History taking

Clinical interviewing in all branches of medicine has been under intensive investigation during recent years, and concern has mounted that many doctors are inept and that medical students are not taught adequately how to talk to patients. When a patient sees the doctor, trust has to be gained, and once a diagnosis has been made it has to be conveyed to the patient and the treatment negotiated. Awareness has increased of the great variation among clinicians of essential communication skills. In all branches of medicine clinical investigation is based on the skills of history taking and physical examination. Special investigations, e.g. X-rays, laboratory tests, supplement the doctor’s findings in general medicine and surgery, but to detect psychiatric conditions the clinician must rely totally on the ability to take a history and to examine the mental state (Leff & Isaacs, 1981). These skills, augmented by the clinical reasoning process, enable the clinician to arrive at a diagnosis and to undertake treatment. Medical problem-solving is the doctor’s ‘science’, which is now recognized as definable, amenable to evaluation, and can be improved on by appropriate teaching. The clinical reasoning process is the most important set of abilities a doctor must possess. It consists of an enquiry strategy based on history-taking and examination which yields information and perceptions, e.g. clinical findings, diagnostic hypotheses and therapeutic decisions. Recent empirical studies of the way a doctor approaches a patient have demonstrated repeatedly that doctors themselves are not aware consciously of the technical approaches they use in clinical work. How they actually practice is very different from what they put forward when engaged in teaching medical students or doctors in postgraduate training. It has become apparent (Elstein et al., 1978) that the clinician characteristically generates only a few hypotheses, usually between two and five, very soon after first encountering the patient. These ideas or hunches or guesses, based on first cues presented by the patient, then serve to focus the clinician’s history taking and examination of the patient. They are based on very little data, and all the working hypotheses are generally developed within the first quarter of the clinical interview. Empirical investigation of doctors engaged in their clinical tasks has been promoted in part by the explosion of interest in computer approaches to medical interviewing. At the same time enormous strides have occurred in quality control of experienced doctors, audit, continuing medical education and issues of recertification. In addition, the rights of patients have been increasingly asserted (Stimson & Stimson, 1980): ‘Unfortunately many people feel that the doctor does not let them explain what is wrong and what they want. The doctor may attempt to cut them off before they are finished, or jump to the wrong conclusions. If you want to make sure that you get everything across, persist until you have jinished’. The passage quoted ends with the observation: ‘But surveys show that one of the most common complaints that patients make is that they are not given enough information’.