The History is Dead. Long Live The History.

[FulfilledDeer]

Hi everyone,

I haven't actually posted in a while and not much when I did, but I'm now an incoming MS4 and I'm heavily leaning towards EM. I'd say decided but I'm only a week into my sub-I and that seems a bit presumptive. Anyway, I'm trying to get better and to that end I watched this video how to think like an emergency physician () that some people recommended and based on that, other discussions on here (lurking) and what I've seen I'm a bit...confused.

What's the point of the history in EM? I mean, I get how getting a history can lead you down one path more quickly (typical MI history and you get an EKG immediately if they didn't already have it, etc.) or make you front-load things in a certain way (again, if you're suspecting MI from the history you more quickly go down that path than sending them to CT for PE) but it seems like that's all it's used for. It seems like you get the CC and then your work-up is pre-defined for you, and the only real point to the history is to identify *maybe* in what order you do things and as an adjunct to help you rule in/out (that is to say there are key specific questions that are yes/no that can help you in the same way a lab test would help you). Seems being the key word - I'm essentially asking what I'm missing.

For example, I saw this 50 yo M with chest pain the other day. He had a + family history, but was otherwise super crazy healthy (triathlete) with no risk factors. But I feel like my presentation could have just been "50 yo M chest pain since this am +family history" and stopped right there because any other details don't matter: he's bound for the same work-up essentially just based on the CC. And sure, I absolutely get the MI workup, but we also got a d-dimer. I can't really figure out how necessary that was.

Reading back I'm not sure if I'm actually articulating my problem super well. It just feels like at triage they could hear the CC, and put in an order set from a dropdown menu based solely on that. Our job would then be to do the specific history and physical questions/maneuvers appropriate to that CC (chest pain needs Q about history of travel, and auscultating the heart), combine that with the results, and work from there. It feels like there's no discretion.

Still feel like I"m articulating this poorly. I'll post it in case anybody gets what I'm saying.

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[BruceWilly]

You're saying emergency medicine is algorithmic.

 

[FulfilledDeer]

I mean, yes. But I've always felt all of medicine is. But it seems in other areas there's discretion: given the history X seems unlikely so I'm not even going to bother testing. But in EM the stakes are so high you're always ruling the same things out for a given cc (that is to say, each and every one each and every time), and since it's not incumbent on us to actually diagnose anything not life-threatening we stop there.

 

[WilcoWorld]

There are two ways to conclude an ED encounter.

1) Rule every emergency out.
2) Rule something in.

If you can accomplish #2, you get to stop. If you can't, you have to default to #1.

Let's look at your chest pain patient to see how this can work with the help of a good H&P. Your healthy 50 yo comes in with CP. On history you note the absence of anginal equivalents and that the pain is a unilateral, constant burning pain that isn't associated with exertion. On exam you note a vesicular rash in a T4 dermatomal distribution. You diagnose zoster and Bam! You're done. OK, so I've probably seen an ECG by now, and maybe a troponin got sent from triage. But because I was able to rule in a diagnosis with nearly 100% certainty I don't need to just do a "standard" rule out. In this case the H&P make a difference.

GERD or pleurisy, on the other hand, don't have anything pathognomonic like a shingles rash. So, even if it sounds like GERD, I'm still going to do the work up. In this case, the H&P are largely done for the billers & coders.

 

[gman33]

The history matters once you get some clinical experience.
I don't do the same workup on everyone with CP.
We do overwork up people in general, but that is another discussion.

The 50 year old healthy guy with CP, the main point is trying to determine what you think is actually going on, while ruling out the worst case.
Does he need to go right to the CT scan (or OR) for dissection?

If one set of enzymes are negative, does he still need to get admitted?

Does he have a pancreatitis pseudocyst?

Does he need a RUQ u/s?

You can't order all these things on everyone.

Well maybe you can, but you'd be a terrible doctor.

 

[Janders]

A good history is ABSOLUTELY imperative to a good ED doctor.

Not on every case. If they come in with a cut on the finger from their kitchen knife... done. Ankle sprain on a staircase? Done. Cough, fever, dyspnea with brown sputum and near-syncope when they stand up? Pretty much done.

Easily 1/3 of my cases I really don't need any more history than the 3 lines the nurse takes at triage. Either because they are very simple straight forward complaints, or they are very algorithmic complaints. Of course, i still talk to the patient... (1) because thats how you show compassion and interest, which goes a long way and (2) because I like to check for "red flags" myself.

That being said, a couple times a day I'll sit with a patient and family and just chat and take a long history for 10+ minutes. Its something of a luxury, but if you pick and chose, you will find those cases where it is ALL about the history. Its a lovely sense of accomplishment when you unravel a complaint just based on a long history. One of the older interests in my med school used to say something along the lines of "listen to the patient, they will eventually tell you their problem", implying a long thorough history will unravel many complaints. Its not true about 90% of ED patients, but sometimes it is.

 

[FulfilledDeer]

Wow, thanks everyone. This actually helped me a hell of a lot.

"Easily 1/3 of my cases I really don't need any more history than the 3 lines the nurse takes at triage. Either because they are very simple straight forward complaints, or they are very algorithmic complaints." This. I think perhaps I get more of those cases than residents and attendings because they're trying to make sure I don't get in over my head (and even these cases are new to me). That combined with the video and general advice which is just enough counter to a lot of what I've learned screwed me up a bit.

It felt like I was missing something since I knew what I was thinking couldn't/shouldn't be true, and I think it's clear I was.

 

[EctopicFetus]

I think to be a good ER doc you have to take a good history. Anyone can order every test. I call these people medical students and residents. Not that its their fault but they lack the expertise and experience. The bad ones are those who have the experience but never gain the expertise in their field.

We all make mistakes and mess up. I think the good ED docs can take a good focused history, a good exam (when needed), and have the clinical expertise and basic knowledge to make good decisions.

 

[Birdstrike]

Hi everyone,

I haven't actually posted in a while and not much when I did, but I'm now an incoming MS4 and I'm heavily leaning towards EM. I'd say decided but I'm only a week into my sub-I and that seems a bit presumptive. Anyway, I'm trying to get better and to that end I watched this video how to think like an emergency physician () that some people recommended and based on that, other discussions on here (lurking) and what I've seen I'm a bit...confused.

What's the point of the history in EM? I mean, I get how getting a history can lead you down one path more quickly (typical MI history and you get an EKG immediately if they didn't already have it, etc.) or make you front-load things in a certain way (again, if you're suspecting MI from the history you more quickly go down that path than sending them to CT for PE) but it seems like that's all it's used for. It seems like you get the CC and then your work-up is pre-defined for you, and the only real point to the history is to identify *maybe* in what order you do things and as an adjunct to help you rule in/out (that is to say there are key specific questions that are yes/no that can help you in the same way a lab test would help you). Seems being the key word - I'm essentially asking what I'm missing.

For example, I saw this 50 yo M with chest pain the other day. He had a + family history, but was otherwise super crazy healthy (triathlete) with no risk factors. But I feel like my presentation could have just been "50 yo M chest pain since this am +family history" and stopped right there because any other details don't matter: he's bound for the same work-up essentially just based on the CC. And sure, I absolutely get the MI workup, but we also got a d-dimer. I can't really figure out how necessary that was.

Reading back I'm not sure if I'm actually articulating my problem super well. It just feels like at triage they could hear the CC, and put in an order set from a dropdown menu based solely on that. Our job would then be to do the specific history and physical questions/maneuvers appropriate to that CC (chest pain needs Q about history of travel, and auscultating the heart), combine that with the results, and work from there. It feels like there's no discretion.

Still feel like I"m articulating this poorly. I'll post it in case anybody gets what I'm saying.

"The history is dead. Long live the history."

Please leave the dramatic and hyperbolic declarations of the deaths of entire cornerstones of Medicine, entire specialties and the like, to a professional, please. Just kidding. No, but seriously, your point is a classic mistaken belief from someone very, very early on in their career, from those not within the medical field, those in other specialties and CNN/MSNBC news anchors. It's sort of like watching a professional basketball game and thinking, "Look how easy that is. They just grab the ball, flip their arms up, and it just goes right in. It seems like it's automatic."

Uh....but it's not. Right now you're in a cozy, protected learning environment where professionals are making it look easy, and automatic, to you. When you're finally left alone, just you, in an ED full of patients and a full waiting room, you'll really realize how hard it is and how lost you are, without massive amounts of training behind you. You'd feel the same way facing Lebron going down the lane: Lost and out matched, in the wrong league.

It only takes one "knee pain" that turns out to be a fatal necrotizing fasciitis not showing up on your "x-ray all sore knees, that's so easy" protocol, or one "Duh! It's so obvious this is heartburn, not a heart attack" that dies in front of you, neither of which fit your thought-optional, assembly-line protocol.

You're not there to show how easy it is to diagnose the 99 out of 100 that are chip-shot tension headaches. You're there to diagnose the 1/100 that looks like, acts like, and the patient tells you is just like, a tension headache but actually is subarachnoid hemorrhage with impending death. You can't do an expensive ct scan with angiogram on every tension headache to find that one, especially in today's climate where there's pressure to test less and eliminate wasteful and unnecessary testing.

Just the same, a blind radiologist can read every head ct scan as "normal" and be perfectly accurate 99% of the time. Of course that's until one comes alone with a subtle head-bleed and doesn't fit his protocol that says, "This is so easy, what a joke! Almost 100% of these are normal." Yeah. Almost.

In the same vane, and despite advanced computerized autopilot systems that make 99% of each airplane flight mindlessly easy, yes, you guessed it, I'm not getting on any airplane with only an autopilot and no human pilot to perform the only portion that really matters: that "Life and death 1%."

You'll see how hard it is one day.

 

[Arcan57]

I know I went through stages in training where the various parts of the work-up had greater or lesser influence on what I actually did with the patient. History, physical exam, and testing all waxed and waned in importance depending on my ability to synthesize a coherent narrative out of the information coming at me. We play defense and try not to let a life threatening condition slip past us and score. Through some combination of the resources available, we have to be certain that our defense holds. The key is not to spend an inordinate amount of resources covering the same part of the field. On an older patient with multiple comorbidities presenting with resolved focal neuro deficits, not much is going to change based on performing a more detailed neuro exam or spending an a couple of extra minutes getting an exact description of every detail surrounding the event. They're going to be admitted for an MRI brain, so I focus my questioning on the things MRI won't pick up (hypoglycemia, spinal cord insults, cardiac, etc). Likewise, if I'm not going to be doing any testing then my history and physical become much more involved. The most common example of this is the febrile or vomiting infant. They get a legitimate head to toe exam and I will let parent ramble during history in a way I don't with less open ended complaints.

 

[styphon]

History is key in all specialties, and often you can limit your differential with a well directed/focused history. I find that medical students/interns undervalue histories and overvalue labs/imaging, I think this may be from lack of experience and not knowing how to use the history to your advantage.

 

[Apollyon]

They're going to be admitted for an MRI brain, so I focus my questioning on the things MRI won't pick up (hypoglycemia, spinal cord insults, cardiac, etc).

Well, not MRI of the brain, but MRI is the best imaging for the cord, right?

 

[RustedFox]

Agree with Birdstrike and Arcan: I've made that mistake, too. I spend more time on the history now than I do anything else. It really does sharpen your differential, and if documented correctly, makes a very compelling story that's difficult for attorneys to argue with.

 

[BAM!]

Hi everyone,

I haven't actually posted in a while and not much when I did, but I'm now an incoming MS4 and I'm heavily leaning towards EM. I'd say decided but I'm only a week into my sub-I and that seems a bit presumptive. Anyway, I'm trying to get better and to that end I watched this video how to think like an emergency physician () that some people recommended and based on that, other discussions on here (lurking) and what I've seen I'm a bit...confused.

What's the point of the history in EM? I mean, I get how getting a history can lead you down one path more quickly (typical MI history and you get an EKG immediately if they didn't already have it, etc.) or make you front-load things in a certain way (again, if you're suspecting MI from the history you more quickly go down that path than sending them to CT for PE) but it seems like that's all it's used for. It seems like you get the CC and then your work-up is pre-defined for you, and the only real point to the history is to identify *maybe* in what order you do things and as an adjunct to help you rule in/out (that is to say there are key specific questions that are yes/no that can help you in the same way a lab test would help you). Seems being the key word - I'm essentially asking what I'm missing.

For example, I saw this 50 yo M with chest pain the other day. He had a + family history, but was otherwise super crazy healthy (triathlete) with no risk factors. But I feel like my presentation could have just been "50 yo M chest pain since this am +family history" and stopped right there because any other details don't matter: he's bound for the same work-up essentially just based on the CC. And sure, I absolutely get the MI workup, but we also got a d-dimer. I can't really figure out how necessary that was.

Reading back I'm not sure if I'm actually articulating my problem super well. It just feels like at triage they could hear the CC, and put in an order set from a dropdown menu based solely on that. Our job would then be to do the specific history and physical questions/maneuvers appropriate to that CC (chest pain needs Q about history of travel, and auscultating the heart), combine that with the results, and work from there. It feels like there's no discretion.

Still feel like I"m articulating this poorly. I'll post it in case anybody gets what I'm saying.

Sure the work up may be similar for all 50 yo's with chest pain. That's why many EDs have triage nurses ordering preliminary orders. But the history is what dictates further management of the patient. Discharge, admission, medications, additional work up, etc.

Example -- Superfit athlete 50 yo M with no coronary artery disease risk factors (aside from being older than 45yo & male) and atypical non-anginal chest pain may be suitable for discharge. Possibly an outpatient stress test. Possibly no additional testing necessary.

Example #2 -- 50 yo M with typical chest pain, DM, HTN, HLD, and strong family hx of heart disease, and an MI last year with similar symptoms, recently placed 2 cardiac stents. Regardless of the workup results (normal EKG, neg trop), it is much more likely this guy will be admitted.


Anyone can order tests. It's the decision-making afterwards that counts. This is where the history and your relationship with the patient comes into play.

 

[FulfilledDeer]

Birdstrike: Just to be clear, I wasn't endorsing that line of thinking. I knew I was wrong, but that's the clearest way I could communicate my confusion. My title was sarcastic. I was absolutely not saying things are actually that easy.

 

[Birdstrike]

Birdstrike: Just to be clear, I wasn't endorsing that line of thinking. I knew I was wrong, but that's the clearest way I could communicate my confusion. My title was sarcastic. I was absolutely not saying things are actually that easy.

I know you were being sarcastic. That's why I snarked back. My dry sense of humor doesn't always come across online. The more serious a post of mine seems, the less likely it actually is. I get what you're saying though. Your post was good. How do you learn, and think cases through yourself, when all these "check box protocols" are already put in place making it feel you have no role? You're thinking, "I know it can't be this easy. What am I missing?"

Keep doing exactly what you're doing: Question everything. Like you asked, "Why order and-dimer when I know it's not a PE?" These are incredibly good questions and you need to know how to answer them for yourself. There might be a reason it was added by your attending or may have been part of a mindless protocol. It's critical to know the difference.

When you're learning and so many things seem so easy and on autopilot and protocoled, it's quiet impressive when you see one of these checkbox protocols fail. When they do so, it's often catastrophic. Then it hits you in the face, "Okay. I get it now. This is why I'm here, and why no one else in the building can do this job (except for your BC/BE EP partners)."

 

[FulfilledDeer]

That, actually, is exactly what I needed to hear I think - I really appreciate it.

 

[CliveStaples]

"The physical exam is mostly a poor diagnostic test that improves the accuracy of the most valuable diagnostic test—the history."

This might be a little bit more applicable to the IM colleagues (since the job of an EM physician involves ruling out emergent pathology moreso than ruling in the correct one), but I think that the ultimate lesson holds true. All of the tests and exams we perform are extremely limited in use without a proper history. You may need less or more history based upon the CC, but I think if I could only choose one thing to evaluate a patient with, it would be the history.