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The art of history takingConsultation skillsWhat questions?SummarisingSharing understandingConclusionReferences

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. Theyare designed for health professionals to use, so you may find the language more technical than the condition leaflets.

This page has been archived. It has not been updated since 20/04/2011. External links and references may no longerwork.

The art of history taking



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It is widely taught that diagnosis is revealed in the patient's history. 'Listen to your patient they are telling you thediagnosis' is a much quoted aphorism.[1]

The basis of a true history is good communication between doctor and patient. The patient may not be looking for adiagnosis when giving their history and the doctor's search for one under such circumstances is likely to be fruitless.The patient's problem, whether it has a medical diagnosis attached or not, needs to be identified.

It is important for doctors to acquire good consultation skills which go beyond prescriptive history taking learned aspart of the comprehensive and systematic clerking process outlined in textbooks. A good history is one which revealsthe patient's ideas, concerns and expectations as well as any accompanying diagnosis. The doctor's agenda,incorporating lists of detailed questions, should not dominate the history taking. Listening is at the heart of good historytaking. Without the patient's perspective the history is likely to be much less revealing and less useful to the doctor whois attempting to help the patient.

Often the history alone does reveal a diagnosis. Sometimes it is all that is required to make the diagnosis. A goodexample is with the complaint of headache where the diagnosis can be made from the description of the headache andperhaps some further questions. For example, in cluster headache the history is very characteristic and reveals thediagnosis without the need for examination or investigations.

To get a true, representative account of what is troubling a patient, and how it has evolved over time, is not an easytask. It takes practice, patience, understanding and concentration. The history is a sharing of experience between patientand doctor. A consultation can allow a patient to unburden himself or herself. They may be upset about their conditionor with the frustrations of life and it is important to allow patients to give vent to these feelings. The importance of thelament, and how it may be transformed from the grumbles of a heartsink patient, to a useful diagnostic and therapeutictool for both patient and physician, has been discussed in an excellent paper.[2]

Consultation skillsThe skills required to get the patient's true story can be learned and go beyond knowingwhat questions to ask. Indeed 'questions' may need to be avoided, as they limit the patientto 'answers'. There is a lot written about consultation skills and different models ofconsulting. These have been developed through consultation analysis and now form animportant part of undergraduate medical training and GP training in the Curriculum forSpeciality Training for General Practice. There are many examples of aspects ofconsulting which may assist history taking for doctors working with patients in allspecialties.

Setting

The layout of the consulting room can assist good consulting. It can facilitateestablishing rapport with patients by, for example, allowing for good eye contact,enabling easy access to computers or notes and avoiding 'distance' between thedoctor and patient.Take care with the opening greeting as this can set the scene for what follows. Itmay assist or inhibit rapport. Generally, it helps to be warm and welcoming so asto put the patient at ease. Good eye contact, shaking hands with the patient and showing an active interest in thepatient should help to establish trust and encourage honest and open communication.Take care not to let the computer intrude on the consultation. This can be difficult when there is usefulinformation available on a screen. Make use of the time before and after consultations to get information from thecomputer.

Listen first and listen second

Let the patient tell you the story they have been storing up for you. This can be encouraged by active listening.



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This implies that the doctor is seen to be interested and attentive by the patient.Give the patient a chance to tell you their pre-constructed narrative, rather than diving in with a series ofquestions to delineate detail (such as the exact frequency and colour of their diarrhoea). This approach affords abetter chance of getting a true 'flavour' of their experience of an illness, its temporal development, and therelative importance to the sufferer of the symptoms that they have (which ultimately is what, from theirviewpoint, you'll be attempting to cure, not 'the diagnosis', about which most patients do not really care).It is important to be able to ask discriminating, delineating questions about particular symptoms to verify theiractual nature and give enough information to support the process of reaching a diagnosis; however, timing iseverything. Get down a record of each of the major symptoms in the order that they are presented to you by thepatient. Then go back to this overall picture and break down any aspects of the history that you need to fromthere. This is a much better way of doing things than interrupting (and probably losing forever) the patient'sinitial narrative.Listening does not just involve using your ears. Use other clues such as facial expression, body language andverbal fluency to give you cues as to what is really troubling someone, and suggest other areas in which thehistory might need to proceed. This is very useful where there is a psychological origin for physical symptoms, ofwhich the patient may be unconscious, but you could get at if you noticed that talking about a certain aspect oftheir story makes them uncomfortable or hesitant. Remember that speech is not the only means ofcommunicating, especially where someone has a poor command of the language in which you are taking thehistory, or has hearing impairment. Make full use of communication aids such as translators, sign-languageinterpreters, picture boards, drawings done by the patient showing where the pain is, when this is a moreappropriate form of discourse.Some patients do not come readily prepared with a narrative of their illness and, in this situation, it isunavoidable to use questioning and clarification of details to 'draw out' the history. However, if your promptingsparks off a narrative, then try to hear it out if it seems to be relevant.

What questions?

Open questions

These are seen as the gold standard of historical inquiry. They do not suggest a 'right' answer to the patient and givethem a chance to express what is on their mind. Examples include questions such as 'How are you?'. There are othersimilar open questions, but it may be effective just to let the patient start speaking sometimes.Open questions can be used to get specific information about a particular symptom as well. For example: 'Tell me aboutyour cough' or 'How are your waterworks bothering you?'. Open questions cannot always be used, as sometimes youwill need to delve deeper and obtain discriminating features that the patient would not be aware of. However, theyshould be kept foremost in the mind as a way to broach a subject or unexplored symptom.

PatientPlus o

History and Physical ExaminationConsultation AnalysisRespiratory System History and Examination

Questions with options

Sometimes it is necessary to 'pin down' exactly what a patient means by a particular statement. In this case, if theinformation you are after cannot be obtained through open questioning, then give the patient some options to indicatewhat information you need. For instance, if a male patient complains of 'passing blood' and it is difficult to tell what hemeans, even after being given a chance to expand on the subject, you could ask: 'Is that in your water or your motions?'.This technique must be used with care as there is a danger of getting the answer you wanted rather than what the patientmeant (he might be having nosebleeds). Try to avoid using specific medical terms such as 'coffee grounds' (one of theoptions you might give if trying to find out if a patient is vomiting blood). If you can use an open question such as:'What colour was the vomit?', rather than suggesting options, it is more likely to give you a true picture of what thepatient has experienced; however, sometimes questions suggesting possible answers cannot be avoided.

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Leading questions

These are best avoided if at all possible. They tend to lead the patient down an avenue that is framed by your ownassumptions. For instance, a patient presents with episodic chest pain. You know he is a smoker and overweight so youstart asking questions that would help you to decide if it's angina. So you ask: 'Is it worse when you're walking?', 'Is itworse in cold or windy weather?'. The patient is not sure of the answer, not having thought of the influence of exerciseor the weather on his pain, but answers yes because he remembers a cold day when he walked the dog and his pain wasbad. You may be off on the wrong track and find it hard to get back from there. It is much better to ask an openquestion such as: 'Have you noticed anything that makes your pain worse?'. When the patient answers: 'Pork pies', youare on firmer ground in suspecting that this may be chest pain of gastrointestinal origin.

SummarisingAfter taking the history, it's useful to give the patient a run-down of what they've told you as you understand it. Forexample: 'So, Michael, from what I understand you've been losing weight, feeling sick, had trouble swallowing -particularly meat - and the whole thing's been getting you down. Is that right?'. If there is a nod of approval orexpressed agreement with the story then it's fairly certain you're getting what the patient wanted to tell you. If not, thenyou may need to try another approach. This technique can avoid incorrect assumptions by the doctor.

Sharing understandingIt's always a good idea to ask the patient if there's anything they want to ask you at the end of a consultation. This canhelp you to impart further information if there's something they haven't understood, and can reveal something that'sbeen troubling them that hasn't been touched upon or got to the bottom of. It is an opportunity to confirm that a sharedunderstanding has been reached between doctor and patient.

ConclusionTry to let patients tell you their story freely.When you use questions, try to keep them as open as possible.Use all of your senses to 'listen'.Check that what you think is wrong, is what your patient thinks is wrong.Keep an open mind and always ask yourself if you're making assumptions.Be prepared to reconsider the causes of symptoms that you or a colleague have decided upon.

Provide Feedback

Further reading & referencesIntroduction to the Symptoms and Signs of Clinical Medicine: A Hands-on Guide to Developing Core Skills.David Gray (Editor), Peter Toghill (Editor) Hodder Arnold, 2000Deveugele M, Derese A, De Bacquer D, van den Brink-Muinen A et al; Consultation in general practice: astandard operating procedure? Patient Educ Couns 2004 Aug;54(2):227-33Tate P; The Doctor's Communication Handbook (5th ed.) Radcliffe Publishing (2003)Balint M; The doctor, his patient and the illness. Churchill Livingstone; First published 1957, update 1964.The Consultation, RCGP Curriculum Statement #2 (revised March 2009)Neighbour R; The Inner Apprentice: An Awareness-Centred Approach to Vocational Training for GeneralPractice. 2nd ed. Radcliffe Medical Press 2004Pendleton D, Schofield T, Tate P & Havelock P; The Consultation: An Approach to Learning and Teaching:Oxford: OUP. 1984Byrne PS, Long BEL; Doctors talking to patients. Royal College of General Practitioners, 1984Stott NC, Davis RH; The exceptional potential in each primary care consultation. J R Coll Gen Pract. 1979Apr;29(201):201-5.Neighbour R; The inner consultation: How to Develop an Effective and Intuitive Consulting Style. 2nd ed.

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Radcliffe Medical Press. 2004Calgary Cambridge guide to the medical interview - communication process, Dec 2006

1. Smith R; Thoughts for new medical students at a new medical school. BMJ. 2003 Dec 20;327(7429):1430-3.2. Bub B; The patient's lament: hidden key to effective communication: how to recognise and transform; Medical

Humanities 2004;30:63-69; Overview of how to turn moaning during consultation into a useful therapeutic anddiagnostic tool

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medicalconditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy.Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see ourconditions.

Original Author:Dr Gurvinder Rull

Current Version:Dr Richard Draper

Last Checked:20/04/2011

Document ID:1643 (v22) © EMIS

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