The most important interaction between a patient and their healthcare provider is the medical history.
Through listening to the story of the patient’s illness and asking relevant questions, a physician may often make a diagnosis, or at least begin to understand the nature and location of the complaint. Then, he or she is in a position to plan the examinations and tests necessary to identify the disease and begin treatment.
By facilitating the interview, patients can make this process more efficient leading to prompt, more precise diagnosis and treatment. Here we have some tips.
Be sure to be on time for your appointment. Being late not only compromises your own time with the doctor, but may also interfere with that of others. While doctors are notoriously behind in their schedules, part of that is due to some patients’ inefficient use of time. Lack of time can interfere with your healthcare.
It helps if you are able to state concisely your chief symptom, concern, or problem. This focuses the discussion. Sometimes there is more than one symptom, or a combination of symptoms.
For instance, a person with a functional gastrointestinal or motility disorder might have a constellation of related symptoms. In this situation, it is important to clearly identify which symptom(s) are of most concern to you. Since most healthcare providers only allot a few minutes to each visit, this enables them to focus on your major concerns and choose treatments that will provide the most relief.
On the other hand, specialists have a little more time and would want to deal with all the problems within his or her expertise. Presentation of a long written list of concerns is unlikely to be helpful.
Describe those that most trouble you now. Whereas a family practitioner or internist can deal, at least initially, with all medical problems, specialists must remain within their area of expertise. Usually, your primary care doctor best handles referrals.
History of the Illness
You should describe the story of your main concern in your own words. A written history is no substitute. The manner in which you describe your symptom is as important to the doctor as the presence of the symptom itself.
- State when and how the symptom began.
- Where is it located?
- Is it steady or does it come and go?
- Does eating, exercise, traveling, stress, or other factors make it worse or better?
- How does it interfere with your life, job, or personal relationships?
- Are there associated symptoms – for example, diarrhea, headache, or blurred vision?
- What diagnosis, if any, have you already received for this? While it is OK to venture your own diagnosis, it is essential that the doctor make up his or her own mind.
- What treatments, if any, have you undergone?
It is important to describe all factors that might bear on the concern, but too much information can be counter-productive. The healthcare provider should help here by prompting or steering the conversation back to the point.
If there are two unrelated problems, deal with them one at a time to avoid confusion.
Keep in mind that time is valuable and avoid digressions.
Do not be shy. If there is a gut problem, a detailed description of your defecation pattern and the nature of the stool is vital information. Similarly, the nature of your urine and other bodily discharges are sometimes keys to diagnosis. Sexual habits may also be important. Indeed omission of such information can delay diagnosis. No healthcare professional will laugh or disapprove of your description. Remember, they deal with such material daily.
While the description of your concern should be verbal, there are certain routine facts that every healthcare provider should have. A written list of these may help.
Demographics – It is helpful to indicate at the top of any list your age, sex, occupation, marital status and ethnic background. Some diseases are unique to certain occupational, ethnic, or geographic backgrounds. Include any insurance information.
Medications – A list of your current medications is essential. Drugs that your doctor might consider for your present disorder may interact with current drugs.
Perhaps your concern is due to an adverse reaction to a treatment. The list should include the dose and the frequency of the medication, and the length of time you have been taking it.
Other Treatments – Have you received any other treatments? Your provider will want to know what has been tried in order to plan management. Moreover, not all “alternative” treatments are harmless.
Sensitivities – This list should include drugs to which you have had an adverse reaction such as a rash, jaundice, or gastrointestinal upset. Allergies to insect stings, hay fever, allergic asthma, or contact dermatitis are also important.
Many reported sensitivities are unsubstantiated. As this could rule out use of certain drugs or diets, you should indicate any evidence you have that they are truly present.
Previous illnesses – This should include the important illnesses you have had in the past, especially those that have led to disability, hospitalization, or surgery.
In the case of surgery, it is important to be sure what was removed and what was left in. It may also be helpful to indicate the doctors who treated you for these illnesses because your present doctor may wish to contact them. Inheritable diseases such as heart disease or cancer in first degree relatives should be listed as well.
Other Factors – Tobacco, alcohol, and recreational drug use are important to reveal.
These lists should be as brief as possible and clearly written so the provider can include them for future reference in your record. This avoids the need for the doctor to write down the lists you give him verbally, avoids mistakes, and saves time for you to describe your main concern.
To help your healthcare provider deal promptly with your concerns you should bring with you any pertinent medical documents you have.
If you have been to the emergency room or other doctors for this problem, their reports are important.
If you have had laboratory tests or other such information, have them sent, have the doctor’s secretary obtain and send them, or bring the results to the doctor yourself. In the case of relevant x-rays or electrocardiograms, you should bring the actual pictures or tracings as well as the reports. Otherwise, valuable time will be lost while the doctor tracks down this information.
If another doctor refers you, do not assume he or she will automatically send this material. You can check this out beforehand through the referring doctor’s secretary.
One doctor should be in charge of your total medical care and records. Normally this is your family doctor or internist (primary care doctor). He or she should make (or know of) all referrals, and should write referral notes that state the problems the specialists are to address.
You should insist that each consultant send his or her report to your primary care doctor indicating the diagnosis, recommended tests, and treatments, and who is responsible for them. This ensures that your doctor has your complete record and permits him or her to supervise your overall care.
In modern medical practice, a shortage of doctors and economic reality contrive to limit the time healthcare providers have to see patients. Timeliness and a concise statement of the main problem(s) along with a clear history of these problems can save time for the essentials.
These should be verbal, but pertinent lists of medications, previous illnesses, and sensitivities can go directly into the records without the need for transcription.
Ensure at the time of the visit that your doctor has vital information for the problem including x-rays, electrocardiograms, lab results, and reports of previous health encounters such as the emergency department.
Attention to such details and ensuring their communication can help your healthcare provider help you.
Adapted from The Medical History: How to Help Your Doctor Help You- IFFGD publication #221 by W. Grant Thompson MD, Emeritus Professor of Medicine, University of Ottawa, Ontario, Canada