Take a chronology instead of a history

A chronology of present illness, an alternative history-taking strategy, can help medical student organize the more traditional history of present illness.


Where: Stanford University School of Medicine in California.

The issue: Finding the best way to conduct and document an initial patient interview.

Background

History of present illness, the traditional approach of formulating a patient's story through a prose narrative, has its drawbacks—especially for trainees. “You'll watch new medical students try to take a history and...they're all over the place. They might start with a good leading question, ‘So tell me what brings you in today?’ But patients don't usually come in with a story that's well written and organized, and students don't have a framework to offer them, so they have a very long, meandering conversation, and they often forget things,” said Laura M. Mazer, MD, MS, a general surgery resident at Stanford.

Enter the chronology of present illness (CPI), an alternative history-taking strategy developed and taught for decades by Dr. Mazer's research mentor, Kelley M. Skeff, MD, PhD, MACP, a professor of medicine at Stanford. With the timeline-based format, dates or times appear on the left side of the page, and patient symptoms, activities, treatments, and other events appear on the right, providing a chronological overview.

How it works

The CPI offers a framework to take the patient's history, write the note, and communicate the history to other clinicians.

Dr. Mazer offered the example of being called to perform a cholecystectomy on a women in her 40s who presented to the ED with obesity, abdominal pain, and gallstones.

When she began to interview the patient using the CPI as a framework, a different story emerged. Dr. Mazer said to the patient, “Tell me the last time you felt healthy and take me from there.” The patient explained that she didn't feel well the day before and hadn't eaten much and that the pain began in the middle of her abdomen before migrating to the right lower quadrant. “Long story short, we wound up taking out her appendix that night and leaving her gallbladder alone,” Dr. Mazer said.

She acknowledged that she could've differentiated between the two pathologies based on physical exam alone but that the woman was difficult to examine because of her body habitus. “Without a structure to the history, it would be easy to get swayed by the factors that would predispose her to gallstone disease rather than the actual time course of her illness,” Dr. Mazer said.

Results

After adopting the CPI, Dr. Mazer and colleagues decided to put it to the test. They presented the CPI format to 22 internal medicine residents, who were asked to use the format to take, write, and communicate all new patient histories for one week of night-float rotation. Researchers then conducted surveys about the method's effects on patient interactions, and results were published in the February Journal of General Internal Medicine.

After using the CPI for a week in about 76% of patient interviews, the residents reported significant improvements in the quality of patient interactions, the clarity of written notes, the quality of the assessment and plan, and the clarity of their verbal morning sign-out. When the study authors surveyed the day team residents, they also reported significant improvements in sign-out clarity and written notes, although attendings did not report any significant differences.

For Dr. Mazer, the big take-home finding was the positive effect on night-to-day handoffs. “I think it was through the study that I started to really see the CPI as this conceptual framework that went through the patient's entire interaction with the health care system,” she said.

Challenges

The biggest challenge that consistently arose was that the CPI method takes longer, Dr. Mazer said. “Not always, as in my appendicitis example, but with a complicated patient, it will take more time because it's forcing you to do the job right,” she said.

However, the initial time investment of establishing charts with timelines of patients' major medical events could save time in future interactions, Dr. Mazer suggested. “It's really easy to slide in a line....You could even imagine going into a patient's room with the last chronology up in front of you and saying something like, ‘I've read up on your chart, I know you've had a really complex history, how about if we go through the events as we have them recorded? You let me know if there's anything I'm missing or anything wrong, and then you tell me what's happened since,’” she said.

Next steps

Internal medicine residents at Stanford continue to use the CPI, and Dr. Mazer said her team is interested in extending the method's reach. “I think the big picture is that this needs to be taught in medical schools,” she said. To make the format accessible beyond Stanford's classrooms, Dr. Mazer hopes to implement Dr. Skeff's teaching into asynchronous learning tools, such as videos and patient vignettes.

In terms of research, the team will perform a chart check in about six months to see how many residents still routinely write their notes in the CPI format. They also hope to have consultants read and compare CPI notes with more typical histories to see if the format changes their clinical decision making.