Medical Student Reflection II: History as conversation, or: creative medicine

by Academy of Clinical Excellence on March 16, 2011

As a dutiful med student, I ask patients with pain the same standardized set of questions:
  • Where is the pain? Does it move anywhere else?
  • What does it feel like? How bad is it on a 1-10 scale?
  • How often does it come? Does it come on gradually, or all of a sudden?
  • Does anything make it better or worse?

If the patient has chest pain, I’ll add the requisite clarifiers to help rule in or rule out a heart attack:

  • Is it worse with exertion? Is it better with rest?
  • It is associated with sweating or nausea?
  • Does the pain go down your arm or up your jaw?

This is all well and good, and is what we med students spend much of our third and fourth years of medical school learning. If I were on a plane and the stranger sitting next to me clutched his chest, these are the questions I would immediately ask him. One of the required national board exams, the United States Medical Licensing Exam Step 2 CS (for “clinical skills”), encourages this approach by grading students objectively (one point for asking how bad the pain is on a 1-10 scale, one point for asking if it’s associated with nausea, etc.).

But the process leaves much to be desired, for the doctor and the patient. If I were to approach the next 100 patients with chest pain in this same way, I might feel more like a walking checklist than a doctor. The patients might feel barraged with rapid-fire questions. Important subtleties might be missed.

Most important, an opportunity for connecting with the patient would be lost. In a busy outpatient clinic, a doctor might only have seven minutes to spend in the room with the patient. He or she needs to connect with the patient, for humanistic as well as practical reasons. Is there a way of taking a patient’s history while simultaneously building rapport? Could a different style of history-taking provide as much, or more, information for diagnosis than the typical approach?

In clinic today, we saw a 32 year old thin, lanky man who had been feeling chest pain off and on since Thanksgiving. First, the fellow took his history in the standard fashion and examined him thoroughly. We learned that the pain was in his mid-upper chest, constant, severe, sharp, not associated with exertion or nausea. In sum, it was very unlikely that the pain was coming from his heart.

Then the attending doctor came in. After introducing herself, she asked:

“What do you like to do for fun?”

“For fun? Dancing, I guess.” The patient had a wry smile and looked away.

“Really?! What kind of dancing? Hip-hop?”

“Yup. My wife and I dance every Friday night?”

“Wow, every Friday? How long do you dance for?”

“About an hour.”

“That’s a long time. I bet you are really good.”

The patient smiled again. “Nah, not really.”

“I just saw that show - what’s it called - Live to Dance, with Paula Abdul. Have you seen that? Will you be on that show soon?”

The patient laughed again. “Yeah, I’ve seen it. I don’t break-dance like them. I do have a couple good moves though”

“Let me ask you - do you ever get that chest pain when you’re dancing?”

The patient thought for a moment, and answered, “No, not when I’m dancing.”

One might argue that the conversation answered only one question (does the pain come on with exertion?), but it did much more. The patient relaxed and connected with his doctor. I would argue that he would be more likely to trust and accept her diagnosis that his condition is benign, than he would if the fellow told him the same thing. The doctor connected with her patient. She told me later: “Ask me who the 32 year old man with chest pain was, and I won’t be able to tell you. Ask me who the man who likes to hip-hop dance was, and I’ll be able to tell you his whole history.”

-Aaron Bobb, MSIV, JHSOM

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meg March 20, 2011 at 10:56 am

another great post! when i interview medical students for our residency program, i often ask them questions about popular books, music, movies, television, etc to assess their ability to build rapport with patients around shared cultural experiences. these kinds of exchanges humanize both patients and doctors, and strengthen the healing relationship.

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