The Q-Wave: July 2018

One of the things I love about podcasts, blogs and newsletters is that I can share information I feel is really important. Especially, important information that I feel is overlooked. In patient care, taking a medical history is the great art of medicine; it really is. Some people might think it is the physical exam but I believe the history taking is what really separates an extraordinary clinician from a weaker clinician.

I ask you this question right now, how good are you at taking a medical history? Do you feel that you could improve at all at that? I don’t care if you’re a new graduate or you’ve been in practice for 30, 40, 50 years. How good are you at your history? How refined is your skill set? Could you learn anything new?

Something that I teach often at conferences is that the most common reason a medication doesn’t work is non-compliance. If you say to a patient, “Hey, you taking your medicine?” They say, “Yes.” How sure are you that they’re really taking their medicine? Is it possible they’re being deceptive? Of course it is.

If you’ve been in medicine any period of time, you know that for some people, deception is part of their language. They don’t want you to judge them for not taking the medicine that you prescribed. That’s important, so I teach providers to assume patients aren’t taking their medicine. Ask this question instead: “How often do you miss taking your medication? Once, twice a week? How often do you forget to take your anti-hypertensive medicine?” If they say, “Well, yeah, once or twice a week I forget.” That means they’re never taking it. If they say, “No, no, I take it every single day.” Well you know that’s legit; they’re taking it every single day.

My goal here is that you get some pearls and tools on how to take an extraordinary history. I don’t care if you’re a beginner or a veteran. You can still teach an old dog new tricks. I’m always open to learning.

Step 1: Look at the Big Picture

Step one is a pre-interview phase. “What does that mean, John; what’s the pre-interview phase?” You want to watch the patient walk and talk to family and friends. If it’s a parent, watch how they engage with their child. If it’s a geriatric patient and their daughter is in the room, you want to see how they engage with each other. I think it’s really important to look at old charts and old visits. Avoid going into a room blindly. Actually, be very, very careful about walking into a room blindly.

I had the privilege of hearing a guy named Eric Maddox speak; he wrote a book called Finding Saddam. He was a Delta Force interrogator that ended up getting the intelligence to find Saddam Hussein.

I even had the privilege of going to breakfast with him the morning after his talk. Now, he works in divorce cases, and mergers and acquisitions to get information out of other people, because that’s kind of what he did. He talked a lot about the pre-interview phase, before he goes into a negotiation. He tries to find as much information about the deal as he can before he walks in.

That’s why old charts, old visits, med records and their medications are really important.

Step 2: Look at Yourself

Self-reflection is a continuous part of the professional development process in clinical practice. You have to constantly look at yourself and say, “How good am I at getting the history?”

Step 3: Look at the Patient as an Individual

Hippocrates said, “It is far more important to know what person the disease has than what disease the person has.” What is he really saying? You want to know a patient’s will to be well. I believe very strongly that every disease has a psychiatric component to it. “What do you mean by that, John?” Three people have exactly the same musculoskeletal back injury. Well, if it’s a surgeon, he’s going to respond differently than if it’s a nurse’s aide. And they both are going to respond differently than a fireman.

We all have different attachments to our diseases. We want to know a patient’s will to be well. I found that very important in clinical practice with patients I classify as a “complaining non-complainer.” A complaining non-complainer is not a frequent flyer; they’re the opposite of it. They’re someone who never comes to the emergency room. It’s the Amish guy who comes in with a headache. You better take that very seriously.

When you look at a patient, you want to look at their cognitive ability and their validity. This means their cognoscibility, or their mental ability to recall information. If they have dementia, they may not be able to recall. Remember that accuracy is precision. How precise are they with their information? Do you rank them as a good historian or poor historian? That should be documented in the chart. Remember validity is the truth of the information. Can you validate what they’re telling you with old records or pharmacy records?

I had a young guy that came in one time and my colleague had seen him a couple days before. He had just come into town and was a hospice patient for some kind of cancer but I don’t remember which. He was out of his pain medications, a really strong pain medication for this hospice-like pain, this malignancy-like pain. So my colleague gave him a bunch of meds at a higher dose than normal. Then when he came in to me, he said, “Oh, I need more medication.”

He showed me some medical records and all of his medical records were very subjective. He told them that he had it, but they never diagnosed it. So, all of a sudden, I can’t validate what he’s saying. I tell him, “I’m not giving you anything until I can validate what’s going on. Even then, I may refer you to pain control.” Bottom line is they could not provide any valid bit of documentation or refer me to anybody who had valid documentation. I was very convinced that he was malingering and trying to be manipulative.

Deception. How do we know if someone’s lying? Based on Dr. Glass’s The Body Language of Liars, here are some things that we should look for:

• They quickly change their head position.
• They stand very still or they shuffle their feet.
• They touch or cover their mouths, or instinctively cover vulnerable body parts.
• They tend to point a lot.
• They stare at you without blinking much, or rapidly blink.

We’re looking for extremes. It’s kind of like a fever, looking at someone’s temperature. They’re febrile and that tells me infection. If they’re at the opposite extreme, hypothermic, that also tells me infection. Liars also provide verbal cues. They repeat words or phrases. They over-provide detail. It becomes difficult for them to speak at times, like they can’t find the words, or they’re searching for words.

“And why would people be deceptive in the first place, John? Why do people even try to deceive you?” Well, it could just be they’re attention seeking. It could be that they want drugs, something they’re possibly addicted to. It could be a work or school excuse. It could be some medical legal issue. It could be because a risky behavior got them sick and they don’t want to come clean about that.

Step 4: Be Likable

It’s important to be likable to get a good history. It’s important that the patient likes you and does not feel judged by you. They are much more transparent in what they say. In Robert Cialdini’s book Influence, there are six triggers of influence. One of those triggers of influence is likability. There are five major components to likability.

1. Compliments: As often as you can, compliment the patient.
2. Attractiveness: If you are considered attractive by another person, you’ll be more influential.
3. Similarity: If you have something in common with them, they want to tell you more because they like you.
4. Cooperation: If you can be on their team, and say, “Hey, I’m here for you without judgment,” they’re going to be prone to give you more valid information.
5. Association: If you happen to be associated with something they’re associated with, you will like them more. I like the Buffalo Bills and if you like the Buffalo Bills, I’m going to like you more.

Embracing the ability to be likable will help you to get a better history.

Step 5: Ask Open-Ended Questions

Make sure you ask open-ended questions, right at the end. “Is there anything more you want to tell me?” Now, I initially start the conversation and the history with, “Why did you come to the emergency room today?” I used to say, “What brought you to the emergency room today?” Then people would say things like, “Oh, an ambulance.” Or, “My dad drove me.” I realized I was clearly not asking a very good question. So now I say, “Why did you come to the ER today, and how can I help you?”

COLDERR FAST is a mnemonic I teach in my emergency medicine course. It’s very basic, but this is where you start getting information.

• Character
• Onset
• Location
• Duration
• Exacerbation
• Relief
• Remedies
• Frequency
• Associated symptoms
• Same symptoms in the past
• Treatment for those same diseases in the past

This is where I start, and this is your basic HPI. I initially start with an open-ended question, then I get into more particulars. This is where I really want to sheep dog the conversation. If you ask too many open-ended questions, patients can ramble too much. So once they tell me they’re there for chest pain, I say, “Describe the chest pain for me. Is it sharp, dull, crampy or pressure?” I’ll give them four choices and steer the conversation so I can be more efficient and get the information that I need.

Tip: Give clarifying options that help put the patient into a disease category. I know sometimes that’s easier than others, especially depending on the disease state.

Character. For character, the 1 to 10 scale is fine; it’s what we optimally use. “On a scale from 1 to 10, tell me how bad the pain is.” It’s very easy for people to say 10 while they’re texting on their phone and eating Cheetos. That really came from the Joint Commission’s mandatory direction that we have to address pain. Part of the reason we got into this pain opiate issue was how we dealt with this pain onset.

Onset. Is it gradual or acute? Is it exertional or rest? Ask, “What were you doing when this happened?” That is very, very important. Especially acute versus gradual. If you don’t get anything else from this bit of information, understand what I’m going to say here. This is key.

Acute onset is like a balloon popping. If I pop a balloon, it comes on very acutely. If it doesn’t come on that way, it’s a gradual onset. Way too many patients will say, “Oh, it came on really acutely.” It’s not what we mean and it’s not what documentation of acute really means. Acute means something happened very abruptly and very suddenly.

The mnemonic I teach is BEST. These are the pain patterns that normally come on very acutely.

• B is a burst, so something burst like a subarachnoid hemorrhage or a thoracic dissection.
• E is an emboli, like a stroke, or a lot of times a PE or embolic phenomena to the belly. If someone has atrial fibrillation, they flick an emboli to their belly, they’ll have a very acute onset of belly pain.
• S is a stone, so when a kidney stone or gallstone pops into a duct, it’s an acute onset of pain.
• T is twisting, that would be of the ovary or the testicle. It comes on very acutely. I could say telescoping for T, because intussusception comes on very acutely as well.

Anytime someone has exertional symptoms, you have to think it’s ischemic in nature, or something going on with the heart. That’s really important to consider.

Location. Try and be as exact as possible. Have them point and be very precise.

Duration. How long has it been going on? Has it been constant or intermittent?

Relief. What makes it better and what makes it worse?

Remedies. What have you tried? Why did you not try Motrin?

Frequency. How often to do you get this?

Associated symptoms. What else is going on? Fever, chills, nausea, vomiting, diarrhea, constipation. With chest pain, DRIVE is an important mnemonic that’s literature based and includes the four high-risk features of chest pain.

• Diaphoresis is a very important part of the history because there are two types of sweating. Part one of sweating is where they just get a little bit glossed over. That’s no big deal. Diaphoresis is beads of sweat running down their face. It’s like someone was playing half a basketball game in 90-degree weather, where sweat is dripping off of them. If someone had chest pain and diaphoresis, that is a life-threatening problem. You have to be very mindful of that.
• Radiation. Did the pain go anywhere? You have to document that.
• I is a filler letter saying, “I’m not going to get burned.” DRIVE is the mnemonic but I is a filler letter.
• Vomiting and nausea.
• Exertion. Did it come on while they were exerting themselves?

Same symptoms in the past. Well, what happened then? When the patient had these symptoms in the past, what happened?

Treatment in the past. What was the treatment in the past?

Pertinent negative symptoms are very important. What they don’t have is just as important as what they do have. You have to document your pertinent negatives. In assessing for a PE, hemoptysis is important to document with some chest pain. However, no leg symptoms such as swelling or pain is also an important pertinent negative.

The big finish is, “Is there anything more you want to tell me that I didn’t ask?” It is important and a lot of times will get right to the bottom of what they are really there for. They may talk about the pain medication, the note for work, or “Hey, I was supposed to be in court today.”

I’ll never forget this case I had. A guy came in with an eye complaint, but I couldn’t put my finger on it. I had no idea what was going on with this eye. He had a completely normal exam but I was burned once by an eye, so I think I’m a little paranoid by eye complaints. I’m getting almost paranoid that I’m missing something, then I finally said, “I don’t know what’s going on.”

I said, “Maybe it’s a corneal abrasion that I can’t quite see, let’s refer you to a doctor.” As he was leaving, he mentioned he had Aflac insurance. When he gets injured, he gets paid money. And I think, “Oh, that’s why he is here, he wants a paycheck.” It just didn’t make any sense to me, until that last bit of information.

It was so funny. About six months to a year later, I told a student about the motivation of the patient to get this paycheck. That patient came in that exact same day, with the exact same complaint. It’s crazy how things work.

My hope is that this information is helpful to you. My hope is that you’re able to take points and immediately apply them in clinical practice. Thanks for being a part of this body of information on the history. Stay tuned for next month’s newsletter.