First year in need of M3/M4 advice

[han14tra]

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Tomorrow is my first standardized patient interview. I don't know how to take a social history. I know to ask about their living arrangement and job. But, do I talk about sex?

We learned sexual history taking this week, and it confused me. Am I really suppose to ask every patient who they are having sex with and if it is vaginal, oral, anal, etc?

I'm seeing a patient with a cough. We are suppose to assume it is their first office visit and take a full medical history.

 

[FlowLimited]

If you've been taught how to do the sexual history, you should do it. It's awkward at first, but it's something you'll get used to.

 

[smq123]

We learned sexual history taking this week, and it confused me. Am I really suppose to ask every patient who they are having sex with and if it is vaginal, oral, anal, etc?

No. Please don't do that.

Tomorrow is my first standardized patient interview. I don't know how to take a social history. I know to ask about their living arrangement and job. But, do I talk about sex?

Unless you suspect an STD or pregnancy (which, admittedly, would not be the first thing to pop in my mind when I hear that a patient has a cough), you generally don't ask about sex.

For all patients, the most important parts of the social history are tobacco, drugs, and alcohol.

I mean, you ask questions based on common sense. "What could this be...and what questions could I ask that would help me figure out what this could be?" You don't ask random questions by rote memory because someone in ICM told you to.

The people who taught my med school classes would probably be upset to hear me say this, but I really don't use a lot of what I learned in those MS1 and MS2 classes in everyday clinical practice.

If you've been taught how to do the sexual history, you should do it. It's awkward at first, but it's something you'll get used to.

For a cough? 😕

 

[han14tra]

If you've been taught how to do the sexual history, you should do it. It's awkward at first, but it's something you'll get used to.

But how far do you go? We were taught how to do it for teens? But, they never really said how to apply it to adults. Do I need to ask a married 60 year old who they are having sex with and what forms?

Or, can I just say:

- Are you sexually active?
- Are you using protection?
And, that's it.

 

[han14tra]

No. Please don't do that.



Unless you suspect an STD or pregnancy (which, admittedly, would not be the first thing to pop in my mind when I hear that a patient has a cough), you generally don't ask about sex.

For all patients, the most important parts of the social history are tobacco, drugs, and alcohol.

I mean, you ask questions based on common sense. "What could this be...and what questions could I ask that would help me figure out what this could be?" You don't ask random questions by rote memory because someone in ICM told you to.

The people who taught my med school classes would probably be upset to hear me say this, but I really don't use a lot of what I learned in those MS1 and MS2 classes in everyday clinical practice.



For a cough? 😕

Thank you. This is great.

 

[Ableton]

For a cough? 😕

I would agree with what you said, except for the fact that the OP hasn't been asked to take a focused medical history.
If it is a patient's first visit, you should do a full H&P and this includes sexual history.

I find an easy way to ask about it is while taking the social history. After asking if they do drink/smoke/do drugs, what they do for a living, all that jazz... ask if they are currently in a relationship, then regardless of the answer, ask if they are sexually active. You should also determine if they have sex with men/women or both, if they use protection while having sex, etc. But also remember to reassure them that these are just routine questions you have to ask everyone.

 

[Mr hawkings]

I agree with the last post. At this stage, they dont want you to take a focused history. In fact, the patient may not even have a chief complaint. They want to see you practice every aspect of history taking that you've been taught. Later, you can start narrowing it down to what you need.

 

[smq123]

I would agree with what you said, except for the fact that the OP hasn't been asked to take a focused medical history.
If it is a patient's first visit, you should do a full H&P and this includes sexual history.

- Having done a similar exercise when I was an MS1 (at the same school that I believe the OP is at), they did specify that we were supposed to do a "focused" medical history. They may have changed it, but I kind of doubt that. They set up the interview as if it's an acute care visit/ER visit type of situation.

- What you do for a patient's first visit varies, to be honest. In our office, if a patient is scheduled for a sick visit only, the office staff puts them into the computer for a 15-20 minute slot, and you approach the visit as an acute care thing only. If they're scheduled as a "new patient physical," then they're given more time which allows you to do the full H&P.

 

[Mr hawkings]

- Having done a similar exercise when I was an MS1 (at the same school that I believe the OP is at), they did specify that we were supposed to do a "focused" medical history. They may have changed it, but I kind of doubt that. They set up the interview as if it's an acute care visit/ER visit type of situation.

- What you do for a patient's first visit varies, to be honest. In our office, if a patient is scheduled for a sick visit only, the office staff puts them into the computer for a 15-20 minute slot, and you approach the visit as an acute care thing only. If they're scheduled as a "new patient physical," then they're given more time which allows you to do the full H&P.

He/she said its a standardaized patient. So the patient has probably been instructed not to lead the student down one path or the other to allow them to go through a full history

 

[45408]

Well, I do think you should find out if it's supposed to be focused or comprehensive. If it's comprehensive, then you might as well do a sexual history. They're not a real patient, so they're just giving you standard answers. It's easier to do a few sexual histories on standardized patients first.

 

[Dral]

The key to taking a sexual history is realizing that people have vastly different sexual habits. You have to be sensitive in general, but you shouldn't let this frighten you away from getting the information you need.

If the patient becomes visibly uncomfortable, you can always stop and reassure them that you ask these questions of everyone and that it is done to help direct their care in the best way possible...in addition to reassuring them that it is confidential information.

As mentioned by someone else, asking about if the person is in a relationship is a good place to start. You can ask if they are satisfied with that relationship (without being too invasive). This may already be established from previous social history. Remember to not assume that a relationship is monogamous. Then establish if the patient is sexually active. If yes, you should ask a person in a relationship if they have sex with others and if they are aware if their partner has sex with others (Again, use words or mannerisms to make you appear non-judgemental).

Next, you move to the more difficult questions. First off, you need to be sensitive to the fact that not everyone engages in heterosexual sex, however, you also cannot assume that a male who has or has had sex with another male is or considers himself homosexual. The way to deal with this is to ask "Do you have sex with men, women, or both?" You don't care about their preference, you only care about the facts of their behavior. If they choose to discuss their preferences, that is their prerogative.

After you have those facts established, you then segue into questions about sexual practices. You can ask if they have vaginal, oral, or anal sex. These are important questions. Someone who has been an anal sex recipient is at an increased risk for certain diseases and conditions compared to those who don't practice that type of sex (anal warts for instance).

Following from this, you can ask about protective factors such as OCPs, condoms, and other methods.

If your tendencies lean to the psych side of medicine, you may ask about sexual satisfaction as well. You may also choose to offer counseling advice at this point. Finally, if your patient is female, you may ask about ob/gyn history. (Again, as far as the sensitivity issue goes, do not assume that a woman who may have identified herself to you as lesbian does not have an OB history).

The process becomes easier as you realize that pretty much most people do not feel (or at least appear to feel) uncomfortable about being asked these important questions. This is especially true if you've let them know that you are not just asking out of curiosity, but out of necessity to direct their care in the most optimal way.

Asking an 80 year old about sex and drugs is odd at first, but remember that most will at the very worst take it as a compliment. I hope when I'm 80, people would still assume that I have an active sex life. heh.

 

[smq123]

He/she said its a standardaized patient. So the patient has probably been instructed not to lead the student down one path or the other to allow them to go through a full history

I know. Like I said, I had to do the same thing with a standardized patient when I was an MS1 there. For us, it was supposed to be a focused physical.

In retrospect, they treated like a Step 2 CS encounter. For Step 2 CS, it's all a series of standardized patients, but it has to be focused physicals there as well (since you have 15 minutes with the patient).

And, if you wanted to get really technical, a full history can take half an hour, since you're also supposed to go through vaccines, health maintenance (colonoscopies, paps, PSAs, mammograms), etc.

 

[Ableton]

- Having done a similar exercise when I was an MS1 (at the same school that I believe the OP is at), they did specify that we were supposed to do a "focused" medical history. They may have changed it, but I kind of doubt that. They set up the interview as if it's an acute care visit/ER visit type of situation.

- What you do for a patient's first visit varies, to be honest. In our office, if a patient is scheduled for a sick visit only, the office staff puts them into the computer for a 15-20 minute slot, and you approach the visit as an acute care thing only. If they're scheduled as a "new patient physical," then they're given more time which allows you to do the full H&P.

I obviously know things in the real world are done quite differently than the ideological methods they teach us in medical school, especially when it comes to clinic visits for specialists. But at the same time, I don't know what medical school does not teach and expect a student to know how to take BOTH a focused medical history and a complete history.

I'm seeing a patient with a cough. We are suppose to assume it is their first office visit and take a full medical history.

Then OP, you should start by taking a focused history of the chief complaint, followed by doing a complete history of the patient for the sake of completeness (medical/familial/social/sexual). This shouldn't take more than 10-15 minutes to accomplish.

 

[smq123]

But at the same time, I don't know what medical school does not teach and expect a student to know how to take BOTH a focused medical history and a complete history.

Well, I would agree that the OP needs to be sure if this is a focused physical or not - if she's interviewing an SP with an already defined CC, then I would guess that it's focused (again, just like Step 2 CS).

Of course med schools teach students how to take a complete history. But, if you're supposed to be doing a focused history and physican on something like a cough, and you're spending a lot of time on the patient's sexual history, then you're not doing what you've been asked to do.

In any case, even in the real world, if a patient came in with a cough and were asking to be seen specifically for that reason, I wouldn't delve into their sexual history. Their baseline new patient visit would have to be deferred to another time, and in that case I would go into the exhaustive history.

 

[FlowLimited]

For a cough? 😕

Yeah, for a cough.

If the OP is being graded on whether or not they know everything that's included in a full H&P, the only way that they can show it is to ask everything. These med school exercises aren't the real world, they're opportunities to practice your technique. You're not going to be a decent sexual history taker as a doctor unless you practice as a student.

So I agree that in the real world you're not going to ask every single person who walks in the door about their sex life, but since when is med school the real world?

 

[richse]

Thank you. This is great.

Hey Han14tra, I think the point is for us to go through the history in as much detail as we possibly can the way they have been teaching us. All the upper years I have talked to basically said we need to ask ALL the questions during these things. In third and forth year we learn to trim it down to the important/common sense parts but for now they are evaluating us on completeness. I definitely asked sex questions, and everything else, even though my guy had a cough. If only because we are being evaluated and my small group would tear me a new one for skipping the stuff we have been told over and over to do.

 

[richse]

Well, I would agree that the OP needs to be sure if this is a focused physical or not - if she's interviewing an SP with an already defined CC, then I would guess that it's focused (again, just like Step 2 CS).

Of course med schools teach students how to take a complete history. But, if you're supposed to be doing a focused history and physican on something like a cough, and you're spending a lot of time on the patient's sexual history, then you're not doing what you've been asked to do.

In any case, even in the real world, if a patient came in with a cough and were asking to be seen specifically for that reason, I wouldn't delve into their sexual history. Their baseline new patient visit would have to be deferred to another time, and in that case I would go into the exhaustive history.

We aren't doing any physical. We are supposed to get a complete history and then leave. We have 15 min max, I think I spent 11 doing mine.

 

[njbmd]

If you can't figure out what is going on in your coursework, pick up a copy of Schwartz's Physical Diagnosis. This book as a DVD that reviews every type of history and physical exam including how to focus the H & P. It's easy reading.

 

[SouthernSurgeon]

Although I don't know what particular med school y'all are talking about or the details of the assignment, I would tend to fall in line with the "completeness" camp. I can't imagine a situation where an M1 or M2 gets faulted for being "complete" and in reality a good, focused H&P is likely well beyond the capacity of an M1.

OP - as for the details of the sexual history, you definitely do not need to ask the kind of details you were bringing up in your first post. Asking if they are sexually active, how many partners, protection, etc. is all perfectly reasonable (and be sure to use "non-judgmental" language).

 

[Jolie South]

Although I don't know what particular med school y'all are talking about or the details of the assignment, I would tend to fall in line with the "completeness" camp. I can't imagine a situation where an M1 or M2 gets faulted for being "complete" and in reality a good, focused H&P is likely well beyond the capacity of an M1.

OP - as for the details of the sexual history, you definitely do not need to ask the kind of details you were bringing up in your first post. Asking if they are sexually active, how many partners, protection, etc. is all perfectly reasonable (and be sure to use "non-judgmental" language).

As a second year about to start rotations in January, I feel like being overly complete is better than lacking information when your attending asks during a report. I won't include all of it, but I'll know it. I really don't have a feel for what's important or not yet, so I just ask everything.

 

[Dral]

As a second year about to start rotations in January, I feel like being overly complete is better than lacking information when your attending asks during a report. I won't include all of it, but I'll know it. I really don't have a feel for what's important or not yet, so I just ask everything.

That's what you'd think, but many of the Attendings really just want a concise report. To find out what a specific attending wants, you have to pick it up somehow or ask them directly. I found most are fairly forgiving if they know you're starting 3rd year. If it's the end of 3rd year, most of them expect you to 'get the job done' which means spend your time as efficiently as possible.

 

[han14tra]

Thanks for all the answers. It is suppose to be a comprehensive history (seeing the patient in a primary care office for the first time).

On a different note, anyone else ever fill in a scantron sheet wrong? Just got 2 questions wrong on I guess because I reversed them on a scantron sheet. I also wrote the answers on the actual test with explanations and showed my work. Think the prof will change my grade? I meet with him this afternoon. It was a 12 q quiz so it will bring my grade up about 20 pts if he does.

 

[Bacchus]

So are you seeing an actual patient... off the street or is it an SP in a FP setting?

 

[han14tra]

So are you seeing an actual patient... off the street or is it an SP in a FP setting?

It's a SP, but Jefferson has a clinical skills building where all the rooms are set up like the exam rooms you would find in a family med setting.

 

[Bacchus]

It's a SP, but Jefferson has a clinical skills building where all the rooms are set up like the exam rooms you would find in a family med setting.

Oh, OK... just got a little confused. It would have been somewhat "useless" to have a real patient before an SP, ya know?

The point of these SPs is for us to learn how to probe and ask questions. We've learned several exams already over here on City Ave (Fundoscopic, pulmonic, cardiovascular) and the order we have to do them in doesn't flow particularly well. So, we're doing them to do them and learn. You'll realize, as will I, when we get out into the real world, or 3/4th years, how to make things flow, ask what we need to, etc. Now you're doing it to learn and for the grade so do whatever your FP preceptor asks you to do.

So: Are you satisfied with your relationship? Are you sexually active? Do you use protection... etc. Gotta ask, for your sake and your grade's sake.

 

[ChiDO]

So basically you have a SP with a cough and you have to take a History.

C - Chief Complaint (what brings you in today?)
O - Onset (when did your cough start)
D - Duration (how long have you had your cough, has it changed, did you have this before, if yes, did you see a doctor, what did he give you)
I - Intensity (scale of 1-10, effect your life? skipping work?)
E - Exasperate (anything make it worse)
R - Remitting (anything make it better)
S - Symptoms (hardest part as a medical student...since you sometimes don't know all the pathology associated with something)
-Fever/Chills/Nausea/Vommiting/Diah/Constipation
-Cough -> anything come up? -> color/smell/content
-Running Nose/soar throat/ear ache/lymph nodes swollen
-Ect...

Then we go to Social (FED TACOS + SMASH FM)

Food?
Exercise?
Drugs?

Tabacoo?
Alcohol?
Caffenine?
Occupation?
Sexual? - since this is the main concern. (are you sexually active? do you have multiple partners/married? do you use protection?)..that's all..normally the SP will answer yes, married, one partner, use protection...if this case was concerning a UTI, your SP would be given certain answers to these questions...

Medication?
Allergies?
Surgical Hx?
Medical Hx?

Family Hx?
If female, also has First day of last normal menstrual cycle.

And now you are done. Ask if they have any questions, thank them, leave the room.

 

[ZagDoc]

I mean, you ask questions based on common sense. "What could this be...and what questions could I ask that would help me figure out what this could be?" You don't ask random questions by rote memory because someone in ICM told you to.

This is the eventual goal, yes. But I remember my standardized patient encounters from MS1. You simply don't know enough pathology as a first year to form an adequate differential to do much of a "focused" anything. Granted, if you're checking DTRs on a patient with rhinorrhea, you're way off base, but taking the history is more of an art.

Along the art analogy, you don't start off an impressionistic painter. First you have to learn about proportion, lighting, scale, depth of field, color. You practice those fundamentals and build on them. Its only after you master the fundamentals that you can play with them and produce a certain style.

In the same way, you start off as a MS1 doing things by memorization. You take histories in a checkbox format (OPQRS, ROS, HPI, etc). You do physical exam in a choreographed manner. The purpose is to get you comfortable with those skills, so that when you learn to form a good DDx you can pick and choose the pieces to use to get the information you need.

To the OP, at this stage in your training, its better to over-ask everything then to miss anything important. A social history should go into habits (tobacco, EtOH, illicit drug use), diet, exercise, job, living situation, sexual habits. At this stage you should be asking everything so that you get adept at asking the questions. The "focused" part will come later.

 

[smq123]

We aren't doing any physical. We are supposed to get a complete history and then leave. We have 15 min max, I think I spent 11 doing mine.

I remember that now; it's just a physical. I remember when we did ours, the people who led the course (which used to be called MP21, and is now called ICM) stressed it was to be a FOCUSED physical. The people who teach the course have changed, though, so I guess they changed the assignment. Our CC was back pain.

Are they going to review these tapes for your small groups like we did? That was kind of excruciating, although they make you videotape yourself interviewing a patient on peds, which is worse.

That's what you'd think, but many of the Attendings really just want a concise report.

Yep, the famous, "<exasperated sigh> Just give me the one liner!!"

 

[Jolie South]

That's what you'd think, but many of the Attendings really just want a concise report. To find out what a specific attending wants, you have to pick it up somehow or ask them directly. I found most are fairly forgiving if they know you're starting 3rd year. If it's the end of 3rd year, most of them expect you to 'get the job done' which means spend your time as efficiently as possible.

I should clarify that I meant I ask the information for me, include what I think is relevant in a report, then if an attending asks something that I didn't include in my report I can have the answer.

I can't think of the complete DDx when I'm interviewing someone, so I ask to have the all info in case.

 

[Dral]

I should clarify that I meant I ask the information for me, include what I think is relevant in a report, then if an attending asks something that I didn't include in my report I can have the answer.

I can't think of the complete DDx when I'm interviewing someone, so I ask to have the all info in case.

That's what I've found is the most efficient for 3rd year and what impresses them the most. Present what's important...have other info if needed/asked. 👍

 

[Disinence2]

Agree with the input above however...

In the interests of passing your exam you should try to find out what your evaluators expect of you. Usually there's some sort of evaluation/grading sheet that's being used. Take a look at it and figure out what they expect.

We had one "sexual concerns" interview where we did have to go into ridiculous detail. Even getting points for asking things that would probably border on harassment in the true clinical setting.

Play the game to get good grades, but use common sense when dealing with real patients.

 

[richse]

Oh, OK... just got a little confused. It would have been somewhat "useless" to have a real patient before an SP, ya know?

The point of these SPs is for us to learn how to probe and ask questions. We've learned several exams already over here on City Ave (Fundoscopic, pulmonic, cardiovascular) and the order we have to do them in doesn't flow particularly well. So, we're doing them to do them and learn. You'll realize, as will I, when we get out into the real world, or 3/4th years, how to make things flow, ask what we need to, etc. Now you're doing it to learn and for the grade so do whatever your FP preceptor asks you to do.

So: Are you satisfied with your relationship? Are you sexually active? Do you use protection... etc. Gotta ask, for your sake and your grade's sake.

As far as I have heard we don't get a grade on these. I double checked that with my small group leaders tonight. They said it kinda ties in with our whole small group grade but that's mostly a participation/effort type grade at the end of the year.

 

[richse]

I remember that now; it's just a physical. I remember when we did ours, the people who led the course (which used to be called MP21, and is now called ICM) stressed it was to be a FOCUSED physical. The people who teach the course have changed, though, so I guess they changed the assignment. Our CC was back pain.

Are they going to review these tapes for your small groups like we did? That was kind of excruciating, although they make you videotape yourself interviewing a patient on peds, which is worse.

Yep, we have to pick up our DVD's before break and then we watch them with out small group at our first meeting next year. We've done quite a few "in class" history practice sessions so I'm hoping this won't be much worse. There was some talk of making a highlight reel instead of watching the whole 15-20 minutes of interview/feedback for each MS1 in the group.

 

[Jolie South]

Yep, we have to pick up our DVD's before break and then we watch them with out small group at our first meeting next year. We've done quite a few "in class" history practice sessions so I'm hoping this won't be much worse. There was some talk of making a highlight reel instead of watching the whole 15-20 minutes of interview/feedback for each MS1 in the group.

We were supposed to present selected moments to small group last year of a cultural SP encounter. I was never so glad as when the TV in the room decided to crap out and we didn't have to do it.

 

[greatnt249]

But how far do you go? We were taught how to do it for teens? But, they never really said how to apply it to adults. Do I need to ask a married 60 year old who they are having sex with and what forms?

Or, can I just say:

- Are you sexually active?
- Are you using protection?
And, that's it.

You tailor your questions to the patient you're dealing with, and you can get a lot of information from questions asked during other histories. If you know the patient's a happily-married 60-y/o female, then your list of sexual questions will probably go as follows:

1. Are you pre-/postmenopausal?
2. (Assuming husband isn't in room) Have you ever had any sexual encounters outside of your marriage?
3. If yes to 2, do you use protection?
4. Do/have you (ever) had an STD?

Asking what forms of sex they have really only seems to be relevant if the lifestyle you discern from the social history/other means puts them in a risk category; in the above case, not so much. Despite the sexual history not seeming relevant when the patient comes in with a CC of "cough," I think the preceptors are more concerned with you being thorough with the HPI/history than actually forming a DDx. At least, that's what was expected of us this semester in clinical skills; we were supposed to assume that this was the first time the patient was in our clinic.

 

[jumpingjax]

Tomorrow is my first standardized patient interview. I don't know how to take a social history. I know to ask about their living arrangement and job. But, do I talk about sex?

We learned sexual history taking this week, and it confused me. Am I really suppose to ask every patient who they are having sex with and if it is vaginal, oral, anal, etc?

I'm seeing a patient with a cough. We are suppose to assume it is their first office visit and take a full medical history.

Are you serious? LOL!

You: I'm Dr. ___, what's bothering you today?

SD: Well, I've had this cough for a few days.

You: Did you have anal sex last night?

Ha! I'm sorry dude, it reminds me of what it was like to be a 1st year. Seriously though, good advice by others above. You'll be fine.

 

[smq123]

Ha! I'm sorry dude, it reminds me of what it was like to be a 1st year. Seriously though, good advice by others above. You'll be fine.

Yep; the first time I saw a real patient (who came in for something really basic, like a cough or something), and I tried to take a complete history, she did one of these:

"😱 😱 WHY ARE YOU ASKING ME ALL THESE UNRELATED QUESTIONS? DO I HAVE SOMETHING THAT MAKES YOU SUSPECT AIDS OR SOMETHING???"

Ooops.