As a clinical negligence lawyer, I don’t need reminding about the importance of taking accurate instructions from my clients and making sure I record them correctly. This also applies to when I am reviewing a client’s medical records – I look at what has been recorded against what happened in real life. Quite often cases are settled on the lack of an accurately recorded patient history.
I know the feeling of having to relive conversations or long conferences to produce as far as is possible an exact note of events – not fun and can feel secondary to other more urgent actions that need attending to. However, I also appreciate how important it is to have a good record of events and accurate timeline to refer to when going forward.
In the middle of what may be a medical emergency or in the midst of an overcrowded A&E department taking a history and accurately recording what is said is certainly an additional task that may not seem important compared to other things happening. But asking the right questions and recording that history is undeniably an essential skill for medics to master. It needs to be habit, and it needs to be accurate. The General Medical Council certainly lays out expected professional standards for note keeping so whilst taking a history is fundamental it is just as important to record it. In some cases, it can mean the difference between a competent treatment pathway or serious harm to a patient.
It was therefore my pleasure that my rather excellent GP recently invited me to help out with her training of some budding Kings College Hospital medical students which brought to light the importance of history taking – asking the right questions, noting down the responses to weigh up the potentials.
If I rewind to 2018, I’d just won a trial at the Royal Courts of Justice and had been feeling really ill but passed it off as stress related. It has been a stressful time after all as on the run up to the trial I had been working hard to make sure my client’s representation was the best it could be. Once the trial was over and happy to report we were successful, I went to see my GP with two complaints, an annoying blocked ear that wouldn’t shift and low level persistent stomach pain. My GP asked all the right questions, noted that I looked unwell and ordered tests which eventually revealed that I had ulcerative colitis. She had undoubtedly asked the right questions, listened, taken a good history, appraised it and decided on the correct pathway.
That was the incident that she chose to use as a “case study” for her students to teach them the value of asking the right questions and recording them correctly so I was asked to relive that experience. The brief given to the students was to ask me accurate questions noting that patients will not always know what is important to tell a doctor. A good doctor should be able to use the reason the patient is seeing them as guide to ask specific questions to enable them to get the information that is needed from the patient.
Each aspiring medic asked me their chosen questions and every single question was well thought out. They then focused on my answers and built on them to form a good patient history. They collated the information given to make a working diagnosis.
It may have been a role play scenario, but it was of a real life lived situation that without taking an accurate history may have had a rather different outcome. The students agreed it was a valuable learning tool for them. And judging by their enthusiasm and the quality of questions, I think the future looks bright.
And yes, they did correctly identify my condition!
