Hypothesis-Driven History-Taking
 

Educational Goal
This module has been developed to expose First Year Medical Students to the process of clinical reasoning
and how to take a medical history using a hypothesis-driven approach that emphasizes pattern recognition. 

Learning Objectives
Completion of this learning module should enable the learner to:

• Trace the movement of Patient Centered Medicine and cite the benefits of Patient-Centered History Taking
• List the goals of the Physician-Patient encounter
• Recognize the clinician's need to be both an empathic listener and an astute diagnostician
• LIst the five cognitive elements or steps ("epistemology") that comprise the process of clinical reasoning
• Appreciate the role of pattern recognition in skilled diagnostic reasoning
• Demonstrate pattern recognition in their history taking activities
   

What's at Stake

Stritch School of Medicine seeks to train students to be both astute clinicians and compassionate care-givers.

This Hypothesis-Driven History-Taking Project aims to accelerate the process by which medical students achieve proficiency
in clinical reasoning, as well as skillfulness in their history taking abilities.

Typically, a First Year student learns to take a history by asking a fixed array of cardinal questions without considering the implications of the answers to these questions.

This "collect first and think later approach" is the common approach taken by First Year students since most have not yet studied Pathology and disease mechanisms.

This approach runs against the grain of how good clinicians actually operate --namely, by allowing working hypotheses to guide and inform the history taking process.

Introducing First Year students to this hypothesis-driven reasoning process is the goal of this educational project! 

Context

Over the past century the defining paradigm for health care has gradually shifted from a provider-centered model to a patient-centered approach.

Some practitioners, however, have resisted this shift, believing that patient-centered medicine means "giving over control" to patients.

What patient centered medicine actually calls for is recognizing the unique competence and perspectives of both physician and patient with the ultimate goal
being service to patients and their well-being.

Evidence suggests that such a patient-centered approach, particularly as it has helped to strengthen the physician-patient relationship,
can have a favorable impact on patient satisfaction, health outcomes, compliance, and even malpractice claims.

The literature, however, also suggests that one of the barriers to effective communication between physician and patient, are physician behaviors
that too narrowly focus on diagnosis and/or treatment at the expense of empathy, patient education, and building trust!

Quality medical care, today, demands that clinicians be proficient in communication and relational skills as well as in their diagnostic acumen!

Stritch School of Medicine is committed to the pursuit of excellence in both of these aspects of patient care.

Good Clinicians must excel in both...

Physicians must recognize their need to be astute diagnosticians operating effectively within the demands and expectations of the richer
and more nuanced bio-psycho-social-spiritual model that now defines the physician-patient relationship.

But these abilities are not "factory-installed equipment" in aspiring clinicians.

They must be learned, nurtured and developed.

This module on Hypothesis Driven History Taking, therefore, seeks to expose students early in their training, while they are
learning the value and expectations of Patient Centered Medicine, to the process of sound clinical reasoning and diagnostic acumen.

We believe that doing so will not only strengthen and accelerate the students' acquisition of clinical skills, but it will foster these abilities
within a patient-centered framework. 

Taking A Patient History.

The medical interview is now seen as an opportunity for a clinician to accomplish three goals:

• Gather and interpret information  (relevant to patients' concerns and to clinical diagnoses)

• Establish relationship    (showing empathy and developing trust while attending to patients' concerns)

• Educate the patient        (empowering patients in appropriate ways to care for themselves)

Clinicians today must be agile in their ability to fulfill their diagnostic responsibilities as they simultaneously work to
build an empathetic, caring, empowering relationship with their patients.

Centering on the Patient

Both physician and patient are under pressure from the pace and demands of carrying our their respective responsibilities.

Some clinicians believe that there is not sufficient time to be both "diagnostic" and "empathetic."

A study by Beckman and Frankel showed that physicians, eager to arrive at a clinical diagnosis, would interrupt a patient within eighteen seconds of the patient's beginning to speak.
 
They found that patients rarely continued to express their true concerns once they were interrupted.
They also found that when patients were allowed to express all their concerns at the onset of the interview, no more than 150 seconds were needed. [Beckman HB, Frankel RM, The effect of physician behavior on the collection of data. Ann Intern Med 2001;134:1079-1085]
 

(That's less than four minutes!)

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What lesson do we take from this?

Interrupting the patient with diagnostic questions before allowing the patient to speak may actually work against a physician's time efficiency.
 

Model Example of a Patient Centered Interview 

"Once all of the patient's concerns have have been expressed, the physician and patient can set an agenda for the current visit and then arrange for subsequent visits to address less pressing issues."

"After the patient has expressed all concerns and an agenda has been set, the physician can explore the most urgent concerns or problems.
The physician should allow the patient to tell their story and guide the patient in the process by using open-ended phrases."

Barrier PA, Two words to Improve Physician-Patient Communication: "What Else?" Mayo Clinic Proc. 2003;78:211-214

Q: "Tell Me More About That..."  (open ended)

The physician should revert to specific or closed questions only after the patient has had the opportunity to fully speak their concerns and tell the story of what they have been experiencing.

Q: "You say that you have back pain, can you show me where?" (getting specific).

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Cardinal Questions

These questions are essential to understanding a problem; but they should be asked ONLY after first allowing the patient initial time to tell, in their own words, about their concerns.

A good clinician requires detailed information to reach an accurate diagnosis.

But, as we have just discussed, a good clinician today recognizes that their inquiry into "the specifics" is best pursued after allowing the patient to speak their concerns and after setting the agenda of prioritized concerns.

Once this has been accomplished, a patient not only understands, but expects that their physician must and will seek out the details.  

A skillful clinician listens carefully for the information they need as they allow the patient to speak.

In order to get a clear picture of the patients experience, a physician needs answers to the following cardinal questions:                                                            

Q: What is the Problem? (Pain, Discomfort, Concern, etc)

Q: What does it feel like? (Quality)

Q: How severe is it? (Intensity)

Q: Where is it Located? (Location of Pain, Discomfort, etc)

Q: When did it Begin? (Onset)

Q: How long does it last? (Duration)

Q: What brings it On? What Makes it Worse? (Aggravating factors)

Q: What Makes it Better? (Alleviating factors)

Q: Does It Go Anywhere Else? (Radiation pattern)

Q: Are there any other Symptoms you are having? (Associated symptoms)
 

The physician may get much of this information by simply listening as the patient initially speaks; when necessary the physician should ask the patient the above questions, or ask for clarification if the patient has been vague in their description.
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Hypothesis Driven History   

Taking a skillful history, however, is about more than simply asking the cardinal questions. A skillful clinician is listening to what the patient is saying, and trying to fit the information into a recognizable pattern known as a "diagnosis."
 

The Hypothesis Driven History reflects the importance of "pattern recognition" in clinical diagnostic reasoning. An experienced and skilled clinician recognizes the "clustering" and "association" of symptoms, signs and test results which are often expressed in a pattern. (Pattern recognition).

As part of the process of pattern recognition, a skilled clinician is always interpreting from among the "pertinent positive" and "pertinent negative" symptoms in the history (as well as on the physical exam).

We shall come back to this, but first let's take a look at the process of human knowing, doing so through the lens of a clinician...
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Clinical Reasoning

The Process
Diagnostic reasoning can be understood as a cognitive process that moves through the following steps: 

Experiencing  /  Understanding  /  Judging  / Deciding  /  Acting

 This is a continually recycling process!  That's why clinicians must make rounds each day!  

The Steps 
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1. Experience
Clinical reasoning can take as its 'starting point' any of a variety of 'experiences' or data sets.
(i.e. Patient history, physical exam findings, lab results, radiologic findings, biopsy reports).

In clinical terms this first step is about encountering a reality and attending to the data associated with it.
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2. Understanding
We then move from the experience to understanding by drawing upon categories of intelligibility --
those disease conditions that form the list of explanatory possibilities or possible 'diagnoses'.
  
We call this part of clinical reasoning that deals with categorical understanding --differential diagnosis.
 
This is the second step in the process -- it is our attempt to understand what may be going on with a patient!  
     
A good clinician is someone who reads enough in an ongoing way in order to continue learning about all the possible
causes to explain a process. Over time an expert clinician stores this information as "illness scripts" that are connected
to problem representations (patterns).
    
Since not all diagnostic possibilities (or categories of understanding) are equally adequate or relevant 
explanations of the problem at hand, our attempt to understand must ultimately be confirmed and the final
diagnosis determined.
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3. Judgment

To do this we must exercise judgment --to determine which among our list of possibilities is the most
plausible explanation.   
   
We do this by weighing evidence. This is a multi-faceted process that looks at the pertinent positive and
negative elements from the history (and physical and lab results) and factors in statistical variables such as disease prevalence,
probabilities, and the operating characteristics of diagnostic studies.

It is a process that attempts to identify the defining features that suggest one particular diagnosis,
as well as distinguishing features that separate out the other competing possibilities.       

Judgment is the process of weighing evidence. (Hence the need for evidence-based medicine --EBM).

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4. Decision
Judgment (weighing the evidence carefully) leads us to a final decision. In deciding, having carefully weighed all the evidence,
we move from differential diagnosis to final diagnosis.

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5. Action
Reaching a decision then moves us forward into action (either further diagnostic investigation or therapy)
on behalf  of the patient.  "We don't know simply to know, we know so that we can act!"
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Diagnostic Thinking

To summarize, clinical reasoning is a cognitive process -- one that conforms to those epistemological mechanisms
by which we come to knowledge and proceed to appropriate action.

Those mechanisms are: 

Experiencing  /  Understanding  /  Judging  / Deciding  /  Acting

Each of the steps in this process has a corresponding 'virtue' that is necessary to make the process most effective:

BEWARE! 
Failure to perform any of the steps properly or to develop these necessary virtues in your clinical practice,
skews the successive steps in the whole process!

A good clinician must take seriously ALL the steps and the necessary behaviors in the process that make up clinical reasoning...

If you haven't ATTENTIVELY examined the patient, or reviewed at the lab results you may miss important initial information at the level of experience

If you don't read enough pathology or learn about disease states, you will not be an INTELLIGENT diagnostician -"beware of the physician with a single diagnosis." 

If you don't weigh evidence in a careful and REASONABLE fashion you will be inaccurate in your diagnostic judgment

Having weighed the evidence, you are RESPONSIBLE for making a final decision and communicating your working diagnosis to the patient and others involved in the patient's care.

Once you have decided the cause of the problem, you must implement treatment, acting in a proper, proportionate, ethical and PROFESSIONAL fashion
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Knowing the requisite virtues in the process allows one to identify how and where one needs to improve their approach to clinical reasoning! 

This is essential for the sake of quality and practice improvement that all clinicians are now being held to for licensure, specialty certification and hospital credentialling.

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  Click On the Drag and Drop ICON to Test Your Grasp of this Concept!

Applying the Process

This reasoning process applies no matter what experience serves as the starting or entry point... 

Three Examples:
(to demonstrate different starting points in the process of clinical reasoning)

Read each line from left to right

Hypothesis Driven History Taking            

A hypothesis-driven-history is derived when a clinician elicits a history by not only asking the Cardinal Questions,
but, in addition, inquiring about and interpreting the "pertinent positive" and "pertinent negative" elements in the history.

Since this is a process of "pattern recognition," doing this well requires knowing about "what associates with what" and in what "patterns."

The process of pattern recognition takes time and experience to master...

It requires knowledge of pathology and physiology, but we shall begin now by relying on memorization of profile scripts
to help introduce you to this process and allow you to begin making pattern associations as you take a history from a patient.
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Lets Get Started...

To allow you an opportunity to take a hypothesis-driven history we will explore two clinical problems -- chest pain and back pain -- each of which has a differential diagnosis list with associated "pertinent positive" elements.

Studying/learning the pattern of pertinent elements for each potential diagnosis for a given complaint will allow you to begin to conduct a patient history guided by your hypothesis of possible causes with their associated clinical symptoms.

Consider the following two problems, their potential causes, and the pertinent positive findings associated with each.

Take time to review and commit to memory these summary profiles for the two problems (Chest Pain, Back Pain)
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To make things simple, learn the following profile summaries:

Chest Pain Profiles:

 Back Pain Profiles:                 

Cough Profiles

Headache Profiles

Click on Drag and Drop to check your grasp of the profiles

In Conclusion...

You are asked to memorize the above profiles so that when you are asked to interview a standardized patient who presents with either chest pain or back pain you can:

 1.  Allow the patient to tell you about what they are experiencing.
 
 2.  Elicit the history for either chest pain or back pain driven by
      your awareness of the possible causes for chest or back pain
      and listen for, ask about, and interpret the pattern of pertinent
      positive elements.        

 3.  Explain to the patient what you think might be going on  before
      you leave the room to "talk to your attending." 

NOTE: In reality, in the early stages of evaluating a patient, you will often not be sure of the exact diagnosis since even a good history
and physical examination do not always yield a clear cut diagnosis.

But, as a good clinician, you should have clues based on the pertinent positives and negatives that can help you to prioritize the possibilities.

Proceed to Self-Assessment Questions

Self Assessment Questions

Click on Each Question

Choose the single best right answer.                                             

 Question 1

 Question 2

 Question 3

 Question 4

 Question 5

 Question 6

 Question 7

 Question 8

 Question 9

 Question 10

Additional Resources

Please take some time to see how other institutions are approaching the process of Hypothesis Driven Clinical Reasoning

 Drexel University Medical School

(Click on Icon to Access Drexel's Hypothesis Driven Clinical Reasoning Web Site)