The recent discovery of a case of Ebola in the U.S. made me wonder: since the patient was seen twice, why was it missed the first time? The symptoms as listed by the Centers for Disease Control and Prevention (CDC) can include fever (>38.6o C), severe headache, muscle pain, weakness, diarrhea, vomiting, and unexplained hemorrhage. These symptoms may appear two to 21 days after exposure, with the average being eight to 10 days.
I picture myself as the ER or urgent care doc in the middle of a busy day, seeing another semi-ill person with an apparent gastroenteritis, worrying about the trauma or more critically ill patient I am seeing simultaneously; or simply at the stack of charts of people waiting to be seen, and getting through the history and physical as quickly as possible because the eyeball glance at the patient in question says he’s not very sick.
The key question that was apparently asked but not communicated: “Have you traveled recently to West Africa?”
There are other questions that are equally important, and have a much higher yield for a positive response, but Ebola, of course, is a critical issue today.
A questions that should always get asked: “Have you been recently exposed to strep?” Because if you have been, and have a fever, sore throat, and tonsils coated in pus and no cough, practically guarantees you have strep. We may not ask because the rapid strep test is readily available, and generates a buck or two in revenue.
“Have you been exposed to anyone else that is sick?” That might be a better question.
You will make the diagnosis 90 percent of the time from the history! Remember that aphorism?
But what happens in real world practice in the daily rush? We do not take a good history. Not a really good one. Not one that includes all the details and the one in a thousand, or one in a million return on investment in the questioning. It’s time consuming, tedious, and there is very little return on investment.
But it is important. So what is the solution?
We need to work at the top of our license, so deferring the history to someone else is an easy answer. But I have heard from clinicians: “I need to look at the patient as they give the history, so I can see the truth.” And: “No one else but me, in my office, can take a history like I can.”
The answer I am going to propose for the more mundane and easily templated problems we see day after day — but also the ones that are full of “Gotcha’s” — is the use of a template, or an electronic solution like Instant Medical History, which can serve for even complicated histories.
The template can ask all the little yield if asked, but nevertheless important questions, because they get asked by someone with more time. We need to utilize tools and staff, using templates, or electronic tools to provide better care.
Yes, it denies us the opportunity to look the patient in the eye when they answer a question. But I will question whether you really do a great job of taking a history, because it takes time, and we do not have enough time in the day to personally take a great history.
I’ll also point out that you can review the history with the patient, and look them in the eye then. And the pertinent negative are critical and don’t need to be reviewed. But tools exist that will allow us to do it. Let’s use them.
More information on Ebola: