Kiran Gupta writes about her experiences as a resident in the Department of Medicine at Brigham and Women's Hospital. She has done research on domestic health policy issues, including health care costs, medical errors, and end-of-life care, and is a former columnist for the Financial Times Weekend Magazine. Kiran received her A.B. in Government with a certificate in Health Policy from Harvard College and earned her M.D. from Harvard Medical School.
One busy call night, while handling multiple admissions from our emergency room, I received a page notifying me that a new patient, Mr. T, had just arrived on the hospital floor. I looked up his medical record number, but no records were found in our computer system. I rushed to his room, expecting the worst.
When I arrived, he appeared remarkably stable. The chart at his bedside provided a working diagnosis for Mr. T’s primary complaint, shortness of breath, but I wanted to hear directly from him about his condition. After reviewing his vital signs, I put down my notes, pulled a chair up, and began taking his history.
I started with the open-ended, “Tell me what brought you to the hospital today.’’ Mr. T was articulate, his account rich with nuance and detail, exactly as I had hoped. I could see that he wanted to continue. I didn’t interrupt. As his history unfolded, the story it told – without fancy imaging, expensive bloodwork, or invasive tests – confirmed his diagnosis. When Mr. T had answered the last of my questions, and as I made my way through each step of the physical exam, I kept thinking about his history. I could hear the murmur in his heart loud and clear, perhaps because I knew what to listen for even before I had placed the stethoscope on his chest.
I had been in his room for less than half an hour, but we had built a rapport. Mr. T had shared with me some of the most intimate details of his life. The act of taking his history had provided me with valuable information about his medical condition. Just as importantly, it offered a glimpse into how his ailment was affecting him, leaving me with a sense of empathy that I could not have gained from perusing his chart.
Though it should seem routine, my interaction with Mr. T felt like a rarity. Contrary to what I had learned in medical school, as a resident I quickly realized that in the hospital setting, a patient’s history is almost never taken in logical or linear fashion, with the patient relaying a sequential series of events to a doctor seated next to him. Rather, it is often pieced together haphazardly from notes in the existing electronic medical record, old test results, and emergency room assessments — often before we even meet the patient. Time at a patient’s bedside is largely spent confirming details already acquired, performing the physical exam, and ensuring that nothing was missed.
This has significant implications for the quality of care we deliver. It means that certain vital information is not always confirmed firsthand. It can be tempting to cut and paste a long oncologic history from an old clinic visit or take the medication list from a primary care doctor’s note, instead of taking the time to confirm this information directly with our patients, their family, or a local pharmacy, especially in the middle of the night or on a busy day. Yet we make vital decisions based upon the accuracy of this information.
It is unrealistic to expect that all patients will understand the conditions they have been diagnosed with, or be able to relay their history using appropriate medical terminology. Dementia, infection, and many other medical and non-medical factors can significantly limit the ability of patients to provide a precise medical history. In these situations, we are forced to rely more on the physical exam, laboratory studies, whatever records we have available to us, and family members if they are present. But we have gotten into the habit of doing this so often that sometimes we forget that, when possible, we should always try to ask our patients for their medical history directly, even if they can’t provide all the details. An inaccurate or cursory history can lead to a delay in diagnosis, unnecessary testing, improper medical management, or worse — harm to our patients.
Taking a patient’s history properly is important not only for providing optimal medical care, but also for helping us as providers find meaning in the relationships we build with our patients. On paper, Mr. T’s history was relatively similar to the story he told me as I sat by his bedside. It would certainly have taken less time to read a note from his doctor. But, the photocopied pages faxed over from a physician’s office wouldn’t have captured the distress in his voice as he relayed how difficult it had become to walk his dog or take a shower because of his shortness of breath – and his deep-seated worry that he would never get better.
I sense that my generation of physicians is losing something precious, the very reason why many of us were drawn to medicine in the first place — time with our patients. In a system burdened with financial pressures as well as significant time and resource constraints, it can be easy to reduce patients to charts, labs, and a list of “to dos.’’ Yet caring for patients involves something more: It requires a sense of humanity. If we are to maintain this, we must find a way to change the current system so that we always have time to listen.