HISTORY TAKING AND GENERAL EXAMINATION

HISTORY TAKING AND GENERAL EXAMINATION 1 History taking TALKING WITH PATIENTS People visit doctors for many reasons. Sometimes it is because something unexpected and catastrophic has happened to them, but usually it is because of an ongoing problem, a relatively minor complaint or because something 'isn't right'. Before coming to the doctor they may have spoken to family or friends, tried remedies suggested by them, spoken to other health professionals, e.g. pharmacists, or complementary practitioners, or may have found information on the internet and brought this with them. Their decision to go to a doctor may only have been made after these attempts to explain or heal their illness or problem have been unsuccessful. By the time they have reached a doctor most patients have formed some idea of what might be wrong with them and will have worries or concerns that they need to talk about. The general practitioner (GP) or family doctor is usually the first point of contact. Even a straightforward visit can be a big event for patients. They have to decide to go, usually make an appointment, work out what they are going to say and may have to arrange time off work or for child care. They then have to sit in a waiting room. This is an almost universal human experience; think about how it affected you the last time you had to do this. Things can become even more perplexing if the visit is to a hospital outpatient department or part of a hospital admission when their anxiety and apprehension can get worse as this is where 'serious' things happen. Whatever the cause, patients are seeking explanation and meaning for their symptoms. Whatever the setting, the doctor needs to try to work out why patients are there, what they are most concerned about and to agree with them the best course of action. The first and major part of that is talking with the patient  .If you listen carefully they will probably tell you what is wrong with them, will certainly tell you what is concerning them, and the physical examination will help you to confirm this or not. Communication is integral to the clinical examination and is most important at the beginning to gather information, and at the end to share information and engage your patients in their management. Table 1-1. Effective communication skills positively influence health outcomes Active listening helps the doctor recognize what is wrong Patient satisfaction is improved if patients understand what is wrong and what they can do to help When a doctor and patient agree on mutual goals health outcomes are improved Positive support and empathy improve health outcomes and enhance the relationship between the doctor and the patient Medicine taking is improved by clear information about what a medicine is meant to do Patient participation Good communication is essential in good patient care; it supports the building of trust between doctor and patient and helps you provide clear and simple information that improves health. This allows you and the patient to understand each other and agree goals together which suit each individual patient. Communication is much more than 'taking a history', it is an integral and important part of looking after patients and is the only way they can be involved effectively in their health care. Poor communication leads to misunderstanding, conflicting messages and patient dissatisfaction and is the root cause of many subsequent complaints and litigation. Beginning That all sounds very well but how do you do it?   Our personal experience of illness is unique and often difficult or embarrassing to explain. To make this easier for your patient consider the following. Where will you see your patient? Table 1-2. BLISS: the stages of the consultation Beginning Preparation Setting Introductions Listening Problems Ideas Concerns Expectations Clarify, summarize, context Information gathering Systematic enquiry Clinical examination Sharing information Chunk it Check it Share decisions Setting goals Ending Follow-up Ideally in a quiet, private space. This is usually easy in a GP surgery, but often difficult in hospital. In hospital outpatient departments nurses or students are often present, and in hospital wards privacy is often only afforded by curtains - which means no privacy at all. You must be sensitive to your patients' privacy and dignity in all circumstances. If you are seeing the patient in a room and have others with you, for example junior colleagues, introduce them and ask permission for them to be there. If your patient is in a hospital bed but can get up, a side room or interview room may be used. Often there is no alternative to speaking to patients at their bedside, so let them know that you understand that your conversation may be overheard and give them permission not to answer sensitive things if they feel too uncomfortable about it. How long will you have? Consultation length varies. In general practice in the UK the average length is 10 minutes. This is usually adequate as the doctor may have seen the patient on several occasions and know the family and social background. In hospital 5-10 minutes may be adequate for return outpatients, but for new and complex problems much longer - 20-30 minutes - may be needed. If you are a student learning to talk with and examine patients allow 30 minutes at least. Plan your time around how long you expect your patients to take so that others are not kept waiting, and be prepared to be flexible. How will you sit? Arrange the seating in a non-confrontational way. If you use a desk, arrange the seats at the corner of the desk. This is less formal and helps communication .If you use a computer make sure the screen and keyboard do not get in the way or provide a distraction. Turn away from the screen to talk to your patient. If you are in a ward, pull up a chair and sit level with your patient. It is important that you can see your patient easily and gain eye contact. Non-verbal communication First impressions are important. Your demeanour, attitude and dress influence your patient from the outset. At all times you need to be professional in dress and behaviour. This does not mean you need to be formal, but you must be neat, clean and polite. Showing concern for your patient's situation is important. Pick up non-verbal cues from your patients. Are they distressed? What is their mood like and how do their demeanour and body language change during the consultation? This gives clues to difficulties they are having that they cannot express verbally. If people are getting uncomfortable during a line of questioning their body language may become 'closed', i.e. they may cross their arms and legs and fail to keep eye contact. Starting the consultation Figure 1.1 Seating arrangements. (A) The desk as a defence mechanism. (B) A more appropriate arrangement of doctor and patient designed to put the patient at ease. (C) Appropriate arrangement of doctor and patient for a bedside interview. Before starting, make sure you are talking to the correct patient. Introduce yourself, as your patients should know who you are and what you do. If you are in training, tell them, as patients are usually eager to help. It helps to create a good impression if you appear to have prepared to see them. Look at the patient records and at any transfer or admission letters before the consultation. It is easier to give your patient your attention if you do not write notes during the consultation, but you may have to write some things, e.g. blood pressure readings or family trees, which are easily forgotten. If you are going to take notes let your patient know. Throughout this part of the chapter there are examples of a doctor and a patient talking with each other. These are only illustrations, not hard and fast rules. Remember that it is the principles of communication that are important. If you get the principles right, then the words you use will change depending on the situation. To begin with, here are a few ideas on how to get an interview going. Good morning Mrs Jones, I have got the right person haven't I? I am Mr Brown. I am a fourth year medical student. I've been asked if I could come and talk to you and examine you as you have just come into the ward today. Is that OK? It might take me 20-30 minutes if that is alright with you. I would like you to tell me what has been happening and then I'll want to ask a few questions and examine you. I see that you can't really get out of bed so I am afraid we'll need to talk here. I'll pull the screens round, but I'm sorry it is not that private, so if I ask you anything that you don't want to tell me in case others hear then just say so. Because I'll have to get quite a bit of information from you, I'll need to make a few notes. I hope that is alright because I'll forget otherwise. Now if I am writing things down it doesn't mean I'm not listening to you, I still will be. Are you happy with all that? Listening The patient's own story is vital. Ask patients to tell you what has happened to bring them into the hospital, or, if in the community, try 'How can I help you today?' or 'What has brought you along to see me today?' Patients know doctors are busy and most will tell you their problem within 1-2 minutes so do not interrupt. This first stage is 'active listening'. This means encouraging patients to talk by looking interested, making encouraging comments or noises, e.g. 'tell me a bit more' or 'uhuh', and giving them the impression that you have time for them. Active listening is used to gather information. Also, it allows them to tell their story in their own words. This might not make complete sense to you, so you may have to ask for 'clarification'. To do this ask them to explain a bit more about their symptoms. You can also tell them what you think they have said and ask if your interpretation is correct. Can we start with you telling me what has happened to bring you into hospital? (Opening) Well doctor, I have been getting this funny feeling in my chest over the last few months. It's been getting worse and worse till it got to the point today I had to call my GP and he sent me in. It was really awful this morning, I got really breathless and felt someone was standing on me. Tell me a bit more about the feeling in your chest. (Open questioning) Well it was here, across my chest, it was sort of tight and I was sweaty. And did it go anywhere else? (Clarifying) No, well maybe up here in my neck a bit. So what you are saying is that you had this pain in your chest this morning that went on a long time - how long do you think? (Summarizing and clarifying) Oh, a couple of hours. And the pain was tight and up into your neck. How is it now? (Open questioning) Oh it is not bad, the injections I had seem to have put it away. OK, now you said that you had had the pain for the last few months. Can you tell me more about that? (Open questioning) Well it was the same but not that bad, though it has been getting worse recently. OK, can you remember when it first started? (Clarifying) Oh 3 or 4 months ago. And how often has it been coming? (Open questioning) To start with just now and again, but in the last 2 to 3 weeks, probably every day anyway. Does anything makes it worse? (Open questioning) Well if I go up steps or up hills that can bring it on. What do you do? Stop and sometimes take my puffer. Your what? (Clarifying) This spray the doctor gave me to put in my mouth. Can you show me it please? OK. And what does it do? (Clarifying) Well it takes the pain away, but I get an awful headache with it. OK, so for a few months you have had this tightness in your chest, which gets worse on going up hills and upstairs and which goes away if you use your spray. But today it came on and lasted a couple of hours but felt the same. Have I got that right? (Summarizing) No, it was much worse this morning. Once you have established what has happened, find out the patient's 'ideas', 'concerns' and 'expectations'. I Ideas C Concerns E Expectations. Patients will have thoughts and feelings about what has happened to them which may or may not be accurate, but which can help you. For instance, a patient with chest pain might think he has indigestion while you are considering angina. This can cause confusion so ask 'Do you have any thoughts about what might be happening to you?' A young mother bringing her child to the doctor with a sore throat may only want reassurance, not medicine. A simple question like 'What were you thinking I might do today?' can get surprising answers and avoid unnecessary prescriptions or investigations. The way you ask a question is important. Open questions encourage the patient to talk. Closed questions seek specific information as part of a systematic inquiry. Both have their place. Open questions usually start with a word like 'where' or 'what', or a phrase like 'tell me more about …', and are more useful at the beginning when you are trying to find out what is going on and to encourage the patient to talk. Closed questions, e.g. 'Have you been sick today?' invite yes or no answers. Exploring your patient's context Illness never happens in isolation. The context of our lives has a major influence on how we deal with illness. This can be complex, and finding out the context is a crucial part of gathering information about your patient. Many people call it the 'social history', but it is more than this. It allows you to understand the personal constraints and supports available to your patient. Your patient's context is a mixture of where they live, who they live with, where they work, who they work with, what they actually do, their cultural and religious beliefs and their relationships and past experience. These are sensitive areas to explore. It may not be appropriate to explore all of them with everyone, but they are important in any long-term doctor-patient relationship. Understanding context modifies the information you give and the way you give it, the treatment you advise and the drugs you use. Establish your patient's job, and explore in some depth what this job entails as it may have a bearing on the illness. This means you need to find out in detail not only what the job is, but what the patient actually does, whether there are any stresses in the job and whether there are any relationships at work that might affect the patient, e.g. a bullying boss or a harassing colleague. Doctor: So tell me what your job is. Patient: I work on a farm. Doctor: Yes - but what do you actually do? Patient A: Well I own the farm and mostly do the bookwork and buying and selling of animals. Patient B: I am a labourer on the farm. Doctor: So what are you doing at the moment? Patient A: It has been a terrible year with the drought, the yields are down and I am trying to get another loan from the bank manager. Patient B: Well just now we are working in the barn first thing in the mornings cleaning up and then laying feed for the cattle. After that we are in the fields doing the early ploughing. Doctor: So when you are laying the feed, what are you doing? Patient B: We are unrolling last summer's hay bales. Doctor: So what does that mean? Patient B: Well we roll them out with the tractor and then spread it out for the cattle a bit with a fork. Doctor: Is there much dust? Patient B: Oh yes, it creates a real dust and it is very mouldy this year. Clearly, one job description can cover many tasks and you need to understand what your patient actually does. Patient A is under stress and patient B may be suffering the consequences of exposure to fungal spores which can cause farmer's lung. However, their initial answer to the first question was the same. Just as your patients' illness can have an influence on their ability to do their job, their job (past or present) may be an influence on their illness. A full occupational history means your patients should tell you what jobs they have done in their working life. Try to find out if any of those could have had an influence on their symptoms . Find out about their home circumstances. Relationships in modern society are complex, so choose your words carefully; for example 'Is there anyone at home with you?' or 'Is there anyone that can help?' are useful ways of finding out diplomatically. You need to be equally tactful in enquiring about relationships and the home environment. For example, if a 15-year-old newly diagnosed diabetic is about to go home you need to know the home circumstances, who is there and whether the relationships are supportive. Different arrangements are made for a patient whose mother is a health worker in a stable home, compared to one from a deprived background, with one parent and poor relationships. The decision to return to work depends on the content of the job, the sympathy and support of the employer and the patient's financial situation. Patients' beliefs influence health care. Religious beliefs affect how a family copes with a disability, a dying relative, or whether some people accept certain treatments, and you need to be sensitive to and tolerant of these issues. Other moral beliefs need to be explored in some situations, e.g. requests for termination of pregnancy. Now gather information in a more systematic way to clarify any issues and focus on the actual problems. Do this through a detailed systematic inquiry and clinical examination of your patient. Once you have gathered that information you reach the most important part of the consultation, which is when you share your findings with your patient. Sharing information Clarifying and summarizing Use the same techniques as at the beginning of your consultation, except now your patient needs to understand your use of words. Clarify and summarize what you say. Set realistic goals to achieve together. Your use of language is vital and you should use words that your patient understands. Tailor your explanation to your patient; you would use very different terms when dealing with a lawyer compared to dealing with a farm labourer. First explain what you have found and what you think this means. Give important information first and check what has been understood. Put the information into small chunks and warn the patient how many important things are coming. For example 'There are two important things I want to discuss with you, the first is …'. Use simple language, if you have to use a term like 'cancer', spend time ensuring your patient understands the treatment options and likely prognosis. If the news is bad, ensure you have time for patients to let the news sink in. Suggest they have a friend or relative with them if they wish. Go at your patients' pace and do not give more information than they want or can handle at any one time. Hearing bad news often blocks patients' ability to retain any further information so you should arrange follow-up to discuss all their further questions. Some doctors try to avoid using emotive terms, e.g. cancer, but if you need to give bad news it should be accurate, unambiguous, and given sensitively. There is no place for being abrupt or for brutal honesty. Most people understand the word 'cancer', but 'tumour' can be interpreted in many ways. Enabling Table 1-3. Talking with patients Speak clearly and audibly Do not use jargon Do not use unnecessarily emotive words Give the important information first in small amounts 'Chunk it' Check what has been understood Negotiate a shared decision Set goals Summarize Make sure that your patients are involved in any decisions; this is called enabling. Share your own ideas with them, make suggestions and encourage them to contribute their thoughts. Help their decision making by giving written information to take home or suggest other sources of information, e.g. self-help groups or the internet. Check they have understood you and discuss any investigations or treatment you think might be needed, including any risks or side-effects. In this way negotiate a mutually agreeable plan. For example a patient with cancer may have the choice of surgery or radiotherapy, each of which has different risks and side-effects. It may not be easy to decide, but by involving your patients and discussing with them the pros and cons of treatments you will reach a decision that they understand and agree with. They have to live with the consequences of the treatment, and it is much easier for them to accept if they have had a hand in choosing. Setting goals Setting goals allows you and your patient to agree on what you are trying to achieve. These might be areas that your patient needs to work on. For example if patients are trying to stop smoking then you may set goals with them about when they are going to stop, what help they will use, e.g. support groups or nicotine replacement therapy or both, how they will identify risky situations, e.g. socializing, and how to handle these in an effort to avoid being tempted to have a cigarette. Goals should follow the SMART principle: S Specific M Measurable A Achievable R Relevant T Time related. Outcomes that might be agreed are that you provide discussion of the problem, advice, or reassurance, or that you may advise referral, investigation, or drug treatment. Finally, you need to arrange for follow-up if necessary, or give patients some idea as to when they might want to return. This depends on how they are feeling and the effects of any treatment you have suggested. End a complex discussion by very briefly summarizing what you have agreed, or ask your patient to summarize for you. Situations which influence communication Transference/countertransference Transference is the process where your patient unconsciously projects on to you thoughts, behaviours and emotional reactions that originate with other significant relationships from childhood onwards. For example, people who are very ill or have just been given some news about a specific diagnosis, the implications of which are overwhelming, may behave in uncharacteristic ways. They might return to a position of dependency and may seek care and comfort that was absent in their past. If you do not provide this, patients may get very angry. These are difficult concepts, but have a major part to play in any doctor-patient relationship. You cannot avoid transference because it is an unconscious process, but be aware that it is happening. Recognizing transference helps you to understand unexpected behaviour and to continue to provide care for your patient. Transference can be used positively, to enhance your communication with your patient. Many medical students have had a patient say 'Oh you are just like my son/daughter'. Countertransference is where the doctor responds to patients in a way similar to significant past relationships. For example the repeated failure to listen to a patient's stories of failed relationships may echo experiences in a doctor's own life. The signs of countertransference are not listening, misjudging your patient's feelings, repeatedly going over the same story and always running late with the same patient. Self-awareness is the most important way to deal with these issues, which arise at some stage for all doctors. Empathy If your patients see you as an empathic doctor it will help your relationship with them, and improve their health outcomes. What is empathy and how do you express it? Empathy is not sympathy, the expression of sorrow; it is much more. It is helping your patients feel that you understand what they are going through. Try to see the problem from their point of view and relate that to them. For example, consider a young teacher who has recently had disfiguring facial surgery to remove a benign tumour from her upper jaw. She has recovered in terms of wound healing, but now has a drooping lower eyelid, and significant facial swelling. She returns to work. Think how you would feel and imagine yourself in this situation. You can express empathy by sensitive questions which show you can relate to your patient's experience. … So you have all healed up from your operation now? Yes - but I still have to put drops in my eye. And what about the swelling under your eye? That gets worse during the day, and sometimes by afternoon I can't see that well. And how does that feel at work? Well it is really difficult, you know the kids and everything, it is all a bit awkward. I can understand that that must make you feel pretty uncomfortable and awkward - that must be very difficult. How do you cope? Thinking about that makes me wonder if there are any other areas that are awkward for you, maybe in the other bits of your life, like the social side …. Sensitive situations Doctors have to explore questions of a personal or sensitive nature, or have to examine intimate parts. These need time and care. Because of what you are telling me I need to ask you some rather personal questions, is that OK? Can you tell me if you have had any casual relationships recently? Are you worried that you might have picked anything up, I mean in a sexual way? Having told me that you think you are at risk of something, can I ask if you have a regular sexual partner? Follow this up with 'Is your partner male or female?' If there is no regular partner ask how many sexual partners there have been in the past year and how many have been male and how many female. So I need to examine you down below since that seems to be where the problem is. I will need to examine you with my hands, I'll have gloves on. I will also need to look at you down below through a small instrument. Is that OK? It would be helpful if we had a chaperone who can help us. Would that be OK? So while I fetch her could you get undressed behind the screens and I'll examine you once you are ready? If you are talking to a patient who you think may have a sexually transmitted disease, you need to be very sensitive in broaching this subject. First give some indication that you are going to ask questions in this area, and make sure the conversation is entirely private. Here are some examples of questions that might work. Use the same sensitivity to seek permission to examine intimate areas. First warn your patients, then seek their permission to examine them and explain what you need to do. Offer a chaperone, and record in the notes if they do not wish this. You also need to give your patients clear instructions about what clothes they need to remove. There may be times when it is appropriate to delay an intimate examination until sufficient time, appropriate facilities or a chaperone is available. Difficult situations Breaking bad news is one of the most difficult communication tasks you will face. Always speak to the patient in a quiet and private environment, ideally, if the patient agrees, in the presence of a relative or partner and if possible with a nurse or counsellor. Be honest. Do not tell your patients anything that is not true; the truth always emerges over time. Your patients may only wish to know some things, and they may appear not to hear or retain what you tell them. This is called denial and is a normal defence mechanism. Go at your patients' pace; find out how much more they want to know and continually check their understanding. They will need time to reflect on what you have said and may need to return to see you at another time. They might ask for a prognosis: 'How long have I got?' is a common question. Take care with this and never give a specific time - you will usually be wrong. Even in the most difficult circumstances do not take away hope. There is always something that can be done for a patient. Dealing with emotions At some point you will encounter angry or distressed patients and relatives who may be crying inconsolably. You may also encounter talkative or over-familiar patients. Illness can bring anger and frustration. Getting angry yourself or ignoring their anger does not help. If you feel angry with your patients, it is likely that they feel angry themselves. Exploring the reasons for this often defuses the situation. Do this by recognizing that your patients are angry and asking them to explain why. If an apology is needed, give it; it may defuse the situation. Use such phrases as, 'you seem angry about something' or 'is there something that is upsetting you?' Similarly with other emotions follow the same basic guidance. Recognize the emotion, show empathy and understanding, encourage your patient to talk and offer what explanations you can. If your patients are too talkative, or where they want to deal with too many things, you have to sometimes lead with statements: 'Now I only have a short time left with you, so what is the most important thing we need to deal with now.' If they have a long list of complaints suggest: 'Well of the six things you have brought today I can only deal with two, so which are the most important to you and we will deal with the rest next time.' It is important to set professional boundaries if your patient becomes over-familiar: 'Well it would be inappropriate for me to discuss personal issues with you. I am here to help you so let's focus on your problem.' Patients who are too ill to talk or who are confused If your patient is very ill, confused or mentally ill, or impaired for whatever reason, obtain what information you can from third parties. Rapidly assess the situation, treat your patient, and review everything when your patient is fit enough . Table 1-4. Transcultural awareness Appropriateness of eye contact Appropriateness of hand gestures Personal space Physical contact between sexes (e.g. shaking hands) Cultures and beliefs surrounding illness What should happen as death approaches? What should happen after death? Communication difficulties When you see patients who cannot speak your language, are deaf or who have expressive problems, e.g. dysphasia, dysarthria or stammering, try to establish some method of communication. This may need an interpreter. Writing things down, lip reading, sign language or someone who is used to communicating with your patient often helps. Transcultural issues Be sensitive when dealing with someone from a culture different from your own .The use of eye contact, touching and personal space is different in different cultures. In western, and North American cultures, holding eye contact for long periods is normal; in most of the rest of the world this is seen as confrontational or rude. In some cultures it is normal to shake hands between opposite sexes, but this is strictly forbidden in others. Understand and accept differences in your patients' cultures and beliefs and be aware of them. When in doubt ask the patients, this lets them know that you are aware of and sensitive to these issues. Third party information You may need to obtain information about your patient from someone else, usually a relative and sometimes a friend or carer. Ideally obtain your patient's permission and have the patient present. In this way confidentiality is not breached. You may be approached by third parties without your patient's knowledge. Find out who they are, their relationship to your patient, and whether your patient knows they are talking to you. Ensure that third parties understand that you can only listen to what they have to say and cannot divulge any of your clinical information about your patient. They may tell you about sensitive matters, e.g. mental illness, sexual abuse, drug or alcohol addiction. This information needs to be explored with your patients sensitively, as only they will be able to confirm the truth and agree to treatment. In all circumstances confidentiality of your patients' information is your first priority. Read Good Medical Practice published by the General Medical Council, which describes the standards of competence, care and conduct expected of you in all aspects of your professional work.