I have a question for any students in the audience today. Are you ready? Here it is: what is the most important part of the medical history?
The medical history, by the way, is what physicians document when they meet a patient for the first time. The doctor asks a series of questions and the answers are shaped into a narrative that documents the details of the clinical situation in order to deduce what exactly is wrong with the patient and maybe even correct the problem. The medical history is recorded in this order:
Chief Complaint
History of Present Illness
Allergies
Medicines
Past Medical History
Family History
Social History
Review of Systems
Following the completion of the medical history the physical examination is performed and tests are ordered. Then an assessment of the problems and the most likely diagnoses are listed, along with the treatment plan.
I suppose the most logical answer to my question is that the "History of Present Illness (HPI)" is the most important part of the interview, for the obvious reason that here is where the patient describes his symptoms, and where doctors formulate their diagnoses. It's hard to treat an illness if one doesn't have any clue as to what the diagnosis is, not that this would ever occur in our fair nation.
I personally feel that the most important part of the medical history is not the HPI, but another section, traditionally neglected by physicians beginning with the third year of medical school. Can you guess what it is?
Answer: the Social History is the most important part of the interview in my opinion, because it humanizes the patient. Taking a social history, that is asking about the patient's living arrangements, occupation, place of birth, children, hobbies and personal habits allows doctors to see the person in front of them as more than a conglomeration of complaints. Learning about a patient's life personalizes the relationship and helps doctors to realize that they are treating a distinct individual, one who has lived a life full of unique experiences, usually aided by wisdom, courage and love.
Once you learn a patient's social history it becomes easy to remember who they are and thus easier to care for them. Once you understand where patients came from in life and how they got there, it is impossible to think of them as only numbers or even worse, hosts for a malignant tumor.
Take it from one who has interviewed thousands of individuals, it always pays off to get to know a little bit about your patients. Here is just a sampling of some of the things I have been told over the years:
"In 1945 I was manning a checkpoint in Germany when a jeep full of soldiers drove up to me. I challenged them and they all started screaming at me. Then the guy in the back got out and it was General Patton. He called them off and said, "Leave him be - he's just doing his duty.' I never forgot that."
"I had two sets of identical twins and then another pair of fraternal twins. They put me in the Guinness Book of World Records."
"My son is a heart surgeon in Texas. He'll probably call you to find out what's going on - he worries about me."
"What a coincidence! We're both from the same state and went to the same college."
"I was a signalman on Iwo Jima, and because we used flags it was easy for the enemy to pick us off. After a while they all gave us flashing lights to use. I was one of only four guys in my unit to make it off the island."
"I retired after teaching high school music for forty years. I was a graduate of Julliard, you know."
It doesn't take a huge commitment of time to get to know your patients, and the rewards are this: they become as real to you as your own family, and hopefully will be treated as such in the time of need.
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Wow! I would really feel cared for and listened to if asked these things and not just "what's wrong with you today".
I would think sometimes such info would also give you clues toward what might be going on and what treatment to plan.
In today's short appointment time allotment, I am sure it can be hard to do this, but in the long run it might be more effective.
Why was I not at all surprised to read "social history" was the more important aspect of the medical history for Dr H?
Speaking from the perspective of one oncology patient, I can only concur that this aspect is also the more important for me, and I am sure, many cancer patients.
This forms the fundamental basis of TRUST between doctor and patient - the most essential requirement in oncology.
In case he's not aware of it, Dr. Hildreth might be interested in work by Nancy Adler (UCSF), Bruce McEwen (Rockefeller U), Michael Marmot (University College, London), Judith Stewart (UCSF), and others. Several years ago, they held a meeting called Socioeconomic Status and Health in Industrial Nations: Social, Psychological, and Biological Pathways, which was published in the Annals of the New York Academy of Sciences. There was a famous study done using the British Civil Service in which it was discovered not only that the top tier was better off than the lowest (no surprise) but also that Grade 14 was better off than Grade 13, which was better off than Grade 12, and so forth (big surprise, given the fine gradations in this particular national civil service setup).
So you're quite right -- the social history is crucial. And it's important for the reasons the other respondents mentioned.
Linda
Wow! Luckily, I have not had to see an oncologist - but I've been in and around the medical world for most of my adult life due to allergies and asthma. The only specialty that I know of that consistently takes a full history is allergy.
Granted, no allergist worth his or her salt can give a proper diagnosis through RAST and scratch test alone, but you would think OB/Gyn's and primary care doctors would take as full history's as possible to help guide patients to proper management. Of course, I have never heard of a good allergist who had less than a 3 hour initial consult. (I am lucky enough to have an allergist who gives his patients their test results to give any other physicians. This has stopped many an argument.)
I'm always thrilled to hear of a physician who actually wants to take a complete history.
Pax,
MLO