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Broome Docs Podcast: the “difficult historian” rant

OK, welcome back to the podcast.

Apologies but this one is a bit of a disgruntled grumble about a few things that really annoy me in modern medicine.

I have just met my new cohort of JMOs, students and trainees and they seem like a really smart bunch.  So I thought I would put this out there for all.

If you are a senior doc then you might appreciate it, and if you are on the way up – then here is some advice:

– Do not use the term “difficult historian”…   EVER

– Dyscopia is not a diagnosis.  It means you have not understood what is going on and have no plan for your patient.

Apologies for the dark tones.  Back to fun and light next post.  Promise!            Direct download here

Casey

Comments

  1. David Berger says:

    Casey, on the scale of rants this is a pretty mild-mannered one! I’ll agree with you on dyscopia or ‘acopia’ (and in fact we had one of these admitted to the ward this week. Drunk, as it not so surprisingly turned out.). I’m less sure about the ‘difficult historian’, or at least I will agree with you that ‘difficult historian’ is a bland, vague, non-contributory phrase.

    However, I do think that making some kind of statement about the nature of the history-giving can be informative:

    “This 46 year old man gives a clear history of excruciating pain radiating from the right loin to groin, lasting for ten to twenty minutes each time, which came on suddenly at 10am today and has recurred three times since then, associated with sweating, nausea and brown urine.”

    or

    “There is limited history available from this 46 year old man, possibly due to language difficulties, but as far as I can make out from him it appears he has been having abdominal pain for the last day or so. The rest of his past history, as gleaned from the notes and the ED staff who know him is as follows…”

    So, as long as a broader picture is painted, then I think it’s helpful. ‘Difficult historian’ is certainly too vague and pejorative to be helpful, but we shouldn’t throw the baby out with the bathwater.

    Cheers,

    David

  2. minh le cong says:

    you dont like dyscopia or acopia terms…so do you accept ” social admission” as a term if presented to you as reason for presenting complaint?

    • I don’t mind somebody writing “Social admission” in the notes -- but it should be followed by a problem list, a plan and some potential solutions to explore!

      I have an airway analogy for you: if somebody writes “difficult intubation” in the Anaesthtic chart that is OK, helps you be prepared. BUt would it not be better if they wrote, “Difficult airway, grade 3 on DL, grade 2 on VL, easy passage of bougie. Suggest a 6.5 ET as tight cords.” This is a plan, a solution and tells me what I need to do.

      Casey

      • David Berger says:

        Interestingly, talking to one of the med students today they don’t get taught to do problem lists, but that can be by far the best way to approach many of our patients. Worth a tutorial sometime, Casey?

  3. Malcolm Forbes says:

    I agree that these terms should be avoided where possible. However, it is not useful or productive to have a go at junior doctors for using these terms. They have simply adopted them from their predecessors and senior staff, in keeping with how most bad habits are acquired. The best way to promote good case presentation is to lead by example.

    I note with interest that in a post on this site only just over a week ago the term “poor historian” was used (http://broomedocs.com/2013/02/clinical-case-080/). Before giving edicts to junior doctors on what to do and what not to do, senior docs should reflect on their own practice.

    • Hi Malcolm. Thanks for your comment.
      Apologies if the podcast was a bit on the negative side -- I was trying to get across a productive alternative concept to the blanket use of terms such as dyscopia and “difficult historian”.
      See other comments below.
      I think my point is that stopping at “difficult” or “dyscopia” does not do the patient any service -- these “terms” should prompt a further look at what the root causes of the patients problems are and hence contribute to a possible solution or pragmatic management plan.

      And these terms are by no means restricted to junior MOs, they are pervasive in the medical culture I was brought up in. I think I learned it from an overworked and tired Med REg when I was a student. I believe that we need to get away from the ” US vs. Them” culture of medicine.

      FYI, re: the use of the term “difficult historian” in Clinical case 080. This case was contributed by my former RMO-trainee, who is an awesome, empathetic and culturally savvy young doctor. I know what she means, the term is a throw-away line in most EDs -- but I want my JMOs to think further. E.g if the patient speaks little English and has not much health understanding, then what is going to happen with compliance with any care -- and how can we anticipate this and make it as easy as possible for the patient to get the care they require?

      If we are going to change the culture -- we need to start somewhere. In my shop that means showing the JMOs a different way. But I agree, a top down, leading by example approach is ideal. We are trying in my place.

      THanks

      Casey

  4. I totally agree that the terms “difficult historian” and “acopic/dyscopic” should not be used as a throwaway excuse for not sorting out one’s (or one’s patient’s) nitty gritty, however I would submit that there is nothing wrong… nothing wrong at all… in using these terms in the same way that we use countless other words and phrases in medicine which serve to help describe an aspect of our patient or their presentation in a concise way which facilitates more efficient communication; whether that is in the context of a junior presenting a case, a handover, or a referral.

    I’ve been practicing for quite a while and have encountered a very large number of difficult historians, and vast numbers of dyscopic people (patients and their carers, staff, etc.) and while simply labelling them as such contributes little to sorting out their specific problems, it does convey some useful information to other healthcare professionals, if not about the patient’s problem, then about the ease (or otherwise) with which that colleague might expect to interact with the patient themselves in the future, and indeed alert them to the very issues you highlight. One might hope that such brief, “uninformative” terms might, in fact, alert a colleague or senior to the fact that this patient, especially, will need more intensive scrutiny than might otherwise have been the case.

    These terms are, therefore, useful… and randomly banishing them is probably not doing the greatest good for the greatest number.

  5. I was glad to hear I’m not alone. I’ve detested “difficult historian” from the moment I heard it. Aside from being linguistically clunky (I always picture a grumpy history professor), it admits our failure to take a decent history. As David commented above, I much prefer to describe why I struggled to take a decent history.

    As for “acopia”, I had a few med teams early on who refused that diagnosis. So refering to them required something like, “This patient is unsafe/unsuitable to discharge from ED because of …(list), and needs admission with the objective of …(list, often of allied health services)”. As someone else mentioned above, unlike “acopia”, this is something we can discuss openly with patients, and seems to help focus the patient on getting out of hospital from the outset.

    • My definition of ‘acopia’ is an acute medical event that otherwise could be managed in an ambulatory setting but due to the borderline baseline function of the patient and precarious social setting will require additional community and social supports for the patient to function independently.

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