FAQs

It is important to note that the example history before is just a model, and so it might not work in 100% of situations. However, it is a template which should always give you a base with which to work from and not panic in stressful situations. Below are some common queries which students have and how to get round them.

1. What if the patient mentions their family history or something different during a different part of the history?

Whilst you might have this model template in your mind, the patient will not. They are just going to answer your questions naturally and will be unaware that you are trying to follow a set structure. This is something that comes with history taking and should not throw you off.

The way to get round this is just to go with the patient. You will have noticed that the model history above had been split up into different sections – PISPFDS. Imagine that each one of these is like a block of lego. Therefore if, whilst talking about the presenting complaint, or more commonly the ideas, concerns and expectations, a patient starts talking about their family or social situation, ask the remaining questions in that block. Once you have done that, that aspect is ticked off (you do not have to repeat it later) and you can signpost to the patient that you would like to resume the presenting complaint.

For example, you ask, “What are you concerned about?”

Patient: “I am concerned that my stomach pain might be sinister as my mum had ovarian cancer.”

You: “Ah, sorry to hear that. When was she diagnosed”

Patient: “She got it at the age of 50”

You: “Ok, are there any other conditions which run in the family” (explore fully).

Once you have finished this, you can resume the ICE simply by saying, “Ok I can see that your mum’s diagnosis might be playing on your mind. What were you hoping to get out of the visit today?”

By going with the patient, and being flexible, you can show you are listening, understand the patient’s concerns, and tactfully manoeuvre the consultation back into the structure that you are comfortable with.

2. Why do I have to screen so many times?

Screening for more symptoms may seem frustrating – however many patients present with multiple symptoms, and it is the most sinister or embarrassing ones that patients will omit until you press them further. In addition, especially during exams, patient actors are told to withhold information from students, and will only reveal their symptoms after asking multiple times. This is a test which (although somewhat artificial) will distinguish the best students from average ones.

3. How can I show empathy using the structure?

By learning the model history, there is a danger that you may seem like a robot, simply bombarding the patient with pre-learnt questions. Therefore, many clinicians might argue against learning a history template, and instead trying to do it more naturally. However I would argue the opposite. The most embarrassing thing you can do as a student is panic, get muddled and not know what question to ask, giving long pauses, saying “Ummm, errrr…” – and you might also forget to ask important questions.

Once you have learnt the template inside out, you will be able to focus less on what question to ask next, and instead be able to have a natural conversation with the patient. This will allow you to listen closer, react to what they say, be more emotive using hand gestures and facial expressions and overall seem like a more experienced, confident doctor. Of course, saying key phrases like “I understand this has been very difficult for you” will also help to how you understand the patient’s plight and demonstrate that you are keen to help them.

4. What do I do if a patient is very non-responsive?

This is every medical student’s nightmare – approaching a patient with the hope of taking a great history only to find that at best they are giving short one word answers. There can be a few reasons for this:

• A patient might not speak English well – in this case, you have to accept that there will not be anything that you can do.You may wish to see this patient with senior help or someone who speaks the language.

• The patient may be tired/in a bad mood – again this is something completely out of your control. However, this is why it is very important right at the beginning of the consultation to ask if the patient is comfortable and if they need something. This will allow them to say that this is not a good time to take a history – even if they don’t, it gives you more time to gauge how engaged the patient is likely to be. If they really seem distressed, probably it is best to abort the history and return at another time.

• The patient might be feeling sad or worried – It is common for sick patients to really worry about their health. People deal with fear in different ways, and a common method is to act withdrawn. A patient might want to engage with you, but this fear may be weighing so much on their minds that they cannot stop thinking about it, and so are unable to answer your questions. This is why asking the ideas, concerns and expectations at the beginning is crucial. It will allow patients to open up and tell you their worries, after which they should feel better. Notice how after some reassurance, the second half of the history should be much easier to take.

Sometimes however there might not a definitive reason, it might just be their personality type. In this circumstance, it is important to remember who is the professional. Despite the patient acting aloof, as a doctor it is your role to try and conduct the best history – so keep smiling, probing, reassuring, being empathetic and maybe at the end you might even get a smile back.

5. How long should a history take to conduct?

There is no set time for a history. However, it is worth remembering that due to the pressures facing the NHS, GP consultations have reduced to 5 minutes per patient in some places. In A&E, you are not likely to get more than 10 minutes too. Similarly in OSCE exams, you would usually get 10 minutes to take a full history from the patient.

Therefore, when starting out, I would not time your histories, especially in the first month. It is far more important that you gain exposure talking to patients, just to overcome any nerves and familiarise yourself with taking a history. Some of your most memorable moments as a student will be talking to patients for over an hour learning about their life stories, families, literally a summary of their life. But that’s all part of the joy of being a student. As you gain more confidence, aim for 20 minutes and then before exams try to give yourself closer to 10 minutes, mirroring what you will get in the exam.