In clinical medicine, it is usually the case that our patients have seen someone prior to seeing us. They come to us with diagnoses, histories, med lists, explanations of prior medical adventures, and certain expectations. Given how often diagnoses are incorrect, and how many medicines are prescribed that are either unneeded or not optimally chosen, it is evitable that much if not most of a patient’s medical history is inaccurate. Even the good care previously received is subject to the poor memory or medical illiteracy of the patient who is doing her best to recall complex stories that far too often have been reduced down to an overly simplistic understanding, filled with misconceptions and connected dots that need to be disconnected.
In order to not make incorrect assumptions, it is a helpful cognitive forcing tool to assume that everyone who has previously seen the patient was incompetent. In taking a history, particularly about the symptoms or disease process of interest, it is necessary to start from scratch and avoid the potentially biasing information found in the chart or other medical records. Many medical errors are the result of inheriting others’ thinking. Once an incorrect diagnosis or treatment is attached to a patient, it takes deliberate work to detach those that are in error.
In practical terms, this means taking a complete history and not assuming the history in the chart is accurate. It means seeing the patient, if possible, before reviewing the notes and opinions of other clinicians. It means deliberately questioning previously established diagnoses and asking what else might be causing the signs and symptoms that the patient is experiencing to avoid diagnosis momentum. It also means clarifying the patient’s understanding of her issues and providing education as needed.
