History Taking and Templates

“You’ll know when to come next” were the ominous words told by the neurologist to the patient diagnosed with peripheral neuropathy when he asked for a follow-up visit.

Eight years later, he showed up to another neurologist, the one I was rotating with. 

“I guess you knew it was about time” I say jokingly to the 80-year-old quite healthy-looking gentleman sitting across me. 

“I guess,” he chuckles, “but that guy is probably dead now.” 

And so we declared him dead throughout the history. 

A short while later, upon discovering that he was very much alive (and retired) and probably in his 60s, both of us burst out laughing.

….

Another patient. 

“So what brings you here today?” I ask knowing the chief complaint on the EMR said memory problems. 

“My youngest son,” she says glancing at him, “he is very caring. He took care of my mom too, got her evaluated for dementia.” 

She seemed reluctant to admit why she was here, switching topics to her mom as a diversion. 

“So would you say your son enjoys taking elderly people to the neurologist for possible dementia as a hobby?” I say playfully. 

Both of them laugh. But she opens up then. 

….

These are the moments I remember, the times I share a laugh with my patients, when I connect with them on a human level. Long gone are the days I could boast of a strong memory, medical school has a way of taking it away. I could never tell you the chief complaints and histories and examinations at the end of the day without consulting my notes, but these moments I can tell you by heart. I could tell you all about my patients from three years ago simply because I shared a human connection with them. I may not be the most empathetic person outside of the hospital but maybe it’s my own convoluted history as a patient, that I seem to have a soft spot for patients. 

Which is why, it pains me to see my colleagues stick fervently to templates, to tick off checkboxes so their work is completed. I don’t blame them, they were trained to follow the template and so they do. But I have been in rooms when they do, and there are no hearty laughs and no human moments. Instead, a structure that doesn’t follow the patient’s story, and a long list of items that doesn’t fit the patient’s complaint. 

Templates should be used to help you, not to rob the patient of their chance at storytelling. Perhaps you are the only outlet they have to listen to their health issues. Let them speak, the template can follow. Make it count.


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