History Taking in Clinical Practice: A Foundational Clinical Skill ? Is it losing stream ?

Introduction

The most fundamental step in the assessment of any patient is history taking. It is rightly considered the gold standard of clinical assessment. We are already in the fast paced Medical practice and information is available at finger click. AI seems to be taking over with a lightning speed. With all these, it appears that the importance of history taking is diminishing fast. There is no doubt about the role of technology and now AI is having a significant impact in a positive way. But in my opinion, going away from basic principles and standards will definitely affect patient care and management.

The other important factor is - not everyone has access to health care facilities and one thing which is going to help us and our patients is our clinical skills. .

The reason I chose to discuss History taking is based on my personal observations (there is scope for argument about my personal bias). During my ward rounds and assessments of Medical students and Resident doctors, I found that there are significant lapses in history taking, unfortunately that too is at a very basic level of principles and standards.

While most of our young students and doctors are not just familiar but excellent with the standard algorithms. The challenges are with “History of presenting illness”. This is often mentioned or recorded as a simple narration from parents/carers or patients themselves. In my opinion- if we continue to lose the skill it will definitely have an impact on our own thought process, patient care, management and is associated with the risk.

The Standard Algorithm-

Presenting Complaints

History of Presenting Complaints

Past Medical History

Allergy/ Medicines/Substance misuse

Birth/Pregnancy and Milestones

Family/Social

System wise history taking can be discussed elsewhere but we can try to discuss some important principles. I am dividing them into 5 points. Let us go through them in reverse order.

5. History of Presenting Illness:

History of present illness is one of the most vital aspects. As earlier mentioned I find them missing from most of our resident doctors and medical doctors. History recorded or narrated is restricted to the patients/parents version. What we all need to understand that -

1. Guiding patients/parents/carer to appropriate questions. Making sure we do not get diverted to information which is not going to help us.

2. There are at least two components - the positive and the negative history.

3. Elaboration of symptomatogy is vital- e.g.-

If someone presents with Cough- our history must include following details-

• Onset of the cough

• Duration

• Severity

• Character

• Diurnal variation

• Aggravating or relieving factors

• Associated symptoms- e.g Fever, Breathing difficulty.

Going through these details helps us to understand the possible problem or diagnosis.

This applies to each and every symptom.

In short “History of Presenting Complaints” - it should be an elaborative and analytical process, allowing us to understand the possible problem/diagnosis. (as an example I am sure most clinicians would have seen Habitual cough being treated as Bronchial Asthma). We all are likely to make such assessments and I have also done so. But it is the revisiting of details that can help us.

The history of presenting illness is central to clinical reasoning.

4. Avoiding Diagnostic Bias

One common mistake observed among trainees and students is attempting to find out the diagnosis from others before personally assessing the patient. As a learning experience I would also suggest that we should not access the referral details (of course this will depend on the situations and settings where one is working). This approach is detrimental both to learning and patient care.

• Independently getting details of history.

• Developing analytical thinking and thought process on differential diagnosis.

• A biased approach can be associated with risk.

An unbiased approach with open mind is essential for sound clinical judgment.

3. Communication and the Importance of Listening

Listening is one of the most critical aspects of communication, yet it is often underestimated. At the same time, it is equally important to guide the conversation appropriately so that relevant information is obtained. Effective history taking is a balance between attentive listening and structured questioning.

2. Parents Concerns-

Parents know their child better than anyone else. Any concern raised by them should be taken seriously. A principle worth always remembering is:

“Parents are always right unless proven otherwise.”

This mindset fosters trust and improves patient safety. Believe it or not we have lost children by not addressing parents/carers concerns.

1. Observation: The Most Crucial-

This comes well before even we start taking history. Identification of sick children based on visual observation can be life saving.

My suggestion would be - Question ourselves-

• Is the child or patient well enough for history taking?

• Is immediate help required?

Recognizing this early can potentially save a life.

Not just recognition of a sick child but observation can reveal numerous important findings, such as:

• Cyanosis

• Rashes

• External bleeding

• Abnormal gait

• Breathing difficulty

• Dysmorphic features/Obvious Congenital Anomalies

Beyond the patient, the surroundings also provide valuable information:

• Presence of inhalers or medications

• Urine pots and the appearance of urine

• Oxygen support

• Monitoring equipment

These details often offer insights into the patient’s condition even before formal examination begins.

Key Takeaways

To summarize the core messages:

1. Observation is paramount—keen observation can save lives.

2. Parents’ concerns must be taken seriously.

3. History taking is an elaborative process, not mere documentation.

4. Always approach the patient without bias.

5. Listening is essential to effective communication.

Conclusion

History taking remains one of the most powerful tools in clinical medicine. When done thoughtfully, it enhances diagnostic accuracy, improves patient care, and strengthens clinical reasoning skills. Let us hope we do not lose it to technology and AI.