50-Year-Old White Female Blogger

Maurice over at the Bioethics Discussion Blog posted a recent take on an old issue: how much information to try and squeeze into that all-important “first line” of the history and physical. Should medical students be taught to include or exclude medically “extraneous” data like race, ethnicity, marital status, etc. in their case presentations? Like this:

45-year-old black female homemaker…
57-year-old married white male machinist…
74-year-old left-handed retired Asian math professor…

The argument is that aside from age and gender, all the other information about ethnicity, marital status and the like is not medically necessary. This is true. The big arguments, of course, center around race, with the presumption that certain diseases have certain racial predilections. This, of course, is also true and not true, in that race is recognized as more of a cultural construct and has much less biological significance than previously recognized, although certain conditions do indeed occur with greater frequency in persons of various genetic backgrounds.

Some other pieces of information are specialty-specific. Neurologists usually include handedness in their opening statement, because it is often germane to the conditions they encounter. Not always, of course; who cares what hand a migraineur writes with. Still, it is part of their schtick. It is also logical for Occupational Medicine notes to make prominent mention of the patient’s occupation. So there are isolated instances where seemingly extraneous information becomes relevant.

The rest of the discussion centers on the perils of physicians pre-judging their patients, falling into stereotypical thinking on the basis of the descriptors included in the H & P’s opening statement. I believe this fear is overblown. Hopefully doctors refrain from jumping to any prejudicial conclusions solely on the basis of the first words of a case presentation.

That said, I think the entire argument is moot.

The unspoken assumption when talking about teaching medical students “how to do a history and physical” is that there is a “right” way to do one, including a “correct” way to present one’s findings to others. It is true that there is indeed a standardized format of sorts for an H&P which ought to be taught to medical students. It usually contains the following components:

• Chief Complaint (CC)
• History of Present Illness (HPI)
• Past Medical History (PMH)
• Family History (FH)
• Social History (SH)
• Review of Systems (ROS)
• Exam
• Lab, Imaging and other studies
• Formulation or Assessment (diagnosis), and
• Plan

The problem is that in real life (as students will learn their first day of their clinical studies) this format is extraordinarily context-dependent. Different sections of the history take on different significances depending on the patient’s circumstances and the physician’s specialty. Past medical history is usually nonexistent in infancy (aside from information about the pregnancy, labor, delivery and nursery course), and family history is immaterial after the age of 80. In essence, students have to learn a whole new H&P format with each rotation.

This is not wrong. One thing that bothered me in medical school was classmates who claimed that they had been taught to do the H&P a certain way, and by Gd that’s the way they were going to do it. Um, no; when you’re doing Obstetrics, it’s not that important to determine what the patient’s grandfather died from and whether or not she ever had her tonsils out. (Just try asking all your Review of Systems questions to someone in active labor and see how far you get.) The idea that the H&P for the initial presentation of an adult patient with a medical (as opposed to surgical) problem, as taught in medical school, is the only “right” way to do an H&P is inflexible and impractical. Similarly, the idea that “presenting the patient” is always done exactly the same, regardless of whom you are presenting the patient to (and the reason for the presentation) is nonsense.

Think of an H&P like a painting. There are many different kinds of paintings: still life, portrait, landscape, miniature, abstract, and so on. There are the basic artistic concepts of design, line, light, color, layout, but different kinds of paintings require emphasis on different principles. If you imagine all students beginning with an oil painting of a still life of a vase of flowers, how silly is it to think of them complaining that a landscape isn’t a “real” painting. In our case, that internal medicine patient presenting for the first time with a new problem (as opposed to a patient in the ER, or a patient needing a pre-surgical evaluation, or a newborn, etc.) is the equivalent of the floral still life. Learning to recognize when that form is appropriate is half the battle.

In terms of presenting the patient, again, context reigns supreme. The formal version discussed by Maurice is designed for the presentation of a new patient to clinicians who do not already know the diagnosis. ie, a clinical puzzle, as seen in the New England Journal of Medicine and elsewhere. As third year medical students will quickly learn, that won’t get you very far on morning rounds. “Hemicolectomy, post-op day three, afebrile, passing gas” is all they want to hear on surgery. “Mulitip at six centimeters an hour ago, comfortable with epidural” will do on Obstetrics. You get the idea.

After all that, though, in answer to Maurice’s question, I’m going to come down on the side of more information in the opening statement rather than less. I’d love to hear something like, “58-year-old married female secretary who just dropped her last child off at college and started art lessons last week…” and here’s why. It has to do with this quote from Sir William Osler:

“The good physician treats the disease; the great physician treats the patient who has the disease.”

The more I know about the patient who has the disease, the better job I will be able to do caring for that patient. How better to get to know the patient than to describe him or her as fully as possible right from the start of the encounter. For those who worry about stereotyping, allow me to offer the following suggestion: ask the patient to describe him or herself, and then include the response in the opening statement. Like this:

This is a 50-year-old white female physician blogger with grown children and way too many animals at home who describes herself as “zaftig but generally healthy.”

I don’t treat diseases. I treat people, and because every person is different, I think it is better to err on the side of more description rather than less.