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June 3, 2011 9:49 pm

Sometimes it’s what patients don’t say that really counts

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Doctors are meant to be reassuring, so it can be a surprise to find that patients like to provide reassurance as well. They may tell you not to worry about their symptoms, playing down their pain and making light of their breathlessness. And often, when you ask about their past medical problems, nothing much comes to mind. “I’m usually pretty well,” Mr J says. “Just a little arthritis.” The next morning the consultant comes round and asks Mr J the same question. At which point he reveals – as you stand by feeling silly – that he did in fact have a “small heart attack” in 2007, now he comes to think about it.

The story of what happened to the patient before he came to see you – his medical history – is the basis of diagnosis. If you can glean an accurate account of someone’s current symptoms and their previous conditions, most illnesses will identify themselves without the help of blood tests or scans. Unfortunately histories are variably reliable.

The commonest problem is omission. Everyone leaves things out. In fact it is essential to leave things out, or every consultation would take an hour. The difficulty arises from editorial differences: the gap between what the doctor wants to know, and what the patient thinks the doctor wants to know.

For the patient, a possible link between a lung cancer that was successfully treated in 2006 and the pain they now have in their hip may never suggest itself, and so Mr J will kindly save you time by not mentioning it. He is probably right – it is almost certainly not a recurrence of his cancer – but you are diagnostically disadvantaged without the information.

Treated illnesses in particular tend be omitted: either they happened so long ago that the patient has forgotten about them, or they’ve been so well fixed that they no longer seem relevant. Rheumatic fever in childhood can cause a leaky heart valve in later life; but who, at 77, connects their swollen ankles to an illness that they had when they were seven? And operations, for some reason, seem amazingly forgettable. It is common for Mr J to tell you that he’s never been unwell and then when you examine his abdomen it is covered in scars. “Oh, that was my gall bladder ... that was my appendix – but that’s a long time ago now, lovey.”

Often the patient assumes that you have it all in front of you already. Which is probably true: in hospital, you will usually have the patient’s “old notes”, a scuffed stack of papers that is intent on unbinding itself; in general practice, a computer screen that scrolls back through time and documents every sneeze. But patient notes aim to capture everything – here is your blood pressure and your temperature as it was on March 19 2009 – and in getting a good history, we only want to know some things.

So it is still usually quicker and easier to find out what you need from the patient himself. Which means you must remember that they may not know what to tell you, and they may not understand what you’re asking, either. Doctors are famous for their unreadable handwriting, but some also speak impenetrable medicine. “Have you ever been in hospital before?” gets you further than “What is your past medical history?” “What is this tablet for?” is clearer than “Do you take any medication?” And “Have you ever been ill?” risks an epic recollection of every last snuffle – but at least then you can decide what it is safe to leave out.

Sophie Harrison is a hospital doctor in South Yorkshire.

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