The medical history: Are you asking questions right?

The medical history: Are you asking questions right?

Nov 01, 2001

From a client's viewpoint, timely differentiation of potentially reversible disease from irreversible disease is an important expectation related to clinical assessment of illness.

After describing their concerns to us, clients often ask, "Can you help him/her, Doctor?"

They are concerned about the probability of recovery of their animals from illnesses with or without therapy, the nature and cost of therapy, and whether recovery is likely to be partial or incomplete. Assessment of the medical history usually plays a key role in formulating meaningful answers to these questions. Most would agree that obtaining a reliable medical history is not only a "science" (i.e. asking the right questions), it is an "art" (i.e. asking the questions right).

To achieve this balance, considerable skill is required to efficiently direct the flow of information without stifling the client's conversation or putting words in his/her mouth. In this context, considering the design of questions is often beneficial.

Requesting rather than suggesting answers

In order to minimize bias associated with preconceived ideas, the concept of avoiding use of leading questions is important. Answers to questions should be requested rather than suggested since clients will sometimes respond by giving an implied answer, even if it is erroneous, in order to please you or to hide their perceived ignorance.

For example, if a question related to detection of polydipsia is phrased, "Has your dog been drinking a lot of water?", a client whose dog's water consumption was normal might answer affirmatively because (s)he perceives that drinking a lot of water is normal. By providing several alternative answers to such questions, this problem may be minimized.

Thus, the question related to polydipsia could be phrased as, "Do you know if the quantity of water your dog has been drinking during the past few days has increased, decreased or remained the same compared to her water consumption two months ago (or other appropriate intervals)?"

One of the most important alternatives that should routinely be included as a potential answer, and yet one that is frequently omitted is, "I don't know." Why? Because if owners provide incorrect responses to questions about which they do not have accurate information, the doctor may formulate an erroneous or even contraindicated plan of management on the basis of misinformation. Won't you agree that it is better to have no information and be open-minded than to formulate erroneous conclusions based on inaccurate information?

Incorporating alternative answers

Consider the following examples of questions incorporating alternative answers: "Is the volume of urine voided during micturition more, less or the same as compared with a month ago? Do you know?" "Is the frequency of voiding urine more, less or the same as compared with a month ago? Do you know?" Clients may be able to accurately assess the frequency of urination of the patient, but unless the dog has been urinating in the house they often are unable to accurately assess the volume of urine voided.

Keep in mind that it is important to ask these questions in such a way that the client will recognize that the alternative of not knowing the answer is acceptable.

Once a historical problem (such as vomiting) has been identified, subsequent questions about its history may incorporate the following:

1. When was the vomiting first observed and by whom?

2. Is there any relationship between the onset of this problem (vomiting) and other problems or events: yes, no or don't you know?

3. What was the sequence (or chronological order) of the onset of this problem in relation to other problems? (For example, vomiting followed by polydipsia might suggest a primary gastrointestinal disorder, while vomiting preceded by several weeks of polydipsia and polyuria suggests a secondary gastrointestinal disorder.)

4. What has been the duration of the problem: acute, chronic or don't you know?

5. During the past week (or other appropriate interval) has the severity of the problem increased, decreased, remained constant, or don't you know?

6. Have you provided any form of treatment? If yes, what type of therapy was given, and who (you and/or others) gave it? Do you know if the severity of the problem improved, remained the same or increased in association with the treatment?

Additional points

1. Strive to conduct the interview about the medical history as a conversation rather than an interrogation.

2. Try to determine if the source(s) of the information about the patient's medical history is directly from the client being interviewed of whether it is "second-hand" information.

3. Strive to discern the difference between observations (facts) and interpretations of observations (inferences). We frequently interview clients who confuse observations and interpretations when describing the illness of their animals to us.

A classic example is the client's tendency to misinterpret the observation of tenesmus in a male cat with urethral outflow obstruction as constipation. Although either observations or interpretations may be erroneous, in my experience misinterpretation of a correct observation is the most common pattern of error by clients. Why is this point worthy of emphasis? Because, a misinterpreted problem is the worst of all problems. If misinterpretations are unknowingly accepted as facts, misdiagnosis followed by misprognosis and formulation of ineffective or contraindicated therapy may result. This is indeed ironic since the patient may then be in a worse condition as a result of having visited the doctor.

4. At the conclusion of the interview, summarize the important findings for the client to ensure that you have identified his/her concerns and placed them in proper perspective.