Stupid interviewing techniques
I had a case recently of a person who went to the hospital with a sudden onset of stroke symptoms. In addition to having expressive language impairment at the time she was also confused and understandably anxious. She was alone and the physicians tried to obtain information from her, which included the estimated time that symptoms began, personal medical history, and family medical history. This is all well and good, provided that it is written in the patient's records that the information was obtained from the patient in an acute confusional state. But it wasn't. The history was reported as if that was the actual true history.
The patient saw what was in the records for the first time when I reviewed them during my own detailed interview. At almost every turn, she said that information in the records was simply not true and emphasized she was interviewed alone in a confused state. This is why when I write reports, I use phrases such as "the patient reported" or "the patient stated." This way, it is clear where the information is coming from. If I have a patient that cannot provide a good history, there are no medical records, and no reliable informants to contact, then I will note that "the patient appears to be a poor historian and therefore the history provided cannot be relied upon as necessarily being accurate." Simple as that. It just amazes me that people cannot use common sense and realize that the information obtained from someone in an acute confusional condition may not be right, and to list in the medical records as if the information is factual is just plain silly.
The patient saw what was in the records for the first time when I reviewed them during my own detailed interview. At almost every turn, she said that information in the records was simply not true and emphasized she was interviewed alone in a confused state. This is why when I write reports, I use phrases such as "the patient reported" or "the patient stated." This way, it is clear where the information is coming from. If I have a patient that cannot provide a good history, there are no medical records, and no reliable informants to contact, then I will note that "the patient appears to be a poor historian and therefore the history provided cannot be relied upon as necessarily being accurate." Simple as that. It just amazes me that people cannot use common sense and realize that the information obtained from someone in an acute confusional condition may not be right, and to list in the medical records as if the information is factual is just plain silly.
posted by MedFriendly | 7:29 PM
12 Comments:
I don't know about you, but I always cringe when I see value-loaded statements such as "the patient appears to be a poor historian."
There can be a lot of reasons for patients not being able to articulate or remember the pertinent details of their medical history. Often they're sick or in pain or scared or confused. Even people who seemingly have their act together can come unglued in a crisis and simply not be able to think straight. This doesn't automatically make them a poor historian.
Perhaps a better turn of phrase is: "We were unable to obtain a good/accurate/complete/whatever history from the patient." That way no one is getting judged.
Otherwise I totally agree - it's critically important to know the source of the information so you can weigh its credibility.
I agree with you! I would think that would be obvious.
One day as an inpatient at the hospital, I was given my chart info in a folder and left to sit in the hallway s/p an IVP. Transport was extremely busy, I was bored and so I read through all of my record. I saw that in the initial eval one of the docs wrote that I was a good historian and I am. Another time when presenting to the ER with my complaint, I gave a quick but accurate rundown of everything I knew the nurse would want to know. I covered all the bases short of doing my own BP and pulse ox. When she went over to the ER doc I heard him ask her why I was there and the she said"Well,she basically triaged herself." I think I had better know what to say with all the experience I had in being around triages. :)
This post and anonymous' comment has given me an idea for a post. I had an occasion where I was not in control and totally lost it emotionally in a public place and am ashamed and mad at myself anytime I think of it which fortunately is not often. Again, the shocker for me is that I worked for 20 years around emergent situations AND was educated for such a scenario. It comes back to, unless you have walked in those shoes you DON'T really know how you will react. I know first hand that your thinking processes can be disrupted during times of acute illness or stress.
I agree with anonymous. I would state (if I was in medicine) something to the effect that we were unable to obtain accurate history at this time due to the patient's current condition or altered state.. (Something along those lines) Putting something down as fact under those circumstances is not safe or prudent at all.
Interesting. I never saw "poor historian" as an insult, just a statement of fact, but then again, I tend to be pretty blunt. The same thing can be said by saying "the patient was not able to provide a detialed history" so I think I probbaly will change to that. One thing I've learned is that people don't always take things the way you intended.
That's why I would choose to say unable to obtain accurate history - instead of putting it on the patient and saying "they" couldn't provide it. A subtle difference, but what would you like to see in your own chart?
I like straight and to the point. I find it to be an admirable quality.
I am a big one for not being taken in the way that I intended, so I hear you on that. I can't tell how I come across in text, but all I can do is explain myself better if someone needs. This is an interesting post Medfriendly.
I actually don't agree with that point chysalis, because if you say that you were unable to obtain an accurate history that does not explain why. Was I not able to obtain an accurate history because I decided I wanted to grab something to eat at McDonalds, because I was too lazy, or because I am not good at interviewing? In my job, it is crucial to say that the patient could not provide an accurate history because as a neuropsychologist, I am assessing cognitive functioning and the ability to provide an accurate and reliable history reveals pertinent information about conitive functioning.
I stand corrected Medfriendly. You are right, the "why" is very important. Forgive me.
No problem and no need for forgiveness. :)
I like hearing constructive criticism, although I can't always promise I'll agree. :)
You refresh a rusty perspective. I welcome it.
Look who is using "quotes"
Ummmm, yes, I am using quotes in my blog posting to convey what I write in my reports. This is not the same as using quotes of what patients say IN THE ACTUAL REPORT. Big difference.
It's me again, the first anonymous.
I've noticed that the value-loaded statement is actually rather common in medicine.
Consider these:
"The patient was unable to tolerate the procedure." "The patient failed chemotherapy." "The patient has an incompetent cervix."
WTH?
I don't think that health professionals are deliberately implying any value judgment; to some extent it's just the language they've been taught.
But consciously or not, it devalues patients and puts the failure on *them.* Maybe it is an unconscious device that allows physicians to distance themselves when something fails. Maybe it unconsciously helps physicians reaffirm their perceived superiority/control.
I can't help but think, however, that this language subtly influences how health care professionals view their patients, and the patient invariably comes off as the one who's flawed.
I just find the whole language thing to be fascinating. Words do influence how we perceive reality.
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