One of the first instructions from our physical diagnosis instructors in medical school was to write down the patient’s words, specifically why was he or she seeking medical attention, what brought humor her to the doctor. Of course, by the time a student got to the patient in a hospital bed, he/she had answered that question two or three times, primary care MD, specialist, resident, intern, etc. but the lesson to learn was to listen to the patient, not the introduction often provided, “go do a history and physical on the gallbladder in room 3009.”
Wrong already, the patient is a person, not a procedure or a room number, he/she has a name, and has complaints that may or may not be related to gallbladder disease. Mrs Smith is in pain, frightened, and probably has little knowledge of what is ahead of her. The value of the student’s interview and examination is at least twofold. The student may find signs and symptoms of a concurrent problem, or maybe even of a different diagnosis. The plan of treatment might have to be modified, or further testing and observation may be indicated. If an examiner approaches a patient as a person with something to “tell” him, he is more likely to find the “other problems” than if he were to focus on the diagnosis from the beginning. Perhaps Mrs.’ Smith’s symptoms and exam are not typical of gallbladder disease. An approach focused on confirming the diagnosis provided beforehand allows complicating factors such as undiagnosed diabetes, bleeding problems, etc. to be overlooked.
The educational value of the student interview and exam is great. Learning the multiple manifestations of a certain condition is a necessary step for the student. Future patients may not have the same constellation of findings, maybe only a few will coincide. With a more open the interview, that is, one with more open-ended questions, the student, who is patiently and carefully listening, will collect more information.
Not all the student writes down will be helpful right away. But on a subsequent admission, perhaps in an urgent situation, or even in a trauma setting where a complete past history may be difficult to elicit, the previous record may be very valuable. It will provide past injuries, previous surgery, bleeding tendencies, medications and allergies, underlying conditions such as diabetes, coronary heart disease, etc.
Patient, empathetic listening is difficult, at times. Doctors are often working on a schedule that limits the time they can spend with individual patients. Emergency calls, unexpected complications can interrupt or shorten a scheduled visit.
As a student on my second medical rotation, I had plenty of time one evening to interview a middle aged woman with the “chief complaint” of “Doctor, from the day I was born my body has been wracked with pain from my head to my toes.” Perhaps you can imagine the hours I spent recording her symptoms, all the time thinking that my resident, who assigned me this patient, was playing a joke on me. The lesson I learned, was that patience and skill are required to sift through the many symptoms in this obviously hysterical personality to be sure that any “real” problem is not overlooked. One cannot assume that all the patient’s symptoms are imagined, just because most of them are.