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Replace me with an app? Just try it

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According to Sir William Osler, we should ‘listen to the patient, because he’s telling us the diagnosis’. Sure, but Sir William didn’t work in Essex, circa 2016, did he? If I listen to the patient, all I hear is moans about getting an appointment, a totally inappropriate request for a scan/referral/antibiotics or an endless white noise of irrelevance. What I’m not going to hear is, ‘Doc, I do believe my symptoms add up to pseudo-pseudo hyperparathyroidism.’

Everywhere, the history-taking process is being undermined

But I’ll listen for a bit, because I respect old Ossie and his wise and pithy aphorisms. And when I’m bored of listening, I fire up that part of the clinical process that I really, truly still believe in – my history-taking skills. I sift through the verbiage the punter has vomited up for anything sentient, then embark on a focused enquiry, starting open, arsey-GP stylee and ending with a yes/no interrogation.

It’s the classic approach. And as any GP knows, the history gives us 90% of the diagnosis. The physical examination only exists a) To confirm what we already know b) To fool patients into thinking we’re being thorough and c) To stretch our legs, because after two hours in surgery, our glutei are glued down. Investigations? Pah! They just encourage the patient to bugger off and allow time to do its diagnostic or therapeutic thing.

Trouble is, while I still have complete faith in the history, I’m not sure the patients do. I’ve just finished a ‘consultation’ with a punter who, fairly typically, chose to interpret my considered history-taking as me obstructing him from his intended goal, viz a referral to a proper doctor who doesn’t fanny around asking questions. So he interrupted my logical enquiry about his pain’s site, sort, nature, radiation, exacerbating factors etc etc with the comment, ‘Look, doc, all I can tell you is I’ve got a pain and it hurts,’ in the manner of someone inviting me outside to experience some pain of my own.

And I can’t blame him. Everywhere, the history-taking process is being undermined. Jeremy Hunt’s latest Big Idea is to reduce it to a few questions tapped into an app. In the meantime, NHS 111 parrots a history-parody that starts with the assumption that you’re either pregnant or dead, even if you’re a bloke with an ingrowing toenail.

Once in hospital, things don’t improve. Patients are subject to some catechismic scoring system and unnecessary investigation to rule out, say, a DVT, when the most cursory history would have confirmed a pulled calf muscle. Or they get an All-You-Can-Scan body investogram, regardless of symptoms, which impresses the patient, costs the NHS a fortune and provides a rat’s maze of blind alleys to pursue – and still misses a diagnosis that a proper history would have picked up in minutes. It’s not a renal cyst, lung nodules and adrenal swelling, you fools, it’s anxiety.

So it’s time to reclaim and revalue this jewel in the crown of clinical method. Educators and supervisors take note. Otherwise, the history will be history. And so will the NHS.

Dr Tony Copperfield is a GP in Essex. You can follow him on Twitter @DocCopperfield

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Readers' comments (13)

  • if I change my name to Dr App by deed poll will they pay me more?

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  • The apps seems to be wanting to replace the reception, not the doctors. The case being made by the article, in my opinion, is without merit.

    How much control of the appointment book we want to hand over is another matter. I see pros and cons.

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  • You couldn't say anything more true.
    The history is king and done well, is in itself a therapeutic intervention with significant power that an App or person over the phone with a flow diagram can never provide.

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  • The NHS needs to be dissolved. Dumb ass politicians stealing the Drs white coat, acting like its them who went to medical school, busy telling us how to do our job. It's time to reclaim our profession and tell the politicians to go stick it. Scrap the NHS. I've had it with being dictated to by nurds

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  • Absolutely spot on as usual - a good history can save a small fortune in unnecessary tests - which will rarely get you anywhere useful anyway - but sadly it's constantly being devalued by the addiction to new technology.

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  • Patients do not give a flying monkeys about our history taking skills and explanations. Google say they need an MRI, end of. Friend if a friend of a friend has similar symptoms and died....investigat all day long otherwise they will keep on coming and contacting lawyers.

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  • Phil Yates

    Well said! One acute Trust I recently visited had 5 CRs & 4 MRIs. How many of these investigations really add value? And which obfuscate and add irrelevant complexity? To say nothing of upping the anxiety of the patient & useless cost to the taxpayer

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  • Don't forget to document your awesome history
    Not written = Not done

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  • David I concur entirely that the history is King. I would add however that a careful examination may often reveal a lot ,or important negatives at least. (and if carefully documented greatly reduces your chance of being sued for not ordering an expensive pantograph)Patients remember being examined,they may not recall what they were asked. It takes a few seconds more,but keep those observing,palpating,percussing and auscultating skills up to scratch folks not knly will they keep you out of court but youwill find more stuff!

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  • I love this blog. Especially the bit about why we examine. I agree 100% and something I am always discussing with trainees.

    The history is not just King- it is God (if you are of a spiritual persuasion)

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From: Copperfield

Dr Tony Copperfield is a jobbing GP in Essex with more than a few chips on his shoulder