Does taking a history do more harm than good?

Posted: August 30, 2012 in Uncategorized

A good history will give you 90% of your diagnosis

We have all heard it, along with some others:

Ask the right questions and the patient will tell you what is wrong with them

This is what is taught in every school. Whether you are practicing medicine, chiropractic, or just practicing being cool, it is ingrained in us that the history is key to our diagnosis and treatment.

**Understand what I am about to say is considered a perfect world scenario where my fellow practitioners who practice manual medicine can rule out serious pathology that should not be in our office (cancer, heart ailment, etc.) This is obviously the reason why we need to always take a good history and Review of Systems.**

My opinion: I think history taking actually makes us worse. It clouds our view of what is truly going on. In fact, it’s a bad habit that you just can’t kick. As much as you really want to just forget about it, it simply won’t go away. And I am confident that I’m not the only one guilty of this.

When we begin to work up a patient, it is very hard to ignore the site of pain and actually go for dysfunction. As health practitioners, it is a huge leap of faith to focus only on dysfunction because we all know that the person standing in front of you has come with pain in a specific region and expects that specific region to get treatment.

Typically, I know the mind game goes a bit like this,

Good Justin:The left ankle has no dorsiflexion. Go after that dysfunction!

Bad Justin: The person came in with back pain. Just massage and adjust the low back. You know it will work!

Just like this

So what does this all mean?

I think in the end, we must find a balance. While assessing the patient for movement dysfunction, you truly may need to play dumb. By dumb, I mean you must forget why the patient is standing in front of you. For that time, literally forget the person had pain and take a clear picture of the dysfunction. Do not be tempted at all to go back to that painful site simply because that person has an ‘ouchie.’

Once that is all figured out, you certainly have every right to go back and treat the painful site with whatever magic trick is in your bag. First though, do yourself a favor. After exercising the dysfunction and before treating the site of pain, re-test everything. You may be pleasantly surprised to find  the painful site is not as painful without ever directly working on it.

Any of this sound familiar?

If you answered yes, then you are probably familiar with the SFMA (Selective Functional Movement Assessment). And, while I have not been formally trained in this yet (I will be taking it this October), it is a system my boss has taught me and one that we use everyday, with every single patient that walks into our clinic.

Using this classification system (DN: Dysfunctional Non-Painful, DP: Dysfunctional Painful, FP: Functional Painful, FN: Functional Non-Painful) I believe this puts a method to the madness. If nothing else, it helps organize thoughts and document findings.

Obviously, there is much more to it than that, and clinicians who are much more advanced with the system than I, who could do a much better job explaining the intricacies of the system.

Above all else, recognize what the patient tells you (history), rule out anything that should be sent out, and then forget everything they said. Find dysfunction. Treat pain if needed.

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Comments
  1. Hi Justin,

    I think stating “history taking actually makes us worse” and “it actually clouds the picture” are ridiculous comments. The history clarifies, more than anything, what is really “going on. Pain is a bioPSYCHOSOCIAL phenomenon with bioPSYCHOSOCIAL influences. What is more prognostic in recovery from LBP…is it having a dysfunction or addressing yellow flags? If the patients just “stands there” as you employ your “magical assessment” you may have the ‘bio” (if that) but missed the psychosocial. The subjective examination should not, in my opinion, be viewed at just an opportunity for you to rule out red flags. Ruling out red flags can most of the time be done after reviewing your intake paperwork, without even taking a formal history.

    In addition to identifying goals and patient expectation of care, the subjective examination provides the patient with a chance to “tell their story” and process consciously and subcounsciously your sympathy, empathy, willingness to listen and desire to help (or lack thereof). All this conscious and subconscious processing is part of the neuromatrix and will contribute to up/downregulation of the nervous system (which is kind of important since the brain is the only thing that “causes” pain). I often encounter this common mode of thinking in the functional rehab community. The ”all I need is to perform my magical evaluation of dysfunction and apply one of my many tools in my toolbox and work “my magic” and “my magic” is what gets the patient better. This thinking is seriously flawed. Dysfunction (whatever that means) never has nor ever will cause pain and if you think identifying and treating dysfunction eliminates pain I suggest reviewing the literature on pain neuroscience.

    Also regarding your suggestion: “literally forget the person had pain and take a clear picture of the dysfunction”. Ok…forget the person had pain….find the “dysfunction” and you will quickly realize that the same dysfunction” has nothing to do with pain and found just as common in asymptomatic populations. And “Above all else, recognize what the patient tells you (history), rule out anything that should be sent out, and then forget everything they said. Find dysfunction. Treat pain if needed”……seriously?

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