Today’s restless society has taken its toll on modern medicine. Among all the strategies for protocol optimization and health insurance improvements, doctors get to spend less and less time actually talking to their patients. Each check-up needs to be performed in a certain amount of time, and every procedure needs to be completed as quickly as possible so that hospitals are efficient and profitable.

While this makes perfect financial sense, it is definitely not the right approach from a medical standpoint. It is crucial that doctors have enough time to analyze the patient’s general history, as well as the main reasons why he has decided to seek medical assistance.

Understanding the circumstances that have led to the patient’s symptoms is essential to identifying their correct cause. Moreover, doctors need to correlate the present situation to the patient’s medical history because this will enable them to visualize it as a whole.

However, this is almost impossible to do in the 20 minutes that are provided for examinations. Doctors are required to focus on treatment implementation rather than a thorough analysis of the causes of disease.

In this case, it is all too easy for them to miss those key details that could guide them towards a complete diagnosis. And when it comes to rare diseases, the answer almost always relies on details about the patient that might be hidden beneath the surface.

Key points in taking a proper case history

The case history is an indispensable component of the medical examination because doctors get to find out the main features of their patients. They need to understand the patient’s medical profile, as well as the symptoms that he is experiencing at that moment and the circumstances that have brought them on.

Medical history

Each underlying medical condition alters the body’s reactions to the stimuli it comes across. A healthy individual, one suffering from chronic disease and one who is recovering from an illness will react differently to the action of the same external stimulus. This is why understanding the patient’s medical profile should be the start point of the examination.

Circumstances of disease

Doctors need to be allowed enough time to analyze the situations that the patients are going through. This means that they need to find out when the patients’ symptoms began and how they have developed up to the present moment. Moreover, they need to ask patients the right questions that can reveal the tell-tale signs of a disease.

Key discussion points that might lead the examination in the right direction

Establishing a connection with the patient. The connection between doctors and patients may actually influence the outcome of the examination. It is important that doctors make an effort to help their patients feel comfortable and safe from the first moments of the discussion. This will actively improve the communication between them and it might help doctors perform a better examination.

The patient’s whereabouts. Whether patients present general symptoms, or rare signs of disease that might point to an illness that is out of the ordinary, doctors need to ask them about any travels that they might have made recently or even the last couple of years, if the situation calls for it. This only lasts a few minutes, and it could offer the doctor valuable information about the disease that the patient might be suffering from.

The patient’s interactions. It is important to know if the patient has had contact with harmful environments, animals or people suffering from certain diseases. Depending on the symptoms displayed by the patient, the doctor will have to pinpoint the risk factors that could have led to them and then find out which of them has the patient come across. This will enable him to make the right connections and determine the diagnosis.

The patient’s psychological status. The patient’s mental state has a great influence on his ability to develop and fight disease. Anxiety and depression may make patients more vulnerable to damaging stimuli, so identifying these as underlying symptoms could lead to a better understanding of the patient’s current state.

The patient’s standpoint

On the other hand, when patients are in need of medical assistance, they often have a difficult time finding the right doctors who can help them get better. Since triage is not always available, patients often struggle with finding the proper specialists to treat their symptoms.

If the patient’s symptoms suggest that he might be suffering from Crohn’s disease, for instance, it is highly important for the doctor who is treating him to recommend a medical practitioner specialized in diagnosing and treating this kind of illness.

It is important that they find a physician they can trust and who can make them feel safe. Most times, they are scared when going to the doctor and they need an authoritative figure who can make them feel that the solution to their issues is within reach.

Another important aspect is being honest with the doctor. Even if they might feel ashamed to discuss some of their symptoms or the circumstances that have generated them, patients need to provide their doctors with all the necessary information because the accuracy of the diagnosis depends on it.

Opening up to strangers does not come easily to people, but patients must bear in mind that they will not be judged and that the information they provide will not be made public in any way. While the reflex reaction is to keep embarrassing details private, they must share the complete information whether they consider it relevant to the diagnosis or not.

Identifying a rare disease depends on interpreting small details properly. These might make the difference between the flu and other viral diseases that are far more dangerous. While the proper diagnostic process entails flawless medical knowledge and skills, communication remains one of the most influential factors.

Factual analysis and establishing connections between the patient’s symptoms and the circumstances that have generated them are the main tools that doctors have at their disposal to provide an accurate diagnosis. Since these rely greatly on the quality of the communication between physicians and their patients, this can easily be distinguished as one of the key factors that can influence the outcome of the clinical examination.

Richard Robinson is a general surgery resident and consultant, XpertDox.

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