Most complaints about doctors relate to the failure of
adequate communication.1,2 Encouraging patients to
discuss their major concerns without interruption
enhances satisfaction and yet takes little time (on
average only 90 seconds).3,4 Giving premature advice
or reassurance, or inappropriate use of closed questions,
badly affects the interview.
Giving a patient the impression that you disapprove
of some aspect of his or her life can put up a major
barrier to the success of the interview. Avoid what might
be seen as a judgemental attitude to anything you hear.
This should not prevent you from giving sensible advice
about activities that are dangerous to the patient’s health.
Expressing sympathy about the patient’s problems
(medical or otherwise) should be a normal human
reaction on the part of the clinician.
TAKING A GOOD HISTORY
Communication and history-taking skills can be learned
but require constant practice. Watch for signs that the
patient is uncomfortable. For example, the sudden
breaking off of eye contact or the crossing of arms or
legs: this body language suggests that the patient is not
comfortable with the questioning and you need to
redirect or change tack.5 Factors that improve
communication include using appropriate open-ended
questions, giving frequent summaries, and using
clarification and negotiation.3,4,6 (See List 2.1.)
THE DIFFERENTIAL
DIAGNOSIS
As the interview proceeds, you will need to begin to
consider the possible diagnosis or diagnoses—the
differential diagnosis. This usually starts as a long and
ill-defined mental list in your mind. As more detail of
the symptoms emerges, the list becomes more defined.
This mental list must be used as a guide to further
questioning in the latter part of the interview. Specific
questions should then be used to help confirm or
eliminate various possibilities. The physical examination
and investigations may then be directed to help further
narrow the differential. At the end of the history and
examination, a likely diagnosis and list of differential
diagnoses should be drawn up. This will often be
modified as results of tests emerge.
This method of history taking is called, rather
grandly, the hyopthetico-deductive approach. It is in
fact used by most experienced clinicians. History taking
does not mean asking a series of set questions of every
patient, but rather knowing what questions to ask as
the differential diagnosis begins to become clearer.
FUNDAMENTAL
CONSIDERATIONS WHEN
TAKING THE HISTORY
As the medical interview proceeds, keep in mind four
underlying principles:
1. What is the probable diagnosis so far? This is a
basic differential diagnosis. As you complete the
history of the presenting illness, ask yourself:
‘For this patient based on these symptoms and
what I know so far, what are the most likely
diagnoses?’ Think about the anatomical location,
then the likely pathology or pathophysiology,
then the possible causes, then direct additional
questions accordingly.
2. Could any of these symptoms represent an urgent
or dangerous diagnosis—red-flag (alarm)
symptoms? Such diagnoses may have to be
a This does not happen often but Christmas disease is an example of a
disease named after the patient rather than the clinician.