to provide your doctors all of the information you can think of. Provide them the FOUR W's, which are reviewed in my book. In brief, they are the what, the where, the when, and the why. If you don't, then it is very likely you'll have lots of tests, told that they are all normal, and you won't get an answer of what is wrong. With increasing out of pocket costs, can you afford to pay for unnecessary expensive tests especially if they don't get you the right answer in 98% of cases?

As this study shows and what good doctors know are that what you say about your symptoms are far more helpful to get the right diagnosis and right treatment than ordering a battery of tests.