med student: getting the patient's history

[NERDY]

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I've received some feedback from some doctors that I need to "improve" my history taking skills. Some say I am not thorough, others say I am being too thorough and asking too much not related to the CC, etc. Sometimes, when I go to present to the patient, I didn't ask a certain question that the doctor asks me (ie did you ask the patient if he/she has x,y,z?). On the other hand, many doctors say I am doing just fine for my level and doing a good job. I know everyone has his/her "way" of taking a history as it relates to the CC but since it has been brought to my attention, I would like to improve this skill.

Sometimes, this occurs because patients give a different story to the doctor than to me, which I can't control. I know EM is a different field than the year 3 rotations where I had no difficulties with getting the history as stated in my evaluations. I make sure to get OPQRSTAA for pain related complaints, asking about related signs/symptoms, getting Family/social/past med hx/past surgery/meds/allergies/etc, ask why they came to ED today, ill contacts, prior episodes, etc. Any suggestions of ways to improve, books to read, templates to follow, etc? I know we all get better with time but any input would be great. Thank you. Good luck to everyone with the match!

 

[deleted109597]

http://intranet.emergency.med.ufl.edu/med_students/peds_rotation/reading_assignment/The%203-Minute%20Emergency%20Medicine%20Medical.pdf

 

[NERDY]

Thanks for posting the link. I've read that article before and I have attempted to tailor my presentations to the articles suggestions. Any other input?

 

[brucecanbeatyou]

When you own the differential and plan, people won't care about the history anymore. Think of the differential, and have this drive your questioning. Then, when you present, again, think of the differential and just give details that paint a story that doesn't leave any room for doubt that you asked the right questions in the h and p.

 

[coffeeeandtea]

When you own the differential and plan, people won't care about the history anymore. Think of the differential, and have this drive your questioning. Then, when you present, again, think of the differential and just give details that paint a story that doesn't leave any room for doubt that you asked the right questions in the h and p.

^^ second this

the best piece of advice i got on my ED rotations was that when you're presenting to the attending, pretend like you're trying to argue your case or like you're selling them something. don't just gather facts and regurgitate them without a clear direction. have in mind what you think is wrong with the patient and then just give the pertinent positives/negatives related to what you think it is. e.g. "most likely gastroenteritis because of XYZ," but always keep in mind the dangerous things first and say why you think or don't think the dangerous ones are what's actually wrong with the patient. also be confident about your treatment plan to go along with what you think it is - if you're wrong, the attending will tell you, but don't be wishy washy. "i think they need IVF, abx, and admission" versus "i think they can go home." remember that dispo is king in the ED

 

[Transmogrifier]

I'd guess you're at the beginning of third year.

It'll really just take time being exposed to lots of patients. I think residents and attendings might forget that its very likely that each patient we see is the first time we've ever actually encountered that complaint in real practice. After you've seen a lot of patients with abdominal pain, you get a lot better at taking a focused, yet thorough history to cover each individual patient. That's probably why you have a mixed back of feedback. Sometimes you ask too many nonessential questions because you don't know any better. For the same reason, you miss important things: you don't know what you don't know and it doesn't occur to you to ask certain things or perform certain physical examine components.

Like others have said, work on honing the differential. That is, get better at weeding out things you don't need to worry about and make sure you know what important things you do need to consider for each patient. I've really like the Diagnosaurus app to help me broaden my differentials.

 

[Daiphon]

Try presenting to a resident first (as long as the patient isn't sick... if they are, get the heck outta the room & get the attending)...

Succinct and appropriate presentations come w/ practice. If you find you're getting tongue-tied and lost in the reeds, running it through once with a resident (who is more likely to recall his/her bumps in the road, and can help you manage the attending in terms of what's important or not) can go a long way.

It comes with time & exposure... you'll get better. Listen to *everything* even if not your patient; if you pay attention to what and how the residents are presenting, you'll pick it up faster.

Cheers!
-d

Sent from my DROID BIONIC using Tapatalk

 

[justaregularmed]

Honestly after thinking about it just ask at the start of the shift what the attending wants, this will make it go much smoother. Some only want to hear about the chief complaint, some want to hear everything, some will crucify you if you present more then one problem to them. Keep it as short as possible and realize some people are just pathological and cannot be pleased. Bottom line is just make sense and you wont go wrong.

 

[The White Coat Investor]

A med student history takes 30 minutes. An attending history takes 2 minutes. Once you figure out why, you'll learn what the attending wants to hear. There are many details that simply don't change what tests are ordered and what the disposition is. Eliminate them. Same with the exam and tests really.

 

[Zanegray]

If you have time, before you see a patient take a look at a quick reference like pocket emergency medicine or skim up to date or emedicine on a topic like back pain or abdominal pain. At a minimum think about your differential BEFORE you go in the room. This will help frame your interview and make sure you ask salient/ important topics.

Also when you are presenting remember you are trying to "sell" your story. What do you think is going on? What do you need to prove it? What don't you think it is? Why not? What do you need to prove it?

And, as stated earlier-yo will get better over time. 3rd year is all about learning h&p for various specialties. 4th s about assessment and plan.

GL

 

[deleted109597]

Honestly after thinking about it just ask at the start of the shift what the attending wants, this will make it go much smoother. Some only want to hear about the chief complaint, some want to hear everything, some will crucify you if you present more then one problem to them. Keep it as short as possible and realize some people are just pathological and cannot be pleased. Bottom line is just make sense and you wont go wrong.

Yes, there is a component of knowing what the person wants.
But you also have to realize that even after all your schooling, you still don't know much. Listening to feedback and changing what you do with instruction is more important to me than just being nearly right the first time.
Asking what they want will always result in "I want to know what is important", which as you've correctly noted, is different for many attendings. Asking the residents will probably help you more.
And if you continue to attempt to tailor your presentations to that article, I can't imagine anyone faulting you.

 

[AlmostJesus]

What do ya'll think about the way EMBasic has for presenting a patient?
http://embasic.org/2012/03/27/how-to-give-a-good-ed-patient-presentation/
Im not a med student yet, but as a paramedic, I have started to loosely use that mindset when I am assessing a patient as a way to guide what path I take with the patient. I feel it helps me with my patient presentations and I end up being more focused in what I communicate.

 

[deleted109597]

He's got good links in his replies as well.
http://emupdates.com/2010/09/15/screencast-how-to-think-like-an-emergency-physician/
https://docs.google.com/document/d/14gNBQ9oQqaieBHv_4BBwh_Jyjg6JkcuPAypXZacc4-E/edit?hl=en