Who is the Poor Historian?

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Patients might not have the best recollection or understanding of what’s important in their visit. Here’s why physicians need to ask the right questions to get the necessary history.

Larry Nassar’s sexual assault of hundreds of Olympic gymnasts is horrendous for innumerable reasons, not the least of which is that he abused his position as the athletes’ physician.(1) It seems that part of the reason he was able to carry out this evil for so long is the environment he worked in. Dr. William Strampel, Nassar’s former boss and former dean of the Michigan State University College of Osteopathic Medicine, was recently charged with criminal sexual misconduct for his own sexual misconduct.(2)

Considering the source, it’s no surprise to hear this quote from Strampel: “The most basic lesson in medicine, medicine 101, that you should have learned in your first week: don’t trust your patients.”(3) Even without considering the source, the idea of distrusting patients revolted me. For what it’s worth, I read that quote in an article in Stat by Dr. Jennifer Adaeze Okwerekwu, a few days before accusations against Strampel were made public.(4)

Trust is a Two-Way Street

Patients come to us for help, and we need to build a trusting relationship with them. For a variety of reasons, the trust needs to go both ways. Now, while I’m still an optimist, I’m also a realist and I appreciate that patients can sometimes be misleading. But I think it’s important to think about the situations where what patients tell us may not be entirely correct and why.

First of all, I think it’s important to disentangle two different categories of scenarios where physicians sometimes feel we may not be able to trust patients. Some patients are actually lying, often for secondary gain; and some patients are unintentionally giving misleading information.

What’s the Scenario?

In regards to the patients who are actually lying, the main scenario we deal with is patients who are “drug seeking” – lying in order to get prescription narcotics. While it’s a very real problem and certainly more salient in the context of the opioid epidemic, in my experience, the fraction of patients who are simply drug seeking is pretty small. Additionally, it’s very difficult for us to identify patients who are drug seeking. Even when we want to control pain, we’re not great at it.

This is partially because we’re getting pulled in a number of different directions in a busy emergency department. It can be tough to deliver appropriate pain control in our environment so many patients with legitimate pain end up exhibiting “drug seeking behavior” just to get adequate pain control. For example, physicians sometimes suspect patients with sickle cell disease may be drug seeking because they name specific medications and doses that work for their typical pain crises.(5)

There are also other situations where patients are technically intentionally lying, but for completely understandable reasons: victims of interpersonal violence who fear retribution; patients who fear that medical information may be relayed (intentionally or otherwise) to law enforcement or other authorities. Or they are afraid their physician is going to judge them for some of their private behaviors, many of which carry societal stigma.

Deciphering the Unintentional Lies

The second category is a whole different ball of wax. Dr. Okwerekwu mentions a patient who had reported they had never had surgery before, embarrassing her on rounds when the team saw an obvious thoracotomy scar. It’s easy to feel burned or betrayed or even embarrassed in front of our supervisors or peers when this happens.

Some patients also see their treated medical issues as no longer problems. “I don’t have hypertension; I take four medications and my blood pressure is great” or “No I don’t have a heart problem; those 2 CABGs fixed me right up.” I understand how that different perspective might be laughable to some physicians, but I do see where the patient is coming from.

We sometimes label patients who unintentionally mislead us as “poor historians,” but I think that mindset is misguided.

Understanding the Mindset of a Poor Historian

There are multiple factors at play here. Patients did not go to school for years to learn about their medical problems. Patients have not been trained on how to talk to doctors. Patients can easily be confused by what we think are clear questions. It’s easy for me to forget how understandable it is for a patient to be nervous in front of doctors, particularly if they are scared because they are sick in a hospital and they don’t know what’s going on.

We’re used to big busy emergency departments full of medical equipment and beeping monitors and all sorts of other noises and smells, but for most people, our natural environment is foreign to them. We’ve been in this world for so long, surrounded by medical professionals speaking medical language around medical care that we forget that we are highly trained, highly paid and yes, still highly esteemed by society. I sometimes forget that our presence alone can be intimidating.

It’s not hard to imagine a scenario where a patient would incorrectly answer whether they had had surgery before when they’re sick and scared and the doctor who might help them is peppering them with seemingly unrelated questions that they haven’t thought about in years.

I remember being embarrassed as a medical student when the story I presented at rounds is completely different from the story the attending received later. Certainly much of it had to do with me being young and inexperienced. On the other hand, perhaps some patients answer questions differently when being woken from sleep at 5 a.m. by a prerounding medical student. I also suspect patients may consider what questions the trainees asked before the attending comes in.

As a resident, I had a patient who came in with vomiting, and when I covered pertinent positives and negatives, they had a headache without concerning features and I told the attending I didn’t think we needed to worry about it. Later, when the attending talked to the patient, they were much more concerned about a subarachnoid hemorrhage.

Of course I could have done a bad job at asking the right questions in the right way. Or, the patient was here for vomiting and had not thought much about their headache, and quickly answered my questions as I rattled them off, and then had time to reflect on it when waiting for the attending. “Hmm I guess I do have a pretty bad headache. And maybe it was the worst right when it started. He sounded like that would be bad…” and when the attending walks in the room, they hear “Doc, I’ve got the worst headache of my life!”

Similarly, there are a number of reasons why patients may be (consciously or otherwise) trying to “justify” why they came to the emergency department, sometimes to me, sometimes to themselves. I have met countless patients who are worried that they shouldn’t have come to see us. Of course this headache is different than their usual one — otherwise, why would they be here? I don’t ask patients directly if this is their usual headache. I ask them all about this headache first, and after listening to their story, I try to backdoor the question. I describe their headache back to them and essentially presume it is similar to their usual. “Your headaches seem pretty miserable. It must be rough vomiting this much every time you get a migraine.” I don’t know if this gets me closer to the absolute truth, but I think it gives patients permission to respond honestly.

Conclusion

When I am talking to a patient, I try to keep in mind that only one of us is trained for this conversation. Only one of us is being paid to be here and, at the end of my shift, I get to go home no matter what happens to the patient. Ultimately, it all comes back to the House of God’s Law #4: The patient is the one with the disease. It’s my job to get the history from them.

Special thanks to Stat Editor Megha Satyanarayana who initially solicited thoughts on Jennifer Adaeze Okwerekwu’s article Twitter [6].

[1] https://www.cnn.com/2018/01/24/us/larry-nassar-sentencing/index.html

[2] https://www.nbcnews.com/news/us-news/william-strampel-larry-nassar-s-msu-boss-hit-sex-charges-n860346

[3] https://www.wsj.com/articles/deans-comments-shed-light-on-culture-at-michigan-state-during-nassars-tenure-1521453600

[4] https://www.statnews.com/2018/03/23/dont-trust-patients-larry-nassar-boss/

[5] https://www.uptodate.com/contents/vaso-occlusive-pain-management-in-sickle-cell-disease?sectionName=CLINICAL%20ASSESSMENT%20OF%20PAIN&topicRef=110699&anchor=H2272263902&source=see_link#H2272263902

[6] https://twitter.com/meghas/status/977149188881383424

ABOUT THE AUTHOR

SOCIAL MEDIA EDITOR
Dr. Trueger is an emergency physician at Northwestern University and Assistant Social Media Editor at Annals of Emergency Medicine. He tweets as @MDaware and blogs at mdaware.org

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