10 top tips for medical history taking

Key points

Engage with the patient
Set the scene
Build rapport
Let the patient talk
Know your stuff
Change direction if needed
Repeat and summarise their answers
Know your biases
Knowledge is key (see 5!) – keep learning
Watch your patient.

The history is vital. Full stop. Why? 80% of the diagnosis is in the history (10% examination, 10% tests) – so its your key diagnostic weapon. More on why it is so important here.

Also, as the placebo effect (convincing the patient that they will get better) = 50% of your healing power (and that comes from the history), you are foolish not to maximise the placebo.

1. Engage with the patient and get comfortable

First impressions matter. They influence the whole of trajectory of the history and consultation.

Be 30 mins early. It will take 10 mins to set up the computer. Power cut. Start again. 20 mins.

Make sure you are comfortable. Make sure you are at eye level with the patient and do not have a computer blocking the eye contact. Is the room clean and tidy? Are your nails clean? You should be bare below the elbows.

Introduce yourself clearly – both name and the type of doctor you are.

Smile and try to communicate warmth and attentiveness. Small gestures tend to tell patients that you have time for them, which encourages them to volunteer important information.

“Thankyou for coming to see me today. How can I help you?” is a good start

2. Set the scene

Tell the patient the purpose of you being there: “Your family doctor has referred you to me as I understand you have hip pain .. is that correct?”

If you anticipate you will get calls or be paged, let them know upfront: “I want to let you know in advance that I am on call for emergencies in the hospital; and I may have to answer my phone/pager during our discussion”. Better still, make sure you are not on call and in clinic at the same time.

3. Build rapport

Although rapport will depend on the entirety of your interaction with the patient, take a minute or so at the beginning (and in the middle) to connect to the patient at a human level. This may sound daunting to some, but in fact can be quite simple.

For example, “yes the parking is awful, drives us nuts too”; or (in the social history if you relate to anything), use that, “yes I’m keen on football too, what team do you support?” (even if that team are your mortal enemy say something nice about their team).

At the very least it serves as a reminder that you are speaking to a human being with their own set of skills, knowledge, and life experiences.

“The patient needs to like and trust you, for your history taking to be effective.”

4. Let the patient talk (but not too much!)

In a landmark study analysing 74 doctor visits, Beckman and Frankel (1984) found that interrupting a patient early in their opening statement and reverting rapidly to closed questioning, often prevented the patient from disclosing very relevant information.

On the other hand, they found that if a doctor allowed the patient to finish their opening statement, more medical issues were raised; and there was a reduction in problems described later in the consultation (or not mentioned at all).

Do not rush the elderly. Show them respect and let them speak.

At the same time, don’t let them get off topic too much. A little is fine. You have a rapport. But if you’re losing control, bring them back to the matter at hand.

5. Know your stuff

By the end of medical school, you will have memorised the important sections of the history (and the correct order) – e.g. past medical history, medications, allergies etc. You knowledge base will be good.

However, you will be surprised how easy it is to get lazy especially when you’re feeling tired. You may forget to ask an important section (smoking, alcohol, recreational drug use, etc).

Or you may not get round to key sub questions. For example, for Type 2 diabetes, a sub question could be ‘how well is your diabetes controlled (e.g. HBA1c)?’ and/or ‘what complications do you have (e.g. nephropathy)’?

There are also special components of the history which might give important clues to the diagnosis but often get missed, such as ethnicity, travel history, developmental history, pregnancy and fertility.

Remember too – almost nobody is a ‘classical presentation’. Few have every symptom and sign of the classic disease as described in the books. For example, diarrhoea in a patient with abdominal pain does not rule out appendicitis. But just makes it less likely.

6. Change direction, if needed

You will notice that medical students and junior doctors, when starting out, often take long, linear histories. But one thing you’ll quickly notice watching more senior clinicians is that they rarely ever follow the original order that we learn in the first year of medical school.

Instead, they change up and down the order of the headings to suit the clinical context. This is a skill and takes alot of practice to do it safely (i.e. remembering to ‘go back to’ the normal order of history).

On the other hand, if you are time-pressured with a sick patient, the history of presenting complaint is often more important to establish upfront. The social history can come later after some oxygen and nebulisers.

7. Repeat and summarise their answers – ambiguity is the enemy

Throughout the history it is important to stop every now and again and reflect back a summary of what the patient has told you. This is important both to aid your memory and to make sure you’ve understood the information and sequence of events correctly. A summary is also a good time to clarify ambiguities or missing pieces in the history and pinning down patients’ understandings of specific terms.

For example after the PMH, you could say,

“In terms of illnesses in the past, you have told me you have Type 2 diabetes and high blood pressure, and also have had your appendix and gall bladder out, and a R hip replacement. Have I got that right? Any other major illnesses or operations?”

Also, there are certain words that you should never leave up in the air – for example, when patients say they felt ‘dizzy’ or ‘sick’, or had a ‘funny turn’ – they should always be followed by a reflex of rapid-fire questions to help differentiate what they actually mean.

If you are dealing with a patient from a non-English speaking background, the safest position is to assume that there will be miscommunication. Always make an effort to arrange an interpreter (even over the phone) to clarify the history directly from the patient rather than relying purely on collateral history or translation from family and friends.

8. Know your biases

We all have biases. We all have weaknesses. We should not – but we do. But you can learn to recognise and reduce them.

When you first start off as a doctor, the primary motive for taking a history is information gathering. But as you transition to fully-fledged doctor history-taking is no longer a rigid process but a dynamic one which involves a complex interplay between you and the patient.

You will be obtaining and synthesising information to increase or decrease the pre-test probabilities (a set of differential diagnoses). This latter version of history-taking is highly shaped by experience and knowledge; and is what allows certain physicians to become very efficient. But you need to aware of the biases that can get in the way of history-taking. These biases include:

Overconfidence (arrogance) bias – “I’m an amazing diagnostician, I must be right!” – common in doctors
Confirmation bias – paying attention to those aspects of the history that fit what you think is going on, at the exclusion of seeking more information to explore other differentials – i.e. fitting the diagnosis into your pre-decided one and treatment plan. I.e. don’t decide on your diagnosis too early!
Availability bias – “I’ve diagnosed a lot of gastroenteritis today, so this abdominal pain must be gastroenteritis”
Personality bias – allowing positive or negative feelings towards a patient influence the completeness of your history-taking. You are not their friend (though should be friendly) and you should try not to like/dislike them
Judgement (of class) bias – do not judge the patient – ‘the nun is as likely to have syphilis as the prostitute’.

The literature suggests the first step to overcoming these biases is to be consciously aware of them. What are yours?

9. Knowledge is key – keep learning

Don’t be mistaken, you cannot be an efficient and balanced history-taker without knowledge. An understanding of different conditions allows you to know what aspects of the history are relevant and which questions to ask.

You will not be able to distinguish migraine from meningitis if you do not know the defining qualities of each condition. A deep understanding of all conditions is impossible, especially when starting out.

However, there are some things you can do to help. For example, try to read around your cases, and if you refer the patient to a senior colleague or specialist team – learn from them.

Keep reading – whatever age and stage of your career you are in.

10. Watch your patient carefully

“Observation is 90% of medicine”

Start looking at them as they get out of the chair in the waiting room. What is their biological age? Are they short of breath? In pain (where?)? What does their gait tell you? Walking ability? What is their demographic background? What are they reading?

There is often important information in the body language of a patient. Watch them carefully. A subtle change in eye contact or the timbre of the voice, just at the right instant, is sometimes the only clue to an otherwise missed diagnosis (physical or mental).

A patient that frequently turns to their partner for the answer to a question can often be a clue to underlying cognitive impairment.

Enjoy the journey

You will spend a lot of your career taking histories from patients and for some, it may be your only interaction with them. If there is one thing we have come to appreciate from the COVID-19 pandemic, is that we are social animals.

Learning to enjoy the journey by taking that little extra time to make a connection with your patient will lead to better clinical outcomes; it will also lead to a greater sense of fulfilment and satisfaction in your professional life.

You will learn alot about life from your patients if you listen carefully.

Summary

We have described 10 top tips for medical history taking. We hope it has been helpful.

Other resources

Review article: Nichol, 2023

https://www.youtube.com/watch?v=4wfjSfoHwl4

Last Reviewed on 13 June 2024