Bedside manner and establishing rapport

History taking requires practice and depends very much on the doctor–patient relationship.³ It is important to try to put the patient at ease immediately, because unless a rapport is established, the history taking is likely to be unrewarding.

There is no doubt that the treatment of a patient begins the moment one reaches the bedside or the patient enters the consulting rooms. The patient’s first impressions of a doctor’s professional manner will have a lasting effect. One of the axioms of the medical profession is primum non nocere (the first thing is to cause no harm).⁴ An unkind and thoughtless approach to questioning and examining a patient can cause harm before any treatment has had the opportunity to do so. You should aim to leave the patient feeling better for your visit. This is a difficult technique to teach. Much has been written about the correct way to interview patients, but each doctor has to develop his or her own method, guided by experience gained from clinical teachers and patients.^5–8

To help establish this good relationship, the student or doctor must make a deliberate point of introducing him- or herself and explaining his or her role. This is especially relevant for students or junior doctors seeing patients in hospital. A student might say: ‘Good afternoon, Mrs Evans. My name is Jane Smith; I am Dr Osler’s medical student. She has asked me to come and see you.’ A patient seen at a clinic should be asked to come and sit down, and be directed to a chair. The door should be shut or, if the patient is in the ward, the curtains drawn to give some privacy. The clinician should sit down beside or near the patient so as to be close to eye level and give the impression that the interview will be an unhurried one.^9,10 It is important here to address the patient respectfully and use his or her name and title. Some general remarks about the weather, hospital food or the crowded waiting room may be appropriate to help put the patient at ease, but these must not be patronising.

Obtaining the history

Allow the patient to tell the whole story, then ask questions to fill in the gaps. Always listen carefully. At the end of the history and examination, a detailed record is made. However, many clinicians find it useful to make rough notes during the interview. With practice this can be done without loss of rapport. In fact, pausing to make a note of a patient’s answer to a question suggests that it is being taken seriously.

Many clinics and hospitals use computer records which may be displayed on a computer screen on the desk. Notes are sometimes added to these during the interview via a keyboard. It can be very off-putting for a patient when the interviewing doctor looks entirely at the computer screen rather than at the patient. With practice it is possible to enter data while maintaining eye contact with a patient, but at first it is probably preferable in most cases to make written notes and transcribe them later.

The final record must be a sequential, accurate account of the development and course of the illness or illnesses of the patient (Appendix I, page 461). There are a number of methods of recording this information. Hospitals may have printed forms with spaces for recording specific information. This applies especially to routine admissions (e.g. for minor surgical procedures). Follow-up consultation questions and notes will be briefer than those of the initial consultation; obviously, many questions are only relevant for the initial consultation. When a patient is seen repeatedly at a clinic or in a general practice setting, the current presenting history may be listed as an ‘active’ problem and the past history as a series of ‘inactive’ or ‘still active’ problems.

A sick patient will sometimes emphasise irrelevant facts and forget about very important symptoms. For this reason, a systematic approach to history taking and recording is crucial (Table 1.1).¹¹

Table 1.1 History-taking sequence

Introductory questions

In order to obtain a good history the clinician must establish a good relationship, interview in a logical manner, listen carefully, interrupt appropriately, note non-verbal clues, and correctly interpret the information obtained.

The next step after introducing oneself should be to find out the patient’s major symptoms or medical problems. Asking the patient ‘What brought you here today?’ can be unwise, as it often promotes the reply ‘an ambulance’ or ‘a car’. This little joke wears thin after some years in clinical practice. It is best to attempt a conversational approach and ask the patient ‘What has been the trouble or problem recently?’ or ‘When were you last quite well?’ For a follow-up consultation some reference to the last visit is appropriate, for example: ‘How have things been going since I saw you last?’ or ‘It’s about … weeks since I saw you last, isn’t it? What’s been happening since then?’ This lets the patient know the clinician hasn’t forgotten him or her. Some writers suggest the clinician begin with questions to the patient about more general aspects of his or her life. There is a danger that this attempt to establish early rapport will seem intrusive to a person who has come for help about a specific problem, albeit one related to other aspects of his or her life. This type of general and personal information may be better approached once the clinician has shown an interest in the presenting problem or as part of the social history. The best approach and timing of this part of the interview must vary, depending on the nature of the presenting problem and the patient’s and clinician’s attitude. Encourage patients to tell their story in their own words from the onset of the first symptom to the present time.

When a patient stops volunteering information, the question ‘What else?’ may start things up again.⁸ However, some direction may be necessary to keep a garrulous patient on track later during the interview. It is necessary to ask specific questions to test diagnostic hypotheses. For example, the patient may not have noticed an association between the occurrence of chest discomfort and exercise (typical of angina) unless asked specifically. It may also be helpful to give a list of possible answers. A patient with suspected angina who is unable to describe the symptom may be asked if the sensation was sharp, dull, heavy or burning. The reply that it was burning makes angina less likely.

Appropriate (but not exaggerated) reassuring gestures are of value to maintain the flow of conversation. If the patient stops giving the story spontaneously, it can be useful to provide a short summary of what has already been said and encourage him or her to continue.

The clinician must learn to listen with an open mind.¹⁰ The temptation to leap to a diagnostic decision before the patient has had the chance to describe all the symptoms in his or her own words should be resisted. Avoid using pseudo-medical terms; and if the patient uses these, find out exactly what is meant by them, as misinterpretation of medical terms is common.

Patients’ descriptions of their symptoms may vary as they are subjected to repeated questioning by increasingly senior medical staff. The patient who has described his chest pain as sharp and left-sided to the medical student may tell the registrar that the pain is dull and in the centre of the chest. These discrepancies come as no surprise to experienced clinicians; they are sometimes the result of the patient’s having had time to reflect on his or her symptoms. This does mean, however, that very important aspects of the story should be checked by asking follow-up questions, such as: ‘Can you show me exactly where the pain is?’ and ‘What do you mean by sharp?’

Some patients may have medical problems that make the interview difficult for them; these include deafness and problems with speech and memory. These must be recognised by the clinician if the interview is to be successful. See Chapter 2 for more details.

The presenting (principal) symptom

Not uncommonly, a patient has many symptoms. An attempt must be made to decide which symptom led the patient to present. It must be remembered that the patient’s and the doctor’s ideas of what constitutes a serious problem may differ. A patient with symptoms of a cold who also, in passing, mentions that he has recently had severe crushing retrosternal chest pain needs more attention to his heart than to his nose. Record each presenting symptom in the patient’s own words, avoiding technical terms.

History of the presenting illness

Each of the presenting problems has to be talked about in detail with the patient, but in the first part of the interview the patient should lead the discussion. In the second part the doctor should take more control and ask specific questions. When writing down the history of the presenting illness, the events should be placed in chronological order; this might have to be done later when the whole history has been obtained. If numerous systems are affected, the events should be placed in chronological order for each system.

Associated symptoms

Here an attempt is made to uncover in a systematic way symptoms that might be expected to be associated with disease of a particular area. Initial and most thorough attention must be given to the system that includes the presenting complaint (see Questions box 1.1, page 9). Remember that while a single symptom may provide the clue that leads to the correct diagnosis, usually it is the combination of characteristic symptoms that most reliably suggests the diagnosis.

Questions box 1.1

The systems review

Enquire about common symptoms and three or four of the common disorders in each major system listed below. Not all these questions should be asked of every patient. Adjust the detail of questions based on the presenting problem, the patient’s age and the answers to the preliminary questions.

! denotes symptoms for the possible diagnosis of an urgent or dangerous (alarm) problem.

Cardiovascular system

1. Have you had any pain or pressure in your chest, neck or arm?—Myocardial ischaemia

2. Are you short of breath on exertion? How much exertion is necessary?

3. Have you ever woken up at night short of breath?—Cardiac failure

4. Can you lie flat without feeling breathless?

5. Have you had swelling of your ankles?

6. Have you noticed your heart racing or beating irregularly?

7. Have you had blackouts without warning?—Stokes-Adams attacks

8. Have you felt dizzy or blacked out when exercising?—Severe aortic stenosis or hypertrophic cardiomyopathy

9. Do you have pain in your legs on exercise?

10. Do you have cold or blue hands or feet?

11. Have you ever had rheumatic fever, a heart attack, or high blood pressure?

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Like this:

Like Loading...

Related

Related posts:

1. Advanced history taking
2. The skin, nails, and lumps
3. The respiratory system
4. The rheumatological system

Stay updated, free articles. Join our Telegram channel

Join