2.2History Taking

Cite as: Crijnen, AAM & Kraan, HF (2024, January 1). History Taking. Retrieved from https://www.maas-mi.eu/explanation/2-history-taking

Explanation

After listening to your patient in Exploring Reasons for Encounter, you need to explore and understand the medical problem through History Taking before you present any explanations and advice in Presenting Solutions.

History taking requires you to use both your problem-solving and your interviewing skills, which are distinct but complementary medical competences.

You must:

• Listen to your patient
• Elicit, uncover and filter relevant facts
• Formulate tentative hypotheses
• Ask specific questions to get the relevant facts you need
• Refine, confirm or reject hypotheses.

As a student of the medical interview, you will be well aware how demanding history taking and medical problem solving can be: problem solving while interviewing your patient draws heavily on your mental skills and can be quite demanding and exhausting, not to say frustrating. But rest assured, applying the order and content of MAAS History Taking will help you to solve the medical problem successfully.

MAAS History Taking helps you to solve the medical problem successfully

Figure 1 provides an overview of the interaction between medical interviewing and medical problem solving.

In the next section, we explain the phasic approach to medical problem solving.

Problem solving requires a phasic approach

Medical problem solving relies heavily on history taking. To obtain the input for the problem-solving process, the physician will ask different kinds of questions, in different ways, relating to each of the three different phases of the hypothetico-deductive approach. 

More precisely, medical problem solving consists of a three-step mental process, repeated a couple of times during the interview, in which:

• Phase 1: Cues – bits of information – are generated to provide input for tentative hypotheses
• Phase 2: Cues are acquired to refine or confirm hypotheses
• Phase 3: Cues are acquired to refute unlikely hypotheses, to obtain background information, and to further reduce the problem space.

The structure of medical problem solving consists of three sequential but distinct phases

The phases follow each other in time and differ in terms of the goals to be achieved, and, consequently, in terms of the type of interviewing skills the physician prefers to use. The phasic structure of medical problem solving with the input from the medical interview is shown in Figure 2.

These three phases of medical problem solving translate into different strategies that largely determine the approaches to history taking that we will discuss in the following sections.

Phase 1. Generating cues to form tentative hypotheses

At the beginning of the medical interview, there is usually a lack of information, which means that the problem space is huge. For this reason, the physician feels a strong need to limit this space before it can be searched and explored more incrementally. So physicians adopt the strategy of generating tentative hypotheses early in the diagnostic process. These early, provisional hypotheses, which are likely to provide the solution to the patient’s problem, immediately reduce the problem space and prepare it for further testing or refinement.

Physicians generate tentative hypotheses early in the interview in order to reduce the problem space

As a clinician, you will pick up one or more salient cues from the patient’s complaint. These cues will trigger the hypothetico-deductive strategy with the generation of initial hypotheses followed by further refinement or testing of these hypotheses. Within less than a minute, you will be asking questions from your medical frame of reference, because you already have a number of hypotheses in mind that urgently need to be tested.

Generate some cues

But first, you need to generate some cues before you can start to formulate tentative hypotheses. Cues are nothing more than a few of words or phrases from the patient that arouse your curiosity, catch your attention, or sometimes make you very alert. 

Cues are a few words from the patient that arouse your curiosity, catch your attention, or make you very alert

Cues can be generated:

• Directly by the patient during the Exploration of Reasons for Encounter in response to questions from the physician
• Or through systematic questioning by the physician during History Taking.

Figure 3 shows how information from the patient’s and the physician’s frame of reference can lead to the generation of tentative hypotheses.

Salient cues generate on-target hypotheses

Allowing the patient some time at the beginning of the interview will reward you with more salient cues, allowing you to formulate tentative hypotheses that are more on target. Although, as a clinician, you may feel the pressure to narrow the problem space and want to ask a few questions – which usually happens after 30 seconds of an interview – we recommend giving the patient enough time to address their concerns. Your patient will feel better understood and your treatment proposal will be better tailored to their needs. 

Your patient will feel better understood when you wait another 30 seconds before asking questions

Generally, cues can be found in the complaints and symptoms presented by the patient. As mentioned earlier, young students, registrars and residents rely on the textbooks and Signs & Symptoms schemes to help them understand the significance of a symptom or the pattern of symptoms presented by the patient. Physicians with years of clinical experience, on the other hand, are familiar with the natural history of a condition, atypical presentations, and the impact of a condition on a patient’s daily functioning. In addition, these doctors feel less pressure to solve the medical problem – because they know they will eventually do so – and better understand the patient’s worries and concerns.

And provides you with more salient cues, allowing you to formulate on-target hypotheses

For you as a physician, it is very important to get salient and rich cues, because they evoke thoughts that are translated into hypotheses in your mind. And you had better make sure that these cues will lead to a set of hypotheses that, from the start, includes the hypothesis that ultimately turns out to be the ‘right’ one. Research shows that, if you’re on the wrong track and haven’t included the ultimate diagnosis early on, you’ll have a hard time with cue acquisition and hypothesis confirmation during history taking . This is why experienced physicians incorporate contextual information into their reasoning, ultimately leading to earlier – and better – diagnoses.

We will have a look at Cue Generation to Form Tentative Hypotheses:

• From the patient’s perspective (§ 1.1)
• Followed by a look at the clinician’s perspective (§ 1.2).

1.1 Cues from the patient’s frame of reference

As the patient is well informed about their complaints and the reason for their visit, cues to the underlying medical condition may well be exchanged during the Exploration of Reasons for Encounter. 

In their concerns, patients express what is really important to them

Similarly, your patient’s comments convey their own and their family’s thoughts and concerns about the underlying medical condition. You should include and address these comments in your discussion with the patient during Presenting Solutions; but why not take them into account early in the diagnostic process? These types of cues not only carry emotional information; they may also contain factual information about the underlying medical condition (see Table 1.)

1.2 Cues from the physician’s perspective

Remember that your goal is to generate any cues that will provide input for the formulation of tentative hypotheses – so be open-minded, stick to the complaint as formulated by the patient, and even probe for the salience of this complaint. For example, you might say: You mentioned that you have a cough and can’t sleep, which of these is most important for you?

You will follow up on the complaint that is most important to the patient, e.g. that they can’t sleep, with the questions from the complaint heuristic (a fuller explanation will follow in the next section):

• Ask them to describe the complaint
• Explore the intensity of the complaint
• Ask about the localization, shifts and radiations of the complaint

Followed by:

• Ask about other symptoms accompanying the complaint
• Explore the impact of the complaint on daily life.

Although the main complaint has been brought up by the patient, these questions may well be the start of the History Taking, followed by the Time-Intensity, Triggering & Decreasing Factors, and the Accompanying Symptoms & Circumstances heuristic explained in the next section.

The demarcation between Phase 1: Cue Generation to Form Tentative Hypotheses and Phase 2: Cue Acquisition to Refine and Confirm Hypotheses is not so clear in our daily work. We have arbitrarily decided that when you examine the main complaint as formulated by the patient, you are working on Phase 1 – the generation of cues to form hypotheses, whereas when you reformulate the main complaint or examine a medical complaint and follow these up with the subsequent heuristics you are working on Phase 2 – the acquisition of cues to refine and confirm your hypotheses.

To continue with our example, you may also decide to pursue your patient’s cough for any reason you consider important, for example because it suggests a more likely area for clinically important hypotheses, and you are working on History Taking.

You know that the examination of the main complaint from the patient’s point of view and from your own as  physician have a lot in common: in both situations, you take the most salient complaint into account. But your patient may choose to do so because of inconvenience or worry, whereas you may decide to follow up a more promising physical sign for medical reasons.

But you must remember: The main complaint is the complaint that your patient wants to be investigated and resolved.

Table 2 summarises the interview behaviour of clinicians in generating cues for hypothesis formulation.

Interviewing Style

In Interpersonal Skills, we have operationalized the patient-centred style of interviewing that is used  favourably during  cue generation.  Interpersonal Skills are achieved through facilitation and active listening, reflection on emotions, open-ended questioning, and summarizing and concretizing when necessary.

Our research shows that a well-structured interview reduces anxiety and facilitates the communication.

Phase 2. Acquiring Cues to Refine and Confirm Hypotheses

MAAS History Taking consists of simple search strategies that make it easy to:

• Collect data from the patient
• Subsequently generate hypotheses in the early stages of problem solving
• Refine and confirm hypotheses.

We call these strategies heuristics, because heuristic is Greek for to discover. 

Heuristic is derived from the Greek word for discovering

History-taking heuristics in the medical interview consist of a series of questions organized around a theme and provide an accurate and reliable description of certain characteristics of the medical problem at hand. They are very helpful in generating hypotheses that can be tested subsequently by more detailed questioning.

History-taking heuristics are sets of questions organized around a theme

By using the MAAS heuristics, your patient’s narrative will be rich and thorough, and full of cues for the generation of tentative hypotheses and their subsequent refinement and confirmation. In our validity studies, we have found that MAAS History Taking leads to better diagnoses.

Ensure that your patient’s narrative is rich and thorough

Figure 4 shows how heuristics – sets of questions – lead to the refinement and confirmation of your hypotheses.

2.1 Cues from History Taking

These sets of questions – heuristics – will be familiar to you, because you use them all the time in your consultations with patients. You ask an open-ended question, listen to your patient’s answer, elaborate a little as you go along, and then perhaps ask a more closed-ended question to make sure you have understood your patient well.

And then you move on to the next heuristic …

We have arranged the heuristics and their constituent elements in the order in which they were most frequently used in experiments, but you may wish to use them in any order that suits you (see Table 3).

Time-Intensity Heuristic

Any change in complaints or functioning over the course of time should be carefully examined and may well provide information about possible causes and underlying vulnerability. 

Any change in complaints or functioning over time should be investigated and may well contain valuable cues regarding causes and vulnerability

A patient’s description of the course and intensity of complaints over time, including accompanying complaints, triggering and decreasing factors, contains many valuable cues for generating hypotheses about the diagnosis and causative factors of the underlying disorder that can be successfully examined.

Help yourself and reduce the problem space by immediately refuting unlikely hypotheses

And, just at importantly, because it reduces the problem space and thus the load on your working memory, it provides cues for hypotheses that can be refuted straight away.

Triggering & Decreasing Factors Heuristic

Questions such as: Did you notice anything that triggered the unset of your complaints? are intended. These questions may reveal very trivial factors–stress, excercise, etc., but can also be revelatory.

An 18-year-old patient of ours admitted that she felt desperate right at the moment that she received her high school certificate; her symptoms increased and she became suicidal.

The factors may also include medical procedures, such as treatment, surgery, medication, etc.

When the Time-Intensity and Trigggering & Decreasing Factors heuristics are combined, they may bring to light some of the pathophysiological mechanisms underlying the symptoms and disorder.

Accompanying Complaints & Circumstances Heuristic

First of all, this heuristic serves as a check to make sure that we didn’t miss any complaint or condition considered important by your patient.

However, this heuristic is also helpful to examine the involvement of related physiological systems or any significant consequences of the main complaint. An example of the search for signs of dysfunction can be found under Review of Systems where we examine for example, in addition to chest pain, also dyspnoe, nausea and vomiting, sweating and weakness.

This heuristic is therefore very helpful in the organization of the Review of Systems where closely-related symptoms are examined and small differences in formulation or understanding may make the difference in the confirmation of a diagnosis.

Follow through on the order of MAAS-items and they will guide you succesfully through History Taking

A closer observation of MAAS History Taking reveals that we already methodologically organized MAAS items in the order of the heuristics – just follow through on MAAS History Taking while interviewing your patient and you will be rewarded with striking cues for the refining and confirming your hypothesis. 

2.2 Cues from the Review of Systems

You will not be surprised, but we organized Review of Systems in MAAS Medical Interview:

• Around the Main Complaints of a dysfunctional physiological system
• While following our – heuristical – search strategy, including:
  • Time-Intensity
  • Triggering & Decreasing Factors
  • Accompanying Complaints.

The Review of Systems may actually be the second or third time that you systematically address the complaints of your patient in order to refine and confirm your most important hypothesis. First, you took your patient’s main complaint; the second time, maybe, you reformulated this in a more clinical complaint. This time, however, the formulation of topic and content of your question is very well-specified, because the goal of this part of History Taking is to be very specific in the confirmation of your hypothesis.

Formulate your questions specific and check that you received a precise answer to obtain the information for the confirmation of your hypotheses

In Table 4, you will find an example of the Review of Systems given that your patient experiences pain in the chest.

2.3 Cues for Treatment Choice

Largely neglected in research on medical problem solving, but present in many consultations, doctors try to understand where the patient is in the patient journey. Patients have previously followed their own, their family’s and other professionals’ advice, and you want to be informed about their treatment choices and outcomes before introducing a new treatment plan.

Therefore, evidence of treatment choice can be sought either in:

• Item 1.7 Asking how the patient has tried to solve the problem themselves
• Or through the Treatment Heuristic we present in Table 5.

It is now up to you to interpret this information and incorporate it into your treatment plan. There are several options:

• Your patient has presented with a new complaint and past treatments are not relevant
• Your patient has presented with a new recurrence of an existing, chronic condition and the experience of previous treatments is very informative and relevant to the current choice of treatment
• Your patient has presented with an exacerbation or worsening of a chronic condition and you need to reconsider the stage of the disease and the type of treatment.

For example, our 18-year-old patient appeared to have been treated for obsessive-compulsive disorder with behavioural therapy alone when she was younger, and we had to reconsider the treatment plan and inform her about medication.

Advanced Problem Solving

From time to time, we find that our traditional problem-solving proces is disrupted, and we become aware of this by feeling that something doesn’t add up. The disruption may come either from our patient or from our own limitations.

When you notice that something doesn’t add up, try to mentalize and think in a different way

H^-1  or Hypothesis-minus-one

The idea behind Hypothesis-minus-one is that you recognize a pattern in your patient’s complaints, but you notice that important cues or salient information are missing, preventing you from confirming your hypothesis. This condition can occur when your patient withholds important information, for example because they do not understand that the information is important, or because they feel ashamed or even threatened by disclosing these cues – as we see often in mental health, but also in somatic care (Nendaz, 2000). In forensic settings, some defendants may decide not to reveal health-related information in order to protect their legal case.

However, in general practice and in mental health,  this situation is quite common in cases of rape and abuse, physical abuse, and coercion or serious threats. Although the victims experience intrusive psychological distress, they are very reluctant to share their experiences for fear of experience overwhelming emotions of fear, anger and revenge, and of breaking down.

Listening to what we don’t hear from our patient can be very supportive – and informative

In the case of H^-1-hypotheses, your original task – of confirming a hypothesis through cue acquisition – changes. Now you need to manage the medical interview in such a way that your patient feels supported, safe and less stressed, which may – but is not guaranteed to – facilitate disclosure. If not, you should manage the situation so that your patient feels encouraged to come back another time.

Ultimately, patients often feel relieved after disclosing their traumatic experiences, but the process can be very demanding and requires a lot of dedication and skill.

In fact, many patients who visit general practitioners and internal medicine departments may have had adverse childhood experiences, such as sexual or physical abuse, neglect, etc., early in life (Felitti, 1998). These unresolved experiences and the subsequent stress can lead to chronic mental and physical illnesses, such as hypertension, obesity, etc.  and even early death. Therefore, disclosure of traumatic experiences in our consultations early, but also later in life, can really help our patients; they experience the relief that can help to reduce a huge burden of distress.

Two hypotheses instead of one

As doctors, we prefer to organize our problem-solving and medical interviews around the idea that we are dealing with one underlying medical condition rather than two or more.

To keep things simple, we sometimes need to think of two causes, rather than one

However, this may not always be the case in our clinical practice where conditions may occur simultaneously simply by chance. Your patient may develop a rash because of the antibiotics that you prescribed, but also because of Pfeiffer’s Disease, the reason for the prescription.

This brings us to the relationship between symptoms and disease – the basic idea behind pattern recognition. In their original approach, Elstein et al. simply assumed that each symptom was unambiguously indicative of an underlying disorder, and that at a certain number of symptoms the threshold for a specific disorder was reached. However, in our daily work this assumption doesn’t hold, because many factors, such as gender, age, stage of disease, treatment, etc. affect the relationship between symptom and disorder.

Be aware that the relationship between symptoms and underlying disorder is never guaranteed and may vary depending on gender, age, stage of disorder, treatment, etc.

Unfortunately, the relationship between symptoms and disorder has almost never been empirically researched. As a result, clinicians have to rely on their clinical expertise to decide whether or not there is any relationship between symptoms and disorders in challenging cases, which ultimately leads to diagnostic uncertainty.

Fortunately, we have explored some conditions about the relationships between symptoms and underlying disorders, taking into account the impact of age-related changes in the relation. You can  look at these considerations and decide whether they apply to your clinical work.

Interview Style in Phase 2

There are three categories of interviewing skills that are appropriate to the above styles of history taking in both general care and in primary mental health care.

Questioning

It is recommended that the questions asked should be as open as possible to avoid suggestive or covert questions (question-sounding statements that do not demand immediate responses).

We argue that the appropriate skill at this phase – in its typical form – is the so-called ‘open to closed cone questioning’: an important cue is raised during the interview; the physician then proceeds with more probing and directive questions, and may end with closed questions to elicit accurate, factual information.

This open-to-closed-cone questioning may suit the underlying hypothetico-deductive strategy of clinical reasoning. 

Active, unbiased listening

‘Unbiased’ listening is a high ideal for physicians who need to select the medical facts essential for a medical diagnosis. Nevertheless, the physician should be constantly aware of possible biases. 

Summarizing

The physician summarizes the patient’s words in his or her own words and invites the patient to check this summary. This is a control against ‘biased’ listening.

Questioning, active and unbiased listening and summarizing are best done in a well-structured interview, as structure reduces stress and thus promotes an accurate exchange of factual information.

Phase 3. Acquiring Cues to Refute Hypotheses and to Collect Additional Information

Although the importance of Phase 3: Refutation of Hypotheses for the quality of your diagnostic reasoning in this particular case and for your professional development in general cannot be overemphasized, it has received little attention in medical education and research. 

Phase 3 distinguishes between two approaches to the acquisition of incongruent and pertinent cues, namely cues to refute hypotheses and cues to obtain any additional information (See Figure 5).

However, through deliberate reflection – and this is where the medical interview comes in – you will be able to formulate the specific questions and recognize the specific cues in your patient’s complaints to disprove hypotheses.

In this way, the questions you ask during hypothesis refutation are very similar to the systematic questions you ask during the Review of Systems.

Find cues that refute previous hypotheses to increase the chances of making the correct diagnosis and to avoid tunnel vision

Collecting Cues for Additional Information

General Questions Regarding Systems

This phase consists of a series of screening questions about the various systems to eliminate any remaining hypotheses that have a low probability of confirmation. However, there is also a risk, as the physician really wants to disprove these hypotheses to avoid having to reconsider their existing hypotheses and start the proces all over again.

Therefore, these questions, often – erroneously – take the form of double-barrelled (or multi-barrelled) questions, such as You don’t have any complaints regarding your heart, lungs, stomach or intestines? where the patient will answer with a no, leaving doubt about the which part of the question the answer applies to.

To refute hypotheses, ask open-ended questions about the systems and give your patient enough time to confirm or deny

For this reason, these questions can act to screen different medical systems, but should be asked openly with enough time for the patient to confirm or deny: Do you have any complaints about your heart? … your lungs? … your stomach and intestines? … etc.

Staging heuristic

In consultations for chronic conditions, you need to understand where the patient is in their journey to understand the diagnosis and guide the choice of treatment.

The questions that make up the Staging Heuristic (see Table 6) will inform you about:

• The stage of the disorder (prodromal, first episode, remission and/or relapse, chronic)
• The appropriateness of the choice of interventions.

There is some overlap with the Selection of Treatment heuristic, but here we focus on the stage of the disorder rather than the choice of treatment.

Medication & Substance Use Heuristic

In every medical consultation, current medication and substance use should be documented according to the heuristic shown in Table 7. There may be some overlap with the Selection of Treatment heuristic, but here we focus only on medication use.

Risk & Vulnerability Heuristic

In addition, underlying risks and vulnerabilities, important information for understanding a predisposition and selecting treatment, can be targeted by the questions listed in Table 8.

Reduce a number of loose ends into one meaningful narrative

The idea is that you feel overwhelmed, because your patient is providing a lot of discrete and disorganized but potentially meaningful pieces of information. And the other idea is that you need to narrow this down to a few salient cues that make sense as causes or consequences of the main complaint.

Make sure you bring to light a few salient cues that are meaningfully related to the main complaint

This is where you need to rely on your interviewing skills, in particular your ability to interrupt and stop your talkative patient in a respectful way, while at the same time helping your patient to choose what is really important.

• First, you need to interrupt, for example with a reflection: You mention lots of issues that are really important to you.
• Followed by a summary: You mention that your child doesn’t sleep well, is easily annoyed, and that you argue a lot. Am I right?
• Followed by a question: Which of these things worries you the most?
• Based on your patient’s answer, you explore the issue further and try to understand how it relates to the main complaint.

In this way, a large number of small and meaningless pieces of information are transformed into a few meaningful sentences, hypotheses about the complaint that should be addressed in the treatment and that are easy to remember. It also makes your patient feel understood, less anxious and therefore less talkative.

It is especially taxing when your patient mentions information that you think is relevant, but are unable to elaborate on because your mind is overloaded and you are likely to forget. Therefore, we advise you to intervene in the way we have suggested well before your mind is overloaded, to reduce the amount of data into refined or confirmed hypotheses, and to continue this process in a new cycle of problem solving with the salient cues provided by your patient.

Reducing a number of complaints into a meaningful hypothesis

The strategy of grouping cues into a set of diagnostic hypotheses, thereby organizing the data and reducing the cognitive overload in your working memory,  was already considered by Elstein (1976). Our mind can only handle about 7 pieces of information and, by organizing, we can reduce 7 symptoms to 1 confirmed hypothesis, leaving room for another 6 pieces of information. Especially in complex cases, you will experience a sense of relief and space when you can refine a few hypotheses. Generating and confirming hypotheses acts as a memory organizer .

We look forward to hearing from you how you managed to reduce the problem space while conducting a successful interview

So much for this introduction. You now have some guidelines for your interviews with patients, and the interviews will again raise some questions.

References

• Crijnen AAM, & Kraan HF, (1982). Meeting patients. Maastricht University Press, Maastricht, the Netherlands.
• Felitti, VJ, Anda, RF, Nordenberg, D et al. (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine 14:245-258
• Elstein, AS, Shulman LS & Sprafka SA (1978) Medical problem-solving – an analysis of clinical reasoning. Harvard University Press, Cambridge
• Mamede S & Schmidt HG. Deliberate reflection and clinical reasoning: Founding ideas and empirical findings. Med. Educ. 2023;57(1):76-85
• Monteira, S, Norman, G & Sherbino, J (2018). The 3 faces of clinical reasoning: epistemological explorations of disparate error reduction strategies. J Eval Clin Pract. 1-8
• Nendaz, MR, Raetzo MA & Junod AF (2000). Teaching diagnostic skills: clinical vignettes or chief complaints. Advances in Health Sciences Education 5:3-10
• Norman G. (2005). Research in clinical reasoning: past history and current trends. Med. Educ. 39:418-427
• Schmidt HG & Mamede S. How to improve the teaching of clinical reasoning: a narrative review and a proposal. Med Educ. 2015;49:961-973

We are very grateful to Prof. Dr. HG Schmidt, a renowned expert in clinical reasoning, for reviewing this chapter and providing valuable feedback.