‘Taking history’

If a doctor asked me “Has this impacted on any of your ambitions or goals?”, I would probably burst out laughing. Surely, no one speaks like that, do they? And so, here are my comments on the new Impact Q framework. The new way of teaching medical students how to ‘take history’.

Whenever I read about clinical communication, I wonder what happens at medical schools. Let me illustrate my point by a fragment of the article. The authors write:

Students begin to feel that demonstrating empathy is a tick-box exercise for both themselves and the examiner, whereby they make generic statements referring to the well-known ideas, concerns, and expectations (ICE) criteria, such as ‘that must be terrible for you’ or something inappropriate such as ‘that’s great — what do you do for a living?’ after a patient discloses that their father died of lung cancer.

I find the word ‘inappropriate’ quite inappropriate in the context, but, more importantly, do trainee medics really need to be told such things? I mean, do they really not know that they shouldn’t say that parental death is great. What happens to you, medics, that you need to be told such things? I also wonder how the IMPACT Q framework deals with the tick-box problem. Doesn’t it suggest 7 questions to go through?

I have said many times that I find guides to communication, lists of questions, scripts for conversations both useless and counter useful. I think they offer nothing more than stilted communication in which the clinician recites phrases. Moreover, any such questions are necessarily out of context and, if anything, they offer false hope. Let’s take the question I mentioned at the beginning:

Has this impacted on any of your ambitions or goals?

When you stop to think about it, there are considerably more problems with the question than solutions it offers. First, it assumes that I actually have ambitions and goals. Do I really need to be like you and go forth through life, identifying a series goals, satisfying ambitions? Has anyone actually thought of asking me first whether I have them? But let’s assume for a moment that people have a goal or two. Why do the authors assume that I would like to share them with the doctor? If I were to be asked a question like that, its pomposity notwithstanding, I would have a hard time deciding what to reveal and what not to reveal to the medic. It irritates me no end that I am assumed to be an open book which simply opens up at a mere question of a doctor. But, let’s also assume that I am prepared to share. Which goals and ambitions do you have in mind? In fact, the ambivalence of the question is quite extraordinary.

I’m afraid, finally, I cannot resist a little silly dig – have you not noticed, authors, that it is the anathema of a question – it is, after all, closed?! More seriously, I shall never understand why not ask, for example:

What has this impacted on?

You know, like, not assuming that the impact must have been on ‘ambitions and goals’, but just waiting for my answer. You could also not assume there has been impact and first ask whether there has been any. I know it’s hard, it’s very hard. After all, you, the doctors, know much better than me what my condition might have had impact on. And so, I fully understand, why bother and let me speak? I should just answer your questions, for you, so completely obviously, cover it all, and I, so completely obviously, might forget something. I am, after all, just a patient and cannot be trusted to tell you how my condition has affected me. I need you to tell me what I should be looking for. Obviously.

Just a little point, though. My CFS, which you are barely interested in, has resulted in me putting on weight. I really hate it. And I really don’t know under which of your wonder-questions I will be able to mention it. I really don’t. I am, needless to say, ready to accept that I simply may well be wrong in thinking about it.

And no, please, don’t insult my intelligence by saying it’s in the quality of life section. I have no idea what you mean when you refer to my ‘quality of life’.

Have a look now at this impactful question:

How has this all impacted on how/where you would ideally like to be right now?

Again – who speaks like that? Well, ideally I would like to look like George Clooney, but, alas, I don’t. I’m not entirely certain this is what you’re asking, I’m also not certain how ‘this all’ is relevant with regard to my ideal look. I also would prefer to be in the Okavango Delta, but I can settle for simply being somewhere else and not having to answer your IMPACT Q questions.

But are you asking me what my ‘condition’ stops me from doing, achieving, being? Then why do you construct it in terms of an ideal? Are you saying it’s all lost and I cannot hope any more? I would also like to suggest that my question:

What has this impacted on?

quite surprisingly I guess, does take care of the issue as well. Yes, I know, it does deprive you of the opportunity of asking your IMPACT Q questions…And I haven’t got a good answer to that. But, if I could suggest a thinking point: how likely am I to forget that I cannot provide for my family? Just saying…

Now, I have a couple of  points more to make in addition to (I am so sorry) undermining the effort behind the new acronym. The tool apparently is about getting future doctors to ask their patients about psychosocial functioning. Here is the idea:

Just as other medical mnemonics are widely adopted for initial learning until they are deeply engrained, the use of IMPACT Q will eventually help our future doctors master the ability to concurrently elicit both medical and psychosocial information, allowing both doctor and patient to feel a sense of connectedness to each other.

So, the trick is to get the new doctors to remember, wait for it, the IMPACT Q phrase and questions, and they will be ‘taking history’ like a dream. Question-answer, question-answer, question-answer, question-answer, question-answer. Questions are like buttons. You push it, information is accessed by the computer-patient and the mouth squirts it out. Obviously. Could I just humbly ask, however, whether the authors have any contact with reality and people who do not simply want tell? There is research on patients’ face saving, on patients’ shame, on patients’ lying. Does any of it feature in the Never-never land constructed in the IMPACT Q framework? Or is the IQ framework (wink, wink) the ultimate passkey to the patient’s experiences? You ask, I tell, because I just can’t stop myself?

My second point is more general. I keep wondering what makes a conversation about what the patient’s worried about now ‘history’. I’m probably too simple to understand, but ‘history’ suggests to me some past, not necessarily very distant, still the past. But the questions proposed in the IMPACT Q framework very explicitly refer to the present. How is it ‘history’?

Of course, I’m very far from suggesting that changing the word ‘history’ will somehow transform the way medics talk to their patients.  But perhaps it will make a medic or two consider that they’re not talking about some past, there talking about life as it happens. Now.

And so, finally, once again, poor unconfident medical students are offered a shortcut. They will have another note above their desk which will remind them of what to ask. And they will recite these pompous questions and probably will get some answers, which will reassure them of their communicative greatness.

And they will join the legion of doctors who are unable to talk with their patients.






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