9780199550463_018_025_CH03.

qxd 3/20/09 10:20 Page 18

CHAPTER 3

How to take a
medical history
Peter Washer

Chapter contents Learning points

Taking a medical history 19 This chapter will:
PODCAST: A professional ◆ describe how to take a medical history
perspective
◆ provide suggestions of ways to phrase the questions
Eileen Rosenfelder, GP 19
you need to ask in non-medical language
Ways to phrase the questions in ◆ discuss how to recognize and respond to a patient’s
non-medical language 20 cues.
Recognizing and responding Taking a medical history is a complicated business; in
to cues 24 order to simplify it for learners, process and content
are often taught separately. In medical school, you
Summary 24
tend to learn about the process (how to do it), often
using a communication model such as the Calgary–
Cambridge model (Silverman et al., 2005). Then, while
on clinical placements, you focus more on the content
of the medical history (what you need to cover), includ-
ing the history of the presenting complaint, past
medical history, social history, systems review, and
so on. Unfortunately, this separation of process and
content is, generally speaking, bad practice because
it leaves many students with the impression that they
are learning two entirely different models, rather than
two aspects of the same thing (Kurtz et al., 2003). It is
difficult at first to remember to pay attention to both
the process and content at the same time – it is a bit
like that children’s game where you have to pat your
head with one hand and rub your stomach with the
other and then swap hands.

© Oxford University Press 2009. Peter Washer: Clinical communication skills

.. ..
 9780199550463_018_025_CH03.qxd 3/20/09 10:20 Page 19

the content of a medical history 19

To add to this complexity, communication skills PODCAST

are often taught separately from clinical skills such
as examination skills, and procedural skills such as A professional perspective
venepuncture or suturing. Of course, in real life medical “When I call the patient in I always, always start
practice, you need to be able to talk to patients at the with an open question. I’ll introduce myself if they
same time as you are examining, taking blood from, or haven’t met me and I say, ‘Please sit down’, and then
suturing them. One of the difficulties for learners is to I usually start with, ‘How can I help?’ In general, start
fuse all these elements, including the clinical skills, the with an open question, and one of the most useful
content of the history, the physical examination, the tips, I would say, is let the patient speak uninter-
clinical investigations, diagnostic reasoning, and team rupted for a good 1 to 2 minutes, even if you’re
working, and at the same time remember the under- feeling the pressure of the full waiting room and
pinning communication skills (Kneebone & Nestel, the time, the clock ticking. Just wait and let them
2005; Kneebone et al., 2006). At the outset, it is best to speak, because they’ll usually reveal a lot if you
separate all these things you need to learn and be as don’t interrupt them, and then you can actually ask
thorough as you can with each aspect. As you get more the closed, more pertinent questions that you have
experienced, you will to start to knit all these elements much more efficiently. If you interrupt them too
together. early on, the patient will forget what they’ve come
with and they’ll remember later in the conversation,
Taking a medical history and it actually makes you much more inefficient.”
The medical history is a structured enquiry in which
Podcast: Eileen Rosenfelder, GP
you need to find out about a number of different topics
to make sure you have covered all the relevant ground.
Each doctor has their own individual style of history
taking, and this is something you’ll grow into as you
mature as a professional. The best advice when you
Once you have listened to the patient’s narrative, you
start taking a patient’s medical history is to begin by
need to move on to the questions you will need to ask
asking an open question. Then sit back, keep quiet, and
for the fuller picture. It is useful to signal to the patient
listen for a good 2 or 3 minutes while the patient tells
that the questions that you are going to ask are ‘nor-
you just about everything you need to know. If you let
mal’ or standard, in case they get concerned that you
patients tell their own stories in their own words, they
are probing some area because you suspect something
will more often than not cover most of the information
sinister is wrong with them. Finally, it is useful to sign-
you require. The trick is to listen attentively, mentally
post when you move from one topic to another, for
tick off the information you need as they give it to you,
example, ‘Now I’ve asked you about the medicines you’ve
and then go back and probe further for the things that
been taking, I need to move on and ask you some ques-
they have not already told you.
tions about your family.’
All this is of course easier said than done, especially
when you are starting out, but if you observe your
seniors, you will see how the two narratives of the
patient’s perspective on the illness and the biomedical THE STRUCTURE OF A MEDICAL
disease model can be fused. The patient’s narrative will HISTORY
not come out in the sequence that you need to write ◆ The presenting complaint(s)
it or present it (as described in Chapters 4 and 5), but
it will be a fuller account of their symptoms, and ◆ The history of the presenting complaint(s)
the impact of those symptoms on their lives, than you ◆ Past medical history
could possibly elicit using a list of closed questions.
◆ Drug/allergy history
◆ Family medical history
◆ Personal and social history
◆ Systems review

© Oxford University Press 2009. Peter Washer: Clinical communication skills

.. ..