The other night, a patient gave me a piece of his mind. Mr. Q was a middle-aged man debilitated by days of nausea, vomiting and intractable belly pain. That morning, his wife finally convinced him to get medical attention and drove him to our emergency department. On arrival, he sat in a cubicle in the waiting room and explained his story to a triage doctor: how he was doing well until he ate a particularly rich meal a few days ago. How he’d vomited five, maybe six times. How he hadn’t noticed any fevers. How he’d tried Tums for his symptoms with little effect.
After he was escorted to a bay in the emergency room, he repeated the unpleasant details for the resident who came in to evaluate him. This time, he added that he takes a statin for his high cholesterol, that penicillin gives him a rash, and that he doesn’t smoke. Within the hour, he gave a repeat performance for the emergency room attending.
Just as he was settling into his slightly-more-permanent bed on the medicine floor, here I was, poised before a laptop on wheels and demanding yet another re-hashing of a narrative that had grown both trite and physically exhausting: So, Mr. Q. What brought you to the hospital?
“Doesn’t anyone write this stuff down?” He followed with a few other choice phrases.
Why do we make patients repeat their stories so many times? My standard answer is that when we assume care for a patient, we need to be sure that we understand his history so that we can take care of him properly. This is true, but it’s worth unpacking further.
Each re-telling has a unique purpose, or at least a unique point of view: In the emergency room, the questions asked of Mr. Q were necessarily brief and to the point. There, the main goal was to rule out potentially fatal causes of his belly pain and to send him either home or to an inpatient hospital bed. When I admitted Mr. Q to the general medicine unit, I needed a more detailed story so that I could continue to diagnose and treat his symptoms, and I needed to cross-check his home medication list so that I could order those drugs for him during his hospitalization. Specialists consulting on a patient would have asked him for a re-telling of his story with a shifted frame: the infectious disease doctor would want to know about him eating uncooked hamburger; the cardiologist about whether he’d ever had chest pain while resting.
Even if I had found all of the seemingly relevant details in prior notes, I might have gotten unexpectedly valuable information from a re-telling: a diagnosis-clinching clarification of the exact quality and pattern of his abdominal pain, or a teased-out recollection of blood in his vomit. Asking those questions myself also helped me understand and remember my patient’s story better than if I had read it from the chart.
So is the repeated story phenomenon a useful, error-reducing redundancy in our health care system? A necessary annoyance in an increasingly complex medical system involving multiple doctors and departments? A vestige of the Every-Man-For-Himself doctoring model in which you must re-check everything and trust no-one? Probably all of the above. But I wonder, in our slow but undeniable transition to team-based care, to what extent should we rely on the story as it has been collected? Where is the right balance between efficiency and patient comfort on the one hand, and Getting It Right on the other?
Later that night, Mr. Q stumbled out of his hospital bed to find me and apologize for his rudeness. Surprised by his gesture, I thanked him and told him it wasn’t necessary – he had every right to be frustrated and had given me something to think about.
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As a frequent patient due to the effects of radiation therapy on my kidneys, adrenals, gallbladder and ovaries I’m well acquainted with this type of repeat questioning. I know from my experience that any medical professional who thinks he/she is getting more information this way quite mistaken. Especially in the case of the patient presenting in pain. Yes, you may get different details, but you’re likely getting details omitted with each iteration as well. “Doesn’t anyone write this down?” isn’t a question borne of frustration. It’s simply a question of being accurate and complete. The same goes for demanding details from a concussion patient who was discharged from the hospital the day before and has a full record on file. In any line of work of any importance, we make a full and complete record of the problem or work to be done. How else can we be sure of being accurate? It’s the arrogance of the medical community that excuses this shoddy work approach while blaming a patient for not being entirely accurate. Of the 3+ people who will ask you the ever patronizing “what seems to be the trouble today?” not one of them is interested in the full story nor do they pass on the information you strained your brain to communicate while in pain or perhaps confusion as well. In ANY other business, treating the customer this way would certainly be a basis for firing based on incompetence and disrespect. That sort of work ethic is what is demonstrated by a firm who doesn’t value the work. As for a specialist having specific questions to their specialty, those questions should be in addition to a full study of your complete and accurate chart. How else can any kind of accurate assessment be made? We’re talking about life and death in this business, not simply dollars. Why does this profession so casually excuse poor work ethic and accuracy? I’ll tell you why. Because the medical profession is the only profession where they are literally trained to be disrespectful and patronizing because the patients are less educated than they are. They are trained to lie to us to keep us calm. They are trained to never admit a mistake and omit any information that may be upsetting if they can. And they are trained to matter of factly tell you that you are going to die and there’s nothing more that they can do. The real question is, did they ever do everything they could’ve done? It’s no wonder that more and more people are seeking alternative health care where they are at least treated with respect and taken seriously. Any doctor that scoffs at that has only their own shoddy work ethic to blame. Maybe in some cases better health care was available to them at a traditional facility, but that doesn’t mean they had any access to it.
This is an insightful story about the frustration of a patient who is required in the current system of care provision to repeat the same or a matching story several times. In this regard it is pretty close to the criminal justice system where the story is probed repeatedly with an objective to see if the subject is able to reproduce the same version each time. Deviation from one version to other often becomes diagnostic. My reason of writing this comment however is entirely different. Ishani in her excellent narration omitted to mention that history taking is also a social phenomenon. It allows both the parties to get to know each other. In the beginning it is a forced conversation but it often leads to some personal observations on each side such as Mr Q might be watching hockey or particular TV show in between his throwing ups or that his grand children were engaged in a fight etc which may start a new topic of conversation and put the patient at ease not just at that time but later on when the physicain comes around to visit the patient. I am sure Ishani was able to do the same that is why Mr Q felt the need to apologize.
Needless to say, if the patient’s review of the history varies significantly or there is major omission, it gives a lead into another type of medical problem.
It is frustrating for patients, but necessary in order to provide the best care. Reading a patients chart prior to performing your assessment will help save a lot of time while providing direction for individual clinician questioning.
Most patients appreciate different specialties asking similar questions in order to broaden an understanding of their health status. This ultimately benefits in the overall provision of care
I don’t think it can or should be eliminated for this reason. Everyone benefits in the end.
L
I am more then happy to review & repeat symptoms, but as a patient nothing irritates and frustrates me more then when despite that information my opinion and input are ignored. I’m lucky I’m relatively healthy but have complex joint problems related to hypermobility. I understand lots of doctor’s don’t know about or understand hypermobility syndrome, but when I am trying to explain it, handing in a note from my family doctor, articles & books on the topic (all of which I did at a Pre-op appointment recently) I don’t really appreciate tuning all that out to tow the company line.
If I didn’t think it was important I wouldn’t have raised it, if my family doctor didn’t feel it important she wouldn’t have written a letter for the occasion. Some days I’d swear doctor’s don’t think anyone else knows what they are talking about except them. I don’t mind repeating myself but I’d appreciate if the person asking would actually stop and listen. I don’t think that is too much to ask in return.
Ishani, excellent explanation of a scenario that is maddening for patients – but ultimately understandable from the lens of good care.
Another reason for re-telling that patient story is the serious issue of clinician bias. For example, we know that women who present to the E.R. with cardiac symptoms are likely to be dismissed as having acid reflux, pulled muscles, gall bladder problems, menopausal symptoms, or anxiety. A report published in the New England Journal of Medicine, for example, found that women under age 55 are SEVEN TIMES more likely to be misdiagnosed in mid-heart attack and sent home from Emergency compared to their male counterparts with similar symptoms.
And having the word “anxiety” written on your chart by the first clinician you meet in the E.R. can have devastating effects during subsequent meetings with other docs. When “anxious female” becomes part of your medical record, the chances of accurate diagnoses of potentially serious conditions plummet unless a second (or third) doctor is willing to go one step beyond that first label. More on this at “When Your Doctor Mislabels You As An Anxious Female” – http://myheartsisters.org/2012/06/04/anxious-female/