History and Physical (H&P) – The Cognitive Structure of Medical Training
Medical training generally works like this:
- 2 Preclinical years – this is the “drinking out of a fire hose,” where you just try and cram as much as possible into your brains.
- 2 Clinical years – this where you are supposed to learn how to think like a doctor, get exposed to all the different specialities, and decide what to do for the rest of your life (don’t worry – no pressure).
- 3-5 Residency years: learn the tools, procedures, and knowledge specific to your specialty and how to apply them.
What is the H&P?
The H&P is the cognitive form that medical training drills into you starting at the end of our preclinical years. All those questions that your doctor asks you that you don’t understand why she is asking them – they are from the H&P. It generally looks likes this:
Chief Complaint – One word/phrase about why you are there
History of Present Illness (HPI) – paragraph about what has been going on
Review of Systems (ROS) – checklist of symptoms from body systems not directly related to the HPI
Past Medical/Past Surgical/Family History – medical events in your personal or your family history
Social History – Smoking/other drugs/alcohol/ maybe profession and/or marital status if someone is being thorough
Vital Signs/Physical Exam/Objective Data – the laying of hands, the stethoscope, and any lab/X-ray data.
Assessment/Plan – What the doctor thinks is going on and what she plans to do about it
The H&P is very useful for communicating a patient’s story between doctors, its original purpose. It is also useful for helping us remember to ask/do certain things. Unfortunately, it has also become the basis for the billing of non-procedural physician work. Physicians base their billing on the documentation in their H&P. No longer just a communication tool, the H&P has become a billing sheet. Nonetheless, even as a communication tool, it is limited.
The H&P does not demand this kind of information:
- Recently laid off
- Going through a divorce
- Friend just got diagnosed with cancer
- Sexually Abused as a child
- Closest full-service grocery store is 5 miles from house requiring a 1.5 hour bus trip with 3 transfers
Some would say all of the above is social history. A reasonable assertion, but Social History is culturally undervalued in medical training – it is not “hard medical fact.” Also, per billing regulations, social history is worth significantly less than ROS or Physical Exam points. It is literally worth less money to ask about the aspects of a patient’s life that most affects their health (see Figure). The social determinants of health deserve, and will probably get, an entirely separate post.
the h&P assumes a certain level of baseline health
The very nature of the headings: Chief Complaint and History of Present Illness create the assumption acute illness. Especially in primary care, this is often not the case.
Currently, even in acute care settings, most problems are actually an exacerbation or destabilization of chronic disease. The very structure of the H&P helps blind us, and by extension patients, to this fact. The H&P helps place our brains into the cognitive trap of trying treat chronic problems as acute ones.
In the middle of a rough primary care clinic day, I often wished I could have used the Chief Complaint of “Same Shit, Different Day.” I don’t mean to invalidate patients’ suffering – but it is CHRONIC, not ACUTE. It has been going on for YEARS and will not improve when treated as an acute problem. Yet, that is what physicians are programmed to do. At a system level, that is what we are forced to do.
The “explanatory models approach,” which is widely used in American medical schools today, as an interview technique….that tries to understand how the social world affects and is affected by illness. …. We’ve often witnessed misadventure when clinicians and clinical students use explanatory models. They materialize the models as a kind of substance or measurement (like hemoglobin, blood pressure, or X rays), and use it to end a conversation rather to start a conversation. – Anthropology in the Clinic By Arthur Kleinman and Peter Benson
THis tendency has been recognized before
Arthur Kleinman, MD has been trying since the 1970s to get medical training to build more of the psychosocial aspects of patient’s lives into the basic cognitive framework we use in treating patients. He popularized “explanatory models” as a way to delve into the patient’s psychosocial world. Explanatory models are popularly taught in US Medical Schools, but they often fall flat (see quote above).
Personally, I saw some of that influence in my medical school, but it was presented perfunctorily, once or twice. Whereas the basic formulation for the H&P is drilled into you on every rotation. By the end of medical school, it would be like forgetting how to tie your shoes. Effectively, little has changed. By omission, psychosocial aspects are taught to be fluff, stuff that is nice to know – if you have the time.
So, I ask: Is it possible that a format based on the assumption of acute illness is failing us in the era of chronic disease?