TAKING A MEDICAL HISTORY
The Heart of the Diagnostic Process
Taking a medical history is the heart of the diagnostic process in Greek Medicine. The medical history is the grand centerpiece, the big picture that provides a panoramic overview of the patient's entire illness or health condition - how it originated, how it grew and developed, and how it is at present.
It is primarily the medical history that tells the physician which specific signs to check for, and what other forms of diagnosis are needed to obtain the information he seeks. And so, all other methods of diagnosis can be seen as auxiliaries to the medical history, which is the principal, or core diagnostic method.
The medical history also has certain distinctive features and attributes that are essential and not found in other diagnostic methods. First, the medical history covers the past tense, or the genesis and development of the patient's various illnesses and complaints. Secondly, the medical history and patient interview is the main vehicle for eliciting information about the patient's subjective symptoms; how the patient reacts to, experiences, or feels about his/her illness may be just as important as, or more important than, the illness itself, and provide valuable keys to treatment.
The Heart of the Doctor - Patient Relationship
In Greek Medicine, the medical history and dialogue between the patient and his/her physician is the heart of the doctor - patient relationship. It is here that the physician establishes a rapport with his patient, and communicates to him/her his sincere caring and commitment to their recovery and improvement of health and wellbeing. This caring in itself can have great therapeutic value.
Sadly, this personal rapport between doctor and patient is what is most lacking in modern medicine. On the average, it is said that the modern doctor spends only about ten minutes or so talking to his patient. This cold impersonality of modern medicine can be anti-therapeutic, and exacerbate the problem.
The success of the medical history and patient interview depends on the good communication skills of the physician. To avoid getting a biased or one-sided account from the patient, the physician must learn to ask unbiased, open-ended questions; he must also, both verbally and nonverbally, learn how to evoke an atmosphere of openness, trust, and cooperation from his patient. The physician must learn how to bring his vast knowledge of physiology and pathology into play by asking the right questions at the right times, to get the information he most needs to know to differentially diagnose and treat the patient's condition. The physician must elicit the desired information clearly and unambiguously from his patient.
Patients want a doctor who is sympathetic and caring, who listens to them and validates their needs and concerns; they also want a doctor who is open, frank and honest in his dealings with them. The physician must also radiate an energy of cheerfulness and enthusiasm, and make the patients feel good about themselves, which is half the battle in healing. The physician must also learn how to walk a fine line, being poised, confident and in control of the situation without appearing pompous, aloof or domineering. The physician must be skilled in human relations, being the right thing at the right time to the right people, as the situation demands.
The physician in Greek Medicine is, above all, a teacher and wayshower, a Natural Philosopher; he must teach health and healing not just by his verbal instructions to the patient, but also by his own personal example. The physician is a personal guide, coach, mentor, counselor and resource person to his patient, making his healing wisdom freely accessible to all who seek his help. The patient's healing and recovery are more complete and lasting if the physician not only prescribes treatments and medicines, but also instructs the patient in the art of healthy living.
The Basic Structure of the Medical History
In all traditional medical systems, the basic format and structure of the medical history and patient interview is patterned after the basic theoretical concepts of that system. In this, Greek Medicine is no exception.
After taking the patient's name, age, sex and other basic data, the thing that starts the medical interview or patient intake process is the patient's chief complaint. The chief complaint is whatever brought the patient in to seek the physician's help.
After the chief complaint come the patient's various subsidiary or auxiliary complaints. These may be closely related to the chief complaint, or they may not be. Sometimes, and actually quite often, the chief complaint, or what brings the patient in to see the doctor, may not actually be the patient's most serious complaint, or disorder. This is due either to ignorance and confusion, or to a distorted ranking of values and priorities on the part of the patient.
After this come inquiries into the patient's dietary, hygiene or lifestyle habits as possible causes or contributors to the patient's health problems and concerns. In Greek Medicine, these inquiries are structured according to the Six Hygienic Factors: ambient air, food and drink, exercise and rest, sleep and wakefulness, retention and evacuation of wastes, and perturbations of the mind and emotions.
Then, a general review of systems is in order. This is done first according to signs and symptoms of aggravations of the Four Humors, then physiologically and pathologically, according to the Four Faculties and their various organ systems.
After this comprehensive inquiry and review are finished, then the patient is asked to inquire about any remaining health problems or concerns; these may give valuable clues and leads concerning things that were missed in previous portions of the medical history. Sometimes, in light of this final dialogue, the physician may also be moved to ask specific questions regarding that which eluded him earlier. After sifting through and carefully contemplating all the data collected from the patient, the missing piece and solution to the puzzle suddenly presents itself, and the physician asks the crucial question to obtain the diagnostic key to the whole case. In homeopathic practice, this is called the doorknob phenomenon.
The Chief Complaint
The chief complaint is what brings the patient in to see the doctor. It's the initial point of departure for the medical history, and everything unfolds from the patient's description of the chief complaint.
The physician usually starts the dialogue with a simple, "What can I do for you?", or "What's been bothering you?" The physician should make this initial inquiry as broad, neutral and open-ended as possible, allowing the patient unlimited latitude in describing the chief complaint as he/she sees it.
After the chief complaint has been described, the physician should inquire about its severity, and whether it is constant or intermittent. If intermittent, the physician should try to ascertain the frequency of attacks, or onsets. In particular, the severity of any pain, if present, should be precisely ascertained and described.
After the nature and scope of the chief complaint have been thoroughly ascertained, the physician should inquire about the time and manner of its origin or onset, and how it developed into its present state. The physician should try to ascertain as much as possible about the various factors and circumstances that led to the onset and development of the chief complaint.
Then, what's very important is to ask questions like, "What makes it worse / brings it on?" and, "What makes it better / provides relief?" These two questions, adjusted or modified depending on whether the chief complaint is constant or intermittent, have to do with what homeopathic doctors call modality. The patient's responses to these questions may provide valuable clues as to the nature and temperament of the patient's illness or condition.
Subsidiary and Auxiliary Complaints
With a simple, "What else is bothering you?" or, "Is there anything else I should know about?", the physician elicits information from the patient regarding any subsidiary or auxiliary complaints that he/she may be experiencing.
The physician should then do a workup of each subsidiary or auxiliary complaint in much the same manner as for the chief complaint. The dimensions to be ascertained are: its degree, or severity; its time and circumstances of onset; its manner of growth and development; and its modalities, or various aggravating or palliating factors.
Sometimes, these other complaints may be directly related to the chief complaint, in which case it is called a subsidiary complaint. If it developed as a direct consequence or outgrowth of the chief complaint, the subsidiary complaint is called a complication.
Sometimes, these other complaints may bear very little connection, if any, to the chief complaint, appearing to be totally independent and unrelated. In these cases, it would be called an auxiliary complaint. However much independence and autonomy an auxiliary complaint may appear to have from the chief complaint, there's always some connection, however tenuous and remote, between the two: The fact is that both of these complaints, or conditions, found hospitable soil in which to take root in the patient's underlying biological and metabolic terrain.
And so, the patient's body is like a garden, in which these various complaints and disorders have taken root and grown. Because the underlying biological and metabolic terrain prevailing in the patient's body is one and the same, there are always some common themes shared by these various complaints that indicate the basic nature and temperament of this terrain.
The physician should always ascertain the relative chronological order in which the patient's various illnesses and complaints had their onset, and then developed. This will tell the physician which of the patient's disorders are primary, and the most chronic and deep-seated, and which are secondary, being consequences, complications or spinoffs of the original complaint.
All of the patient's various illnesses, complaints and disorders fit together into one big composite picture, or gestalt, of the patient's overall condition. In various traditional holistic healing systems, the patient's original or most chronic, deep-seated complaints are likened to the roots or trunk of a tree, whereas the secondary complications are likened to a tree's branches, or to the fruit that the tree bears.
Whatever the analogy used, the fact is that the whole picture or gestalt of the patient's condition and its various complaints, or pathological manifestations, in their relative severity and chronological sequence of development, is as unique and distinctive to that patient as his/her fingerprint. In disease and pathology, as well as in constitution and physiology, each patient is a unique individual.
Usually, the patient's chief complaint is the most serious disorder he/she faces, but, surprisingly often, it's not, and one of the other complaints reveals itself to be the root problem or condition, the most serious and deep-seated. This may indicate either ignorance and lack of awareness on the patient's part, or it may actually be due to a confused, disordered or inappropriate system of values and priorities, as in a preoccupation with weight loss and surface appearance when serious underlying health problems exist. Hopefully, in these cases, the physician can re-educate and re-orient the patient towards a healthier arrangement of values and priorities.
There are times and circumstances in which the physician can turn his attention to treating the roots, or serious, deep-seated disorders the patient faces, and there are other times when treating the secondary branches is more appropriate. The relative degree of urgency is the key consideration; if there is a fire that is raging out of control, it must be put out.
Above all, the physician must communicate to his patient that he is their partner and guide in achieving their healing goals. It helps to get the patient to clearly define what these goals are, and then for the physician to discuss with the patient how they should be prioritized, and whether they are immediately attainable, or relegated to the long term. The physician should communicate clearly to the patient what he/she can expect from the doctor in the realization of these healing goals, and what is the responsibility of the physician, and that of the patient in this healing work.
Interlude for the Tongue and Pulse
It is here, after a thorough workup and evaluation of the patient's chief and subsidiary / auxiliary complaints has been done, that the time is right for taking the patient's pulse and looking at his/her tongue. The tongue and pulse are important barometers as to the basic nature and temperament of the patient's condition, and the pathogenic factors that are causing the patient's various symptoms and complaints. Often, the tongue and pulse will suggest or indicate important lines of questioning that will turn up new diagnostic information and complaints.
Constitutional Assessment and Family History
By this point in the patient interview, the physician practitioner of Greek Medicine should definitely have formed some impression of the patient's constitutional nature and temperament. This will be evident not just from the patient's account of his/her various symptoms and complaints in response to the physician's inquiries, but also from visual impressions of the patient's physiognomy, physique, complexion, behavior, vitality level and mannerisms. These initial impressions can later be altered or modified by data collected in the subsequent parts of the medical history.
At this point, it's a good time to ask the patient about diseases that run in his/her family. Since one's native constitution is generally inherited from one's parents, such family diseases are often good indicators of the patient's constitutional type and its predispositions.
It's also a good idea for the physician to prepare a form, checklist or questionnaire that the patient fills out beforehand to define more precisely his/her constitutional nature and temperament. This questionnaire can be constructed based on the Four Temperaments page in the Basic Principles section of this website.
Constitutional nature and temperament can also be determined through the pulse. For more information on pulse and temperament, please see the Pulse Diagnosis page in this section. If the practitioner's proficiency in pulse diagnosis is not yet advanced enough to precisely pinpoint the patient's constitutional nature and temperament, it can provide valuable clues and leads in this direction.
The Six Hygienic Factors
A review of the patient's daily habits of diet, hygiene and lifestyle is essential to any good medical history. In Greek Medicine, this portion of the medical history is structured after the Six Hygienic Factors.
This portion of the medical history is important for two main reasons: First, errors and indiscretions in diet, hygiene and lifestyle are major causative factors in the majority of diseases, especially the chronic and degenerative diseases so prevalent today. Secondly, information on the patient's daily habits of diet, hygiene and lifestyle provides important clues as to the nature of the patient's physiology and metabolism, and his/her constitutional nature and temperament. With this portion of the medical history, we often uncover causative factors behind the patient's illnesses and complaints that were previously obscure.
So, here are the Six Hygienic Factors, and the main inquiries the physician needs to make in relation to each:
Ambient Air: Respiratory problems, difficulty breathing, shortness of breath. Expectoration, phlegm discharges. Seasonal allergies. Living environment - its ventilation and exposure to the elements: sunlight, wind, dryness, rain, dampness. fog, mildew, molds, etc... Air purity and pollution levels. The country, climate and terrain.
Food and Drink: A typical meal menu for breakfast, lunch and dinner. Meal frequency and regularity; skipped meals. Meal scheduling. Favorite foods and drinks. Problematic foods and drinks. Food allergies and sensitivities. Meat consumption and its effects. Dairy consumption and its effects. Consumption of fresh fruits and vegetables. Fluid and water consumption, hydration levels. Dietary supplements and herbs taken. Digestive problems, symptoms and/or discomforts after eating, such as sluggishness, somnolence, gas, distension, bloating, etc...
Exercise and Rest: General degree of sedentariness versus activity. Frequency and duration of vigorous exercise and physical activity per week. Favorite sports and recreational activities. Aerobic and cardiovascular capacity. Endurance levels. Athletic performance. Fatigue, stress, trauma or injury after exercise. Athletic injuries, muscular aches and pains. Ability to rest, recover and rebound adequately after exercise.
Sleep and Wakefulness: Sleep habits - duration and scheduling of sleep. Time to bed and time to rise (average). Soundness and regenerative capacity of sleep. Tendency towards insomnia or excessive sleep and somnolence. Nature and character of dreams; incidence or frequency of troubled or disturbing dreams. Daytime napping. Energy levels in general, and throughout the day.
Retention and Evacuation of Wastes: This is a particularly important area, as Hippocrates considered autointoxication from retained toxins, wastes and morbid humors to be the primary causative factor in most diseases. Constipation has been called the Mother of All Diseases. However, excessive evacuation and an inability to adequately hold on to wastes is also pathological.
There are four major bodily wastes in Greek Medicine, and pertinent inquiries are made about each:
Sweat (Fire): Easy or excessive sweating. Spontaneous or furtive sweating, even without undue heat or physical activity. Complete absence of sweating, or inability to sweat. Sweating from nervousness or stress. Burning or itching sweat. Heat rashes. Hot flashes. Night sweats.
Exhalation (Air): Excessive yawning. Stuffy chest, constricted breathing. Excessive sighing. Bad breath.
Urine (Water): Urine frequency and volume. Urine color. Frequent, urgent or painful urination. Gravel or sediment. Difficulty passing urine. See Urine Diagnosis page for details.
Stool (Earth): Frequency of defecation, and size of stool. Stool hardness, softness, texture, consistency. Color of stool. Presence of diarrhea or soft stools. Alternating constipation and diarrhea, irritable bowel. See Stool Diagnosis page for more details.
Perturbations of the Mind and Emotions: General mental and emotional outlook. Relationships, sex, love life, marital relations. Relations with children, offspring. Relations with bosses, coworkers. Job related stress. Stress in general. Note patient's mannerisms, general behavior, body language.
A Review of Humors, Faculties and Systems
As part of the initial intake process, the patient can check off items on a check list. This will save the physician time when taking the medical history, as he only needs to focus on and inquire further about items the patient checked as being applicable to him/her. For each of the complaints or conditions checked, the physician needs to inquire at least about its general frequency and severity; if he feels that the symptom, condition or complaint is important, the physician may go into more detail about it with the patient.
The first section of this checklist should consist of four groups or columns of symptoms, with each group pertaining to common symptoms associated with the aggravation or plethora of a certain humor. The second part of this form should have common symptoms and complaints listed according to faculty and organ system. To draw up lists of these common symptoms and complaints, please refer to the relevant pages in the Physiology and Pathology sections of this website.
Conclusions and Diagnosis
Finally, there should be space on the patient intake and history form for the physician to draw up his conclusions about the patient's overall condition, and formulate a working diagnosis. This is the end towards which the physician is striving, through all the signs, symptoms and other diagnostic information that he takes in. If the medical history has been orderly and thorough, and the right supplemental methods of diagnosis have been used where necessary and indicated, the right diagnostic conclusions should naturally fall into place.