Every doctor has had the opportunity to work with patients who are poor historians; patients who make the history process almost torturous.
Regardless of the reason, the result can be detrimental to the patient. There are some things we simply must know in order to help. I have struggled with this over the past 24 years and have made several attempts to eradicate the problem. Some worked well; some only to a degree and some not at all. The purpose here is to share one of the attempts that has worked reasonably well. It is a combination of two ideas.
A Simple Game Sparks a Big Idea
Several years ago, my children had an electronic version of the game 20 Questions. Everyone is probably familiar with the original version of the game, but a little background won't hurt. The game originated in the United States. It is a spoken game that does not require a game board or game pieces. It does require at least two players, but many more can participate. One person (the answerer) selects an object and then the other player(s) [(questioner(s)] attempt to identify the object by asking no more than 20 questions.
The first question is usually, "Is it animal, vegetable, mineral or other?" Subsequent questions like, "Is it bigger than a bread box?" are intended to narrow the possible choices down to the item in question.
The electronic version my kids had was a round, plastic device the size of a tennis ball. It had a simple screen and a few buttons. Like the original game, the answerer (player) selects an object and the questioner (in this case the machine) asks 20 questions. The player has to answer the machine's questions truthfully. The possible answers are yes, no, sometimes and unknown.
The accuracy of this little machine is amazing. It will guess the exact object, a version of the object or something very close almost every time. It can be stumped, but to do so takes some effort. The electronic game is still popular and there are now special editions that focus on particular topics, sports, etc.
When I was the clinic director at Cleveland Chiropractic College in Kansas City, I bought one of the games while I was waiting for a prescription to be filled in a drug store. As I played the game, I wondered if there were 20 history questions that could narrow a patient's complaints down to a specific diagnosis as effectively as the game could narrow down to a specific object.
A few days later, I demonstrated the game to my clinical staff at Cleveland and let them play. Actually, I gave them a task: play the game and then start working on identifying the 20 perfect patient-history questions. They were fascinated by the game. One clinician selected Tyrannosaurus Rex and the machine guessed dinosaur. Not bad. We were all entertained for a couple of weeks – but the list of 20 perfect history questions never developed.
The primary reason we failed relates to the basics of the game. In the original version, the answerer selecting the object obviously knows the object and can answer the questioner accurately. In the case history game, the answerer is the patient and doesn't know the object (condition) and thus cannot answer the doctor's (questioner's) questions accurately.
I decided there are probably 20 best questions for past, social, family and occupational histories individually. This is probably true for the history of the presenting illness and each of the 14 systems that can be reviewed, too. This would result in hundreds of questions, which is not practical for a history, other than the type used in a clinical teaching environment. (It may even be a bit much for that setting.)
Jarring Patient Memory
OK, that covers the first idea. It did not work, but it was a good lesson. I was just happy to have figured out why it did not work. The second idea came to me one day while taking a patient's history. I noticed the patient was very detailed about the circumstances of his accident; not necessary his injuries, but the circumstances and events surrounding the injury.
A thought hit me. I wondered if there were 20 questions regarding circumstances, events, locations or activities that would jar patients into remembering history information; questions other than signs, symptoms and specific conditions. Eventually, this thought and subsequent brainstorming resulted in the 20 questions. Versions of some of the questions are already part of a typical history; others are a little different. I have the list of questions taped to the front of a clipboard in case I need them. I put any information I obtain on the normal history form.
The list of questions with comments follows. The list isn't perfect, but it can be very helpful. The only exceptions to their use are cases in which being a poor historian is due to mental defect.
20 Thought-Provoking Health History Questions
1. Have you ever been treated in an emergency room?
a. As a child?
b. As an adult?
I have traveled the world, but I find an emergency room can be the source of sites as memorable as the wonders of the world. Patients usually remember their emergency-room experiences if for no other reason than the other people and the wait. Find out why they were there.
2. Have you ever been transported by ambulance? If the ride isn't memorable, the bill will be.
3. Have your ever called a doctor after office hours? Calling a doctor after hours is usually due to an acute illness. The pain and situation around the illness will probably be memorable.
4. Have you ever had to see a doctor while you were out of town/traveling?
5. Have you ever had emergency dental care? The reasoning behind questions four and five are the same as for question three.
6. Have you ever had an allergic reaction?
a. Food?
b. Drug?
c. Insect?
d. Substance (latex)?
In the majority of cases, questions regarding allergic reactions focus on drug reactions. Including more categories is much more practical.
7. Have you ever carried / do you carry medication in case of an emergency?
a. Nitroglycerin?
b. Glucose?
c. Insulin?
d. Inhaler?
e. Epi pen?
This question covers conditions that are often such a part of the patient's life that the presence of the conditions becomes an unconscious thought. We have all had patient start to lie on the adjusting table with their glasses on. The glasses have become part of them and they don't think about them. For a patient carrying nitro for angina or heart problems, the nitro just becomes something they always have in their pocket. It is just there and only the pain may remind them of its presence.
8. Have you ever worn any type of medical alert jewelry? This question is similar to question seven. The jewelry may have become a part of the patient.
9. Have you ever had a tetanus shot? Stepping on a nail, a bad cut, a dog bite and seemingly almost anything warrants a tetanus shot in the medical world. Information here could relate back to emergency-room visits.
10. Have you ever received stitches? The need for stitches can range from emergency-room situations to outpatient surgeries.
11. Have you ever been fitted for a special brace, worn a brace or worn a cast? We often ask about fractured or broken bones, but casts and braces can be used following tendon surgeries, sprains and other conditions.
12. Have you ever been admitted to a hospital?
a. Surgery?
b. Childbirth?
c. Tests?
d. Observation?
e. Psychiatric?
Admissions for tests and observation are often overlooked compared to surgery and childbirth. Psychiatric admissions may be deliberately omitted by the patient unless a direct question is asked.
13. Have you ever been anesthetized or had a body region numbed? This question can be applicable to surgery, dental procedures, childbirth and other situations.
14. Do you have any implanted medical devices or imbedded foreign objects from traumas (pacemaker, bullets, etc.)? Pacemakers, stints, joint replacements, bullets and other implanted objects, whether they are intentionally or accidentally present, need to be identified for MR scanning, therapies, etc.
15. Have you ever been X-rayed? Patients are always fascinated with their X-rays; if they have viewed one in the past, they usually remember it.
16. Have you ever used a:
a. Cane?
b. Crutches?
c. Walker?
d. Wheelchair?
If a person has ever used crutches, their armpits will certainly remember it. The other devices are often memorable, too. Of course, this question is about previous use, as it will be evident if they are currently using one of the devices.
17. Have you ever undergone a series of injections? Epidural injections are usually given in a series and they are definitely of interest historically to chiropractors and other clinicians treating the spine.
18. Have you ever been diagnosed as having a permanent condition (diabetes, arthritis, etc.)? As with the questions regarding medical alert jewelry and emergency medications, this question can bring forth information about ongoing conditions.
19. Have you ever been disqualified from any of the following for health reasons:
a. A job?
b. The military?
c. Participation in a sport?
20. Have you ever been denied medical or life insurance? Questions 19 and 20 are closely linked, as disqualification from any of the items listed could cause disqualification from the others. Permanent conditions, disabilities, pre-existing conditions and other pertinent health information can be identified with these questions.
When I use these 20 questions, I usually discover something I would not have discovered otherwise. I recommend you try a few or all of these questions the next time a patient seems to be unresponsive or less than forthcoming. I think you might be surprised by the additional information you receive.
Click here for more information about K. Jeffrey Miller, DC, MBA.