Thursday, 4 January 2007

History, History, History

History taking is the most basic and yet the most effective skill of a doctor, which relies on the skill of the physician and not the scanning machine to elucidate the problem.

However, it is whether one asks the right questions which determines whether you get the right answers from your patient and hence leading to the ultimate goal, the diagnosis.

I am always asked 'how do you take a history?'. Taking a history depends upon experience and depth of knowledge of not just medical ailments, but also the problems seen in other specialties over many years.

A first year doctor may be unable to take a goal-directed abbreviated history to attain the right diagnosis unless the doctor can recognise the pattern of symptomatology from the chief complaint(s). Junior doctors should, in any case, be taking a detailed and comprehensive history, asking not just questions related to the chief complaint, but also the other body systems in the Review Of Systems section nearing the end of their history taking, which acts as a 'Safety Net' to pick up on problems the patient may have failed to inform the doctor about.

However, as depth of knowledge and experience of medical cases in the physician's own personal mental data bank enlarges, the depth of questioning of specific symptoms becomes more accurate and hence, a specific diagnosis or at least a list of differential diagnoses should be produced from history alone.

This is something that is ignored or remains unrecognised by many junior doctors, until one day, they have the realisation as I once did, perhaps akin to Buddist Enlightenment, that there is a better way-- a time efficient and goal-directed way which leads to faster diagnosis and faster therapy and more fulfilling tea breaks !! (Sorry-- English humour!)

Physical examination should be used to confirm or refute what the doctor considers is the problem from history alone and the other tests such as laboratory data, Xrays and more detailed scanning should not be used to make the diagnosis (unless it is a rare / unusual disease and that no one has any vague idea of what is going on!!)-- it is merely a guide to confirm or refute the Clinical Diagnosis of the Physician.

Of course, there is the occasion when asymptomatic tumours or such like are picked up on CT scans or unusual anatomical phenomena are identified at which time, the latter of which, we all scratch our heads in wonder and then question why we did the scan in the first place! Don't misunderstand me, I think CT/MRI scanning is a wonderful addition to the physician's battery of tools, but it should not be abused by overuse. Such modalities should be used to fine-tune a diagnosis rather than as a screening tool.

History, in my opinion, is under-utilised by junior doctors when it can be and should be their strongest tool.

In time, I hope that my work here in Japan will provide the basis for thorough history taking and I envisage the newly trained physicians under my tuition to be less reliant on the machine and more reliant on their intellect and clinical accumen.