Posted by: Tony Copperfield29 September 2016
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