What Ever Happened to a Good History?January 10, 2014
By Karen Roush, MS, RN, FNP, clinical managing editor
What ever happened to a good history? We were taught as NP students that the history portion of the exam was as important as the physical. In fact, in most cases it’s what you learn in the history—from asking the right questions and really listening to the patient’s answers—that gives you the information you need to figure out what is going on. The physical findings either support what you’re thinking or lead you to ask more specific questions.
A good history isn’t just listening to the patient’s answers to your questions; it’s listening to all the information they offer. Take for example, the middle-aged construction worker who takes his lunch hour to come in to the clinic complaining of a cold. He lists the usual symptoms, cough, fatigue, a little shortness of breath, and then as you’re starting the exam he casually mentions that he hasn’t been to a doctor in 15 years.
Someone who’s managed to stay out of a doctor’s office for 15 years and now shows up, on his lunch hour, because of a simple cold? So, you ask some more questions and learn about some chest pressure he attributes to the coughing he’s been doing and about his father’s death at 58 of a heart attack. And you realize it’s not a cough that has brought him in; it’s something more that doesn’t fit a neat checklist of symptoms. An ECG shows some nonspecific changes—nothing dramatic—but knowing what you do based on the history, you start an IV, give him an aspirin to chew, a little nitro, call an ambulance, and he’s off to the ED. Later you learn that he was immediately sent to a regional care center and into surgery for a triple bypass.
Any good NP can tell you their own version of this story. It was just something the patient said, or the way they said it, that heightened their alertness and led them to a diagnosis that could so easily have been missed.
But taking a good history is a skill that is in danger of getting lost in this age of computer checklist care. (That and eye contact, but we’ll save that for another blog post!) Two recent visits I made to clinics, one for primary care and one for urgent care, found me looking at the backs of nurses’ heads as they ran through standardized lists of questions, dutifully clicking them off a checklist on the computer. The provider at the urgent care center took a look at the answers and then proceeded, silently, with the exam. This may seem extreme, but unfortunately it or something very much like it is too often the norm.
Checklists are great for many things. They can save documentation time and remind us to do things we may otherwise overlook. But they cannot substitute for critical thinking, intuition, and an iterative approach. And they can’t substitute for letting the patient talk through their story, which is often when some very interesting details reveal themselves. I once had a patient who denied any history of early heart disease in his family. The only member of his family who’d died young was his father, who was killed in a car accident when he was 48 years old. It was only after a series of questions asked in different ways as I proceeded with the exam that he “mentioned” that his father’s accident happened when he suffered a heart attack at the wheel. In his mind, it was the car accident that killed his father; to him, the heart attack was incidental, and no checklist was going to get to that fact.