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Harvard Commentaries
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Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


What Your Doctor Is Saying What Your Doctor Is Saying
 

Learning From History


October 10, 2013

By Robert H. Shmerling M.D.

Beth Israel Deaconess Medical Center

Contrary to the notion that tests provide the most useful information to your doctor, your current symptoms and past information about your health (collectively called the "history") are critically important to your doctor's ability to be helpful. I was taught that the history could provide 75% of the information needed to establish a diagnosis — most of the rest was provided by physical examination and an even smaller portion by testing. Yet, many patients (and some doctors) focus most of their attention on test results to detect problems or provide reassurance.

In fact, the focus on technology and testing is so pervasive in many corners of medicine, some are concerned that health care professionals will lose their skillful ability to ask the right questions. While there are times when testing must take precedence (as in many emergency situations), for the vast majority of office visits, the history is exceptionally helpful and critical in deciding which, if any, tests to order.

What Is The History?

When healthcare providers talk about "the medical history," they are talking about your individual experience with health and illness over a period of time. The medical history includes several parts:

    • Chief complaint — This is the reason you are seeing a doctor or other health-care provider; if it is a routine visit for no specific reason, there may be no chief complaint. Headache, back pain, and cough are common chief complaints. As part of the history, you will be asked questions about when your symptom(s) started; what makes it better or worse; its quality ("Is it a sharp pain or is it dull?"); whether it is getting better, worse or fluctuating over time; and other details about your predominant, current complaint.
    • Past medical history — Any significant or prolonged medical problems you have had in the past are parts of your past medical history; a cold you had six years ago that lasted three days may not be worth mentioning, but medical conditions that were significant or serious, long-lasting or ongoing should be mentioned; examples include pneumonia that required antibiotics or a hospital stay, heart disease, pregnancies, hypertension, or any surgery you have had.
    • Medications — If you take a prescription or nonprescription (over-the-counter) medication regularly, your doctor will want to know about it; this also applies to supplements, vitamins, birth-control pills, herbs, or other alternative and complementary therapies. Be sure to include those you take on occasion or "as needed."
    • Allergies and intolerance to medications — This refers to any reaction you have had to medication that might lead your doctor to avoid giving it to you again. If you aren't sure about a medication allergy, err on the side of mentioning it.
    • Family history — Tell your doctor about first-degree relatives' medical problems, including your parents, siblings and children, especially if it seems as though one particular type of problem is common or unusual in your family. Keep in mind that many conditions do not run in families, and that even when a family history for a condition is strong, it does not mean you are guaranteed to get it. Also, recognize that if your family is big enough or if family members live long enough, you are bound to have a family history of something. That does not mean that you must suffer the same destiny. On the other hand, there are conditions that are clearly hereditary and may have important implications for your health: early breast cancer, early heart disease and Huntington's disease are examples. Genetic testing may be an important consideration if you have a strong family history of disorders known to be inherited.
    • Social history — Information about your family, including your marital status, how many children you have, lifestyle, habits and work belong here. This information could have an impact on your physical or emotional health ("I work as a professional bungee jumper" or "My husband and I are separating"), or it could simply contribute to your doctor knowing you as an individual and what's happening with you when you are not in the office. Your usual alcohol intake, history of smoking and past or current drug abuse are also included here.
    • Review of systems (ROS) — This is a survey of sorts that asks about symptoms or signs you may have noticed in various regions and organs of the body. Some health-care providers use a written questionnaire to obtain this information, while others prefer to ask about them during the office visit itself. Sometimes symptoms you may not have thought to mention — because they were vague, mild or seemingly unrelated to the reason for your visit — turn out to be quite helpful in figuring out what is going on, and it may only be uncovered by the ROS.

Traditionally, medical students learn to interview patients to obtain the medical history in the order listed above (chief complaint, past medical history, medications, allergies, family and social history, ROS), but some health-care providers use different approaches. As you think about your symptoms and past medical information for an upcoming appointment, it may help your doctor if you organize the information in your own mind or even on paper into these categories.

The Bottom Line

Increasingly we live in an age in which astounding details about a person's anatomy and bodily function can be viewed painlessly with imaging tests, and a person's genetic makeup can be analyzed for the prediction of disease or its outcome. Increasingly, the practice of medicine has embraced these new techniques of medical investigation. Even so, technology is not always the answer.

In most office visits, your doctor will want to start by talking with you about your symptoms in some detail. It's not just small talk. What your doctor is saying by asking all those questions is that he or she wants to start at the right place to investigate your symptoms. It's an essential part of figuring out what is truly going on with you. Understanding what your doctor is saying usually starts with understanding what your doctor is asking.

Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.

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