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Are we better or worse historians in the age of electronic medical records? The EHR makes it “easy” to gather information, certainly easier than taking the time to talk with our patients.

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I once had a patient who complained of “the whites”. It took quite a while for me to determine that she was passing large volumes of white mucus from her rectum, sometimes without warning or control, unrelated to her bowel movements. She had limited education and life experience, so she lacked the words to describe her experience. Beyond that, it turned out to be a problem that I had never encountered before (or since, for that matter!). Her anatomical knowledge didn’t extend to knowing the proper names of her urethra, vagina, and anus, so I had to figure out what she called the various holes between her legs. I don’t think she’d ever had much opportunity to talk to anyone about how her bowels worked. The word “diarrhea” wasn’t in her vocabulary, so it took a while to figure out that it wasn’t diarrhea. She was pooping normally. She had an outhouse, so she didn’t routinely inspect her normal bodily outputs, let alone the stuff she was trying to describe, except when it appeared in her underwear. She had no idea what mucus looks like. Mucus looks like snot, but in her case there was a lot of it and it wasn’t coming from her nose! We talked at length about what other words she might use to describe her problem, what exactly was coming out of her body, what hole it was coming out of, what else came out of the same hole at other times, and what other bodily functions her problem might be connected with, such as bowel movements, menstrual cycles, and urination, all while learning and then using her unique “lingo”. In the end, it turned out that she had a relatively uncommon tumor in her rectum, something called a villous adenoma. To figure that out, she saw a specialist. Throughout the entire process of investigation and treatment, I continued to provide translation services, because she never did learn how to tell her story in language that most doctors would understand.

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Then there’s what should be simple terms. Like “shoulder.” The complaint is “my shoulder hurts” and they are talking about their trapezius spasm. I like to ask the patient “point to where it hurts.”

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Aug 12, 2023Liked by Adam Cifu, MD

With respect to the specifics of taking a history from a patient complaining of dizziness, your comments remind me of the lectures I heard over the years given by Dr. Martin A. Samuels from Harvard. I recall his advice, delivered in a very funny style, to ask the question, "What do you mean, dizzy?" then sit back and stay quiet. Most of us take a history by going through our ROS series of questions when what we should be doing, at least initially, is remaining silent and just listening. Appreciate your articles.

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What was BW’s diagnosis?

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I'm in the middle of figuring out a foot problem, and I am appalled at how docs I have seen have not heard what I have said. And then part of the history is the thing, and how the thing was (wrongly) interpreted. Sometimes I find it hard to communicate symptoms, because we may think in language, but we don't feel with language. The worst doc I have seen over the last couple of months *laughed* at me when I described a sensation as "humming". The most recent doc I have seen (and the one I will keep seeing because he is, in my opinion, a good clinician) responded with an enthusiastic "that makes sense!" when I tentatively offered the "humming" descriptor. This comment is perhaps a bit tangential, but wanted to take the opportunity in the middle of my frustration, to emphasize the importance of listening to patients - all of what they say - and believing them. Patients - and docs - are human and imperfect.

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Patients often fail to find words for their dizziness, but to be fair, the medical profession is also still in its infancy in understanding vertigo and how to treat it!

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The history is USUALLY the source of the diagnosis, but sometimes it's just a sed rate.

Learn when to quit pondering over sed rates.

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Love this. I used to find that the “less educated” in my population of addicted folks were often easier to get info from due to their “ignorance” of the way they described their use. The worst patients? Healthcare providers. From nurses to pharmacists to doctors.

Some very creative folks with addiction could manage to fool many; sadly most of all themselves.

I’ll have to list some of the more creative things I’ve heard over the years at some point. And also the ways some were able to “get past” UTOX screens.

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Being accused of exaggeration of symptoms of sinus infection is exactly why I keep a record of the number and TX of episodes. I was TX with levaquin and high doses of steroids every 6 to 8 weeks for 18 months. Wound up with MRSA IN sinuses.

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Excellent piece Adam! 👏 Such an accurate description of how both patient and professional can clarify and obscure the path to the "truth".

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Aug 11, 2023Liked by Adam Cifu, MD

It's not polite to say it, but low intelligence is a big barrier to a good interaction.

You politely call this "low education," but there are those who have low intelligence and a very limited vocabulary.

In my experience, this is an "elephant in the room" that we somehow never speak of. It's not polite to call someone "dumb."

Maybe, if intelligence is distributed normally, we communicate best (take the best history) with patients closest to us on the old bell curve. Get too far to the right or the left and I have a hard time understanding you.

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Aug 11, 2023Liked by Adam Cifu, MD

Very true to a point. But there are patients who do not relate their medical history correctly or completely regardless of your strategies. For example yesterday I had the wife of a colleague in for an emergency who I have seen for at least 10 years. I have an exhaustive medical history on her that is reviewed at every visit. Fortunately she was experiencing a fairly simple combined dental abscess/sinus infection, I just needed to bridge her to the surgical date with some antibiotic. I discussed the situation with her and we agreed that Augmentin would be the best option. The pharmacy called to inform me that the patient was allergic to amoxicillin which the patient agreed with. Even though I had explained to the patient that Augmentin was a combination of amoxicillin with a chemical agent to make it more effective, she was completely oblivious about her allergy while I was talking to her.

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Nice way to approach this issue. Thanks.

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Aug 11, 2023Liked by Adam Cifu, MD

Don't forget the cultural aspect of this as well.

I distinctly remember my surprise when first caring for Filipino mothers who were very worried about their newborn babies dizziness"

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Aug 11, 2023Liked by Adam Cifu, MD

Then there’s the other ‘poor historian’ question students hate: “Have you spoken with the family?”

Communication as a whole remains problematic, from both sides of the situation.

PS. I’ve dropped my amlodipine down the drain once or twice but admittedly haven’t had to ask for a refill because of it.

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