Storytelling

One of the reasons I went into medicine was to really understand people. As stupid as it sounds, I have always been intrigued by the questions of who we are and what the hell we are doing here. I had always sought out people who were very different than myself. And I loved to listen to them talk. Some of my favorite memories are of listening to strangers tell their stories. I remember sitting on a curb in Seattle listening to a homeless man named Sampson instructing me on medicine “Everytime you blink, your mind takes a picture”. And wandering with a stranger through Vancouver as she gave me a clubbers tour of the streets and asked “Have you ever wondered what God smells like?” And there were so many others. The nuances of how they talked, the foreign ways in which their minds worked, enriched my view of life.

I went in to medicine expecting that, if anything, I would hear more of these stories. Who else can you be honest with if not your doctor? Somewhere in my naivety I thought that being involved in thousands of patient’s lives would help me understand this world more.

It turns out that doctors have very little time for conversation. I can count on my fingertips the number of times I’ve been able to sit in a chair at a patient’s bedside and just relax and really talk to them person to person.

The one story that we are expected to hear as physicians is called “The History of Present Illness” (HPI).  A very elegant way of saying “What the hell happened to you?” For those of us in Internal Medicine it may be the most important thing we do, because tells us what the problem is way more than the physical exam usually does. It is also important for the patient as it is likely the longest contiguous time a doctor will speak with them while they are in the hospital.

So what makes a good HPI? Well…if you talk to a coder/biller there are specific elements, and you must hit a certain number of these elements to bill at certain levels.

  1. Location
  2. Quality
  3. Severity
  4. Duration
  5. Timing
  6. Context
  7. Modifying factors
  8. Associated Signs and Symptoms

Garbage, I say. Those are all important elements. But a good HPI is essentially a story. When you are presenting later you are able to present the HPI because the story has a flow and it has a style. The main character is your patient. And the HPI should play in your head like a movie.

How do you get a good HPI?

I can tell you how you don’t get a good HPI. You don’t get it by copy and pasting the ED physician’s note.  The ED is a different world from Internal Medicine. I have always said that the ED has the most difficult job in the hospital because they have to know a little of everything.  Their job is not to get a complete history. Their job is to triage, decide what the main problem is, whether it requires admission, who would be best to take care of the patient and resuscitate the patient to get them to the admitting team in a stable manner. Doing that requires a brief and focused history. Totally different that the HPI that is required on the wards. Besides, if you copy and paste, I’ll kill you.

So if you aren’t going to copy and paste, how do you start?

I always start with a chair and an apology. Pull a chair up to the patient’s bedside so you don’t look like you’re either hovering above them or ready to run out the door. Then say “I’m Dr. Bradford. I’m one of the lung doctors and we were asked to see you. I know you’ve told your story to at least ten different people by now but I’m going to be taking care of you and it always helps for me to hear it firsthand rather than from the chart. So if you don’t mind, can you tell me how this all started.”

Okay, so you shouldn’t call yourself Dr. Bradford unless that’s your real name. But that is how you start. Very open-ended.  If you start from the beginning, the patient will usually lead you from there up to how they came to be in the hospital. Getting a continuous story is essential. The patient may jump over parts and I will usually interrupt. “You said you went to the bathroom and then called 911. We did you do in the bathroom? Did you take anything in the bathroom to help with the nausea? Did you vomit? Did you call right from there or did you go back to bed first?” Unless the patient’s symptoms began immediately before coming to the hospital, one of the most important questions you can ask is “What was it that finally made you call 911 or drive to the hospital?” You can’t imagine how difficult it is for many patients to know whether they should come to the hospital or not. Especially in patients with chronic disease there is usually something very specific that triggered alarm bells for them. The chest pain that reminded them of their last MI, the vomiting that they’ve never had before after missing a dialysis session, or pissing the bed because they were too weak to get up.

The problem with getting a history like this…it takes time. And time is what a doctor does not have. So you have to keep the patient focused while letting them do majority of the talking. If a patient has been talking for thirty seconds and hasn’t said anything medically useful, alarm bells should be going off in your head. You need to regain control over the story. There are several ways to do this. My favorite way is to take a second while the patient continues to talk and think back to where the history got derailed. They were talking about their how their doctor had been changing their medications for pulmonary hypertension and now they are talking about their cat. Interrupt them, you have to. Look pensive and say…”I want to go back to something you said before that may be important. You said doctor Farber was changing your medications. But you didn’t say why, or what he changed them to.” As a rule patients don’t mind being interrupted for a doctor to clarify something as much as they mind the entire conversation being cut short as the doctor backs towards the doctor because they have completely run out of time. And by taking them back to something they were talking about before, you are showing both that you were listening to them then, and that you are continuing to think about their problem.

I usually wrap up the HPI when I have all the information I need by giving the patient my impression of what is going on and the testing that will need to be done. But as you walk out of the room feeling smug and self-satisfied there is one thing you should realize. The history will change. They say that the minute you drive a new car off the dealer’s lot it loses half its value. Your HPI is the same. After you leave, the patient will remember things that they did not tell you. When your attending comes to see the patient after hearing the HPI from you, they will ask the same questions in slightly different ways and therefore get completely different answers. It is expected. We all use slightly different vocabulary and phrasing and this will affect the history the patient gives. This phenomenon is particularly important for consult services called because the patient isn’t getting better. That is the time to get the HPI from scratch to see what was missed and what changes. On pulmonary consults one thing I always like to ask for these patients is “Is there anything that you’ve thought of that may be important that you haven’t told a doctor yet?” That’s when they admit to taking amphetamine-laced sexual enhancement  supplements prior to that orgy during their trip to the Caribbean.

So for my money, the HPI is by far the most interesting part of medicine. Your differential diagnosis is directly related to it. You physical exam serves no purpose except to confirm it. Your treatment is based on it. And if your treatment isn’t working as expected, it is often because you didn’t do a good enough job getting it in the first place. Spend time getting the history, because it is also one of the few times you'll get the chance to connect with your patient.

 

The Mandatory Disclaimer: All information on this website is purely for educational and training purposes. Use best clinical judgement, the most current reference articles, medical standards of care, and specialist consultations when making clinical decisions for your patients.

Last Updated December 16, 2012