Wednesday, September 16, 2015

Wisdom Wednesday: The Patient History

I was taught that “history is 75% of the diagnosis.” I often repeat that phrase adding “without a history I might as well be practicing as a veterinarian.” No offense to vets, but without some dialog, just where do you begin?

Patients often are not very detailed in the their history. I frequently get “back” listed as the chief complaint and only history on my entrance case history form. If the patient is feeling a little more expressive, he will write “low back.” These patients are not engaged in their health. I believe they learned this behavior from health care providers that also were not engaged.

A study by Beckman and Frankel showed that 75% of the time physicians interrupted their patients within 18 seconds of them beginning to express their complaints. Less than 2% of the time did the patient ever return to complete their concerns.

Most patients have more than one complaint on entry with an average of three concerns per visit. Furthermore, some experts note than contrary to common opinion, most patients do not express their primary complaint first. It is up to the physician to listen carefully and arrange the various complaints by priority.

The engaged patient will provide a detailed history. We e-mail our entrance forms to new patients well ahead of their appointment so they can fill them out completely. If the history is complex (I love a complex health history), they will attach several pages to the form. Too often these are patients that have never been provided an opportunity to relate their history and they are desperate for help.

I recently had a new patient that had been prescribed 64 different medications for her symptoms. She even had exploratory surgery of the abdomen in vain attempt to arrive at a diagnosis. There were eight major complaints and several pages of history and diagnostic testing. By the time we finished the history, I had a very short, concise differential diagnosis compiled. She told me I was the first physician that had ever listened to her story.

After completely the history (oral and written) the physician should have a differential diagnosis - a short list of possible or probable diagnoses. The examination and all subsequent testing are designed to eliminate all but one diagnosis, hopefully the correct one.

Unfortunately, modern health care uses most diagnosis testing as screening procedures rather than confirmatory tests. As a result, the U.S. has the most expensive and least effective health care system in the industrialized world today.

Beginning on October 1, 2015 the U.S. health care system is switching from the ICDA 9 coding system to the ICDA 10. The ICDA 10 codes have been in use in the rest of the world for several years. One of the many benefits of the “new” system is the emphasis on the differential diagnosis. Physicians will be compelled to form a differential then document the various steps they take to confirm or dispel each of the possible outcomes. This should bring the history back to the forefront where it belongs.

The Bottom Line:
Please provide a complete written history for all of your health care providers even if you do not see the need. Make sure they are engaged when you are providing the oral history. Your health depends on it.

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