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The Lost Art of Medical History

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Daniel Dilling, MD
Loyola University Medical Center
Chicago, IL, USA

"Hello Mrs. Anderson, I'm Dr. Dilling, one of the pulmonologists on our lung transplant team. It's great to meet you and your family."

We have some of the usual introductory chatter and I ask them what they understand about the reason for this referral. I swivel my chair around to the computer consul in the exam room and enter my sign-on password. I click on her name in the patient roster. I turn to her and her family and say, "what we are going to do today is to talk about your medical history and the story of your lung disease. I'm going to be typing on the computer some of the things you tell me while we are talking (because I have to) but I am listening. So... tell me your story".

I sometimes start my new patient appointments this way. Thankfully, I'm a good typist! (I think that typing was the most important class I took in high school. Back in 1987 I really didn't even know why I would need the skill but my mother had suggested it for a summer school class.) Yes, conducting my appointments this way adds an element of "impersonality" to the encounter, but I think patients understand why I have to do it. Most have seen other physicians do the same. In these complex appointments, where I have to efficiently collect and document the medical facts and the content of our conversations, I find that it is the only way to accomplish what I need to do in our limited time together - and so that I won't forget important details, as I might do if I tried to recount everything later in the day.

Electronic medical records have become nearly universal. They are touted as means to make records more understandable, reduce errors in medication ordering, foster communication between care providers, and reduce the paper waste and need for paper record storage. That sounds all good, right? But does the computerized medical record get in the way of the physician-patient relationship?

In some computer record systems, there are sections about social history and family history that are inputted once by a nurse or doctor in a particular hospital. From then on, the computer "auto-populates" these sections in subsequent physicians' histories. Medications are imported into the note in the same way. How many physicians never double-check these sections? Not to mention the problem that some of the most important patient-physician bonding occurs during the collection of information about the patient's occupation and family life. How sad to miss those parts!

And how many times have you seen "copy and paste" sections to the notes (which are sometimes not well-updated) and which over time become both monotonous and meaningless.

When René Laennec at the Necker-Enfants Malades Hospital in Paris invented and introduced the stethoscope into the patient encounter, it was actually met with some of the same concerns. Both physicians and patients saw the tool as an impediment to the important close physical proximity and intimacy of the physical examination. It separated them physically, and (many believed) professionally. Before that time, hearing a heart murmur or adventitious lung sounds was possible only by putting an ear to the chest wall. The stethoscope enhanced the examination and improved the quality of diagnosis. The instrument eventually became intricate to the profession and now symbolizes medicine itself. Similar arguments were made for radiography (first x-rays, and later computed tomography), but their diagnostic prowess allayed such concerns. Some lament that technology and testing has largely supplanted the dying art of physical examination.

Has the electronic medical record - and the computer we use to interface with it - brought with it a wall between our patients and us? I think so, despite its apparent necessity. That said, just yesterday I was starting to see a new consult in my clinic - a young man with a rare cystic lung disease called Birt-Hogg-Dubé syndrome -- when suddenly my computer froze up. I fumbled around and pushed some buttons on the keyboard, but, alas, it remained non-functional. I thought about moving to a different room, but then I saw a blank piece of paper on the shelf. I picked it up and started jotting a few data points on the paper as we talked. I looked him in the eyes as we spoke more than any patient in years. It was a delight! Thankfully, his history was not a deep one and there weren't as many details as is usual in one of our transplant candidates -- and so it was manageable to translate it all into a note afterwards in the charting room. But the encounter made my week!

links imageWe already have robotic surgery. Pocket ultrasound devices have started to replace a stethoscope and other parts of the physical examination. Who knows what's next, virtual reality (VR) appointments? The impersonalization of medicine will certainly continue into the future. Let's just all hope for that occasional technological malfunction when we get to do things the old-fashioned way.

Sit down. Look a person in the eye. Get to know them and their family. Let them get to know you. Do a thorough examination. It's a privilege to get to talk to people so intimately and know people in the way we do. Enjoy! ■

Disclosure Statement: The author has no conflicts of interest to disclose.

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