Patient Stories Medical Histories

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Patient Stories Medical Histories

• The Role of Language in Diagnosis and
  Professional Identity

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The Patient History

• A formalized record of the medical history and
  physical examination of the patient at a
  particular time
• Usually constructed around a single issue, or
  problem, called the presenting complaint, or
  presenting concern
• May be presented orally, or in written format
• These oral presentations are often done by
  learners to their preceptors, seniors and peers.

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Learning to do the History

• Usually begun in first year communications
  skills courses
• Followed by clinical skills courses, like the
  Gilbert Scholars program
• Students interview patients, take notes, then
  construct and compose these documents for review

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Year One
Communication Skills (Introductory Block and
Patient Centred Care) (September April)

Gilbert Scholars (small groups (January April)
System-based Physical Exam (Courses) (December to
April)
Second year Program Preceptor program Pediatric
Clin Skills More Block Clinical Skills.
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Later years

• In clerkship, students recite these in hospital
  hallways on rounds, or in larger settings for
  more formal review
• Students write these on patient charts on
  admission, for use as a record of the patients
  care.

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Examples

• Helen Armstrong has a 4-5 year history of chest
  pain. Previously only occurred in the winter, but
  now is a "real nuisance" and is ongoing. Helen is
  bringing up mucous frequently which is green in
  color. She has also noted some ankle swelling in
  the evenings and she "can't put her shoes on".

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• Ms. Armstrong has a 4-5 year history of lung
  complaints (infections?). Her previous physician,
  Dr. Jones, had prescribed "black/red capsule"
  antibiotics for her, and she reported that her
  symptoms were alleviated. Lung symptoms have
  worsened recently have pt. complains for
  interference with sleep, productive purulent
  cough and SOBOE when shopping. On questioning pt.
  admits to passing chest pain for "few seconds"
  left of sternum. No neurological Sx reported. 2.
  Ms. Armstrong is also reporting ankle edema at
  the end of the day to the point where she cannot
  put her shoes back on.  

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• Helen Armstrong is an 80 year old woman. She
  presents with a complaint of "Chest" problems and
  is requesting a refill of her antibiotics, which
  were prescribed by her former physician, Dr.
  Jones. The patient's breathing problems began 4-5
  years ago. Her symptoms consist of a productive
  cough and shortness of breath. Initially it was
  worse in the winter but has recently increased in
  severity. She coughs up large amounts of green
  mucous. The cough is disrupting her sleep, and
  she experiences shortness of breath during mild
  exercise, such as shopping. The patient also
  complains of ankle edema, which prevents her from
  putting on her shoes and is worse in the
  evenings. This shortness of breath and productive
  cough is affecting the patient's functioning as
  it prevents her from doing mild exercise, like
  shopping, and is a "nuisance" as it affects her
  sleeping.  

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• Mrs. Helen Armstrong is a chronic smoker who has
  had progressive chronic cough and exert ional
  dyspnea over the past 4-5 years. Her symptoms
  previously occurred only in winter but have
  lately been constant and are becoming a nuisance.
  She becomes easily "winded" during everyday
  activities such as shopping and she now
  experiences night time symptoms that interrupt
  her sleep. She has been coughing up large amounts
  of green coloured sputum and she would like a
  refill of antibiotics ("black and red capsules")
  her previous physician Dr. Jones prescribed to
  ease sputum production and decrease green colour.
  She has tried using an inhaler but felt that it
  did not have any effect. She experiences
  occasional retrosternal pain lasting for a few
  seconds. Mrs. Armstrong is also concerned about
  swelling in her ankles in the evenings, resulting
  in inability to put her shoes on once she's taken
  them off. She experiences occasional heartburn
  and constipation.  

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What happens to the patients story?

• It can be told verbatim
• It can be transformed into medical terminology
• It can be re-organized into a sequence
  chronologically
• It can be re-told in the order required by
  convention

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Convention

• Identify patient (age, occupation, relevant
  concomitant problem) and chief complaint
• Elaborate on severity, frequency, length of time,
  relieving and exacerbating factors, associated
  problems.
• Risk factors
• Other relevant history

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The Rules

• Do not say the diagnosis
• Leave out irrelevant detail
• Include important negatives.

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How does this change in rhetoric take place?

• Explicitly by intended feedback, by personal
  choice
• Implicitly by role modeling, by un-intended
  feedback

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Evidence
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Working Off the Record Physicians and Nurses
Transformations of Electronic Patient
Record-Based Patient Information Practice-Based
Learning Varpio, Lara Schryer, Catherine F.
Lehoux, Pascale Lingard, Lorelei
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Learning needs

• Making diagnosis
• Taking the history
• Doing the physical exam
• Interpreting tests
• Choosing therapy

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Learning needs

• Making diagnosis
• Taking the history
• Doing the physical exam
• Interpreting tests
• Choosing therapy
• Professional identity

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Conclusions

• Language is important for ..the negotiation of
  professional relationships
• Most learning about oral presentation is ..trial
  and error rather than through teaching of an
  explicit rhetorical model.. and may result in
  unintended professional values.

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Lessons

• It would be of value to make more explicit the
  rules of both written and oral presentation.
• Feedback should be given about the appropriate
  translation of patient language, and the
  inclusion or exclusion of detail.
• Feedback should also include comments on the
  inclusion of content related to the components of
  patient feelings, ideas, fears and expectations.
  Such inclusion should be rewarded in the clinical
  setting.