The chief complaint driven medical history: implications for medical education

It is the purpose of this paper to present an approach to teaching a concise, focused method to obtain a medical history from patients in the Emergency Department. Diagnostic reasoning starts with the medical history. Nowhere is obtaining an accurate history more important than in the Emergency Department. Here the demand for a quick focused and effective assessment and presentation prompts some to propose that medical students be able to accurately present a case in as little as “three minutes”.1 The key is for the student is to learn to determine what pertinent information is. There exists a robust history of inquiry into how expertise is developed in clinical reasoning.2 Experienced clinicians work through the early development of diagnostic hypotheses which they then use to account for clinical findings. This problem solving method was initially referred to as “hypothetico-deductive” reasoning.3 Rather than a general reasoning skill, it was soon found that clinical reasoning was dependent on a specific knowledge domain, that diagnostic accuracy depends more on mastery of specific medical content than it does on general diagnostic strategy.4,5 Case relevant recall differs between expert and novice clinicians.6 Experts have more accurate initial diagnoses. However, they do not recall more total information about a presentation. They recall more relevant information. Experts make better selective use of data, choosing relevant over relevant to retain, retrieve and apply. To learn how to determine relevance, the clinician must learn to apply certain patterns to organize patient information and relate it to a structured knowledge base. Students learn to place data and knowledge into larger units of meaning and connect the units of meaning together to form higher structures of meaning.7 One explanation for how novices learn to organize data to separate relevant from non-relevant pieces of information uses the idea of “semantic qualifiers”, which are oppositional, contrasting or dichotomous relationships.7 A clinical complaint can be described along a number of different dichotomous axes. These dichotomies can be used to compare, contrast, and draw distinctions between diagnostic possibilities. Consider the chief complaint of “chest pain”, one of the most frequent reasons for visits to an emergency department. The chest pain can be characterized as either acute or chronic, sharp or dull, constant or intermittent. It can be associated with dyspnea or not, and occur in the context of multiple risk factors or not. These axes are of key importance, both to represent the problem adequately, and in the formation of clinical meaning for the elements of the history as they pertain to the differential diagnosis. The traditionally taught method8 of obtaining a medical history acquires elements of the history in sequential separate categories. What has been called the “History of the Present Illness” starts with describing the ‘chief complaint’. This History of the Present Illness is then followed in order by the Past Medical History, Family History, Social History, and Review of Systems. Only after gathering each bit of history in this separate manner are students asked to integrate the acquired data into a whole. Experts in the emergency setting do not gather or present information in that manner. Clinicians in the emergency department use a combination of simultaneous problem solving and hypothesis generating and testing. As early as first hearing the chief complaint, the expert clinician begins immediately to head toward a diagnosis and evaluates each of several competing diagnostic hypotheses. For each diagnostic possibility, the provider specifically seeks and selects elements from other areas of the history, namely from the ‘past medical history’, ‘family history’, ‘social history’ and ‘review of systems’, which may lead one toward, or away, from each possible diagnosis. These form the relevant or pertinent positives and negatives. Knowledge of what is pertinent separates the expert from the novice.