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Are We Missing the H in H&P?

Op-Med is a collection of original articles contributed by Doximity members.

Roger and Joseph were both farmers and good friends. They were the same age, went to the same Lutheran church, and lived on the same section of fertile Iowa farmland. They were now roommates, hospitalized with a community acquired pneumonia. Roger’s admission preceded Joseph’s by 24 hours. After two days of IV antibiotics, Roger wasn’t improving as he should have; his chest X-ray continued to demonstrate a patchy infiltrate. On morning rounds, he was informed that a transfer to a tertiary care facility would be best. His options were Iowa City or Des Moines. He asked if he could be transferred to the VA in Des Moines. 

“Certainly,” I replied. After calling the VA and discussing his lack of progress with the officer of the day, transport was arranged and the VA’s ambulance was dispatched. The following morning, Joseph — who had no doubt overheard my earlier conversation with Roger — was given the same recommendation and options. He simply said, “Can I go to the VA, too.” For the second time in two days, the officer of the day accepted my patient in transfer and dispatched the VA ambulance.

That afternoon, a knock on the exam room door interrupted a patient’s office visit. Through a slight opening in the door, the receptionist said, “The VA’s on the phone.” I told her to tell them I‘d call right back. Through the opening she motioned me out of the room. Once the door was closed, she whispered, “He sounds really mad.”

After closing the door to my office and sitting down at the desk I picked up the phone. “This is Dr. Holm.”

An angry voice poured out the receiver. “Dr. Holm, are you the one who sent Joseph Beck to us?”

I admitted as much and began to reiterate his history. 

Cutting me off, the voice at the other end then demanded, “Did you even ascertain if your patient was a veteran?”

Now my mind was churning trying to recall his history or any conversations we might have had about the war. “Of course, he’s a veteran, he fought in WW2.”

“Yeah, for WHAT ARMY?”

The officer of the day wasn’t finished. He then told me the VA didn’t take care of soldiers of the Wehrmacht and they would be transferring him to the county hospital. Before he hung-up, he suggested that in the future I do a better job of securing a patient history. 

A few months back, prior to an appointment with a local clinician, I received an email declaring I had to enter the patient online portal and complete my history at least 24 hours before my scheduled appointment. As I typed, I remember thinking, Why is it I’m doing my provider’s job for them? At the completion of my visit, I was more puzzled. Nothing was mentioned about the history residing unmolested in the computer that sat on the counter next to the exam table. No ancillary questions leading to another line of inquiry — nothing. 

Just where, I’d like to know, did the “H” in “History and Physical” go? I’m pretty sure its importance and significance began to rapidly dissipate with the mandated adoption of the EHR in 2009. Much has been written and opined regarding the EHR and its impact on the practice of medicine and not all of it has been good. And it isn’t just the lost H that is of concern. 

I’ve always felt the cognitive process of crafting and actually writing a complete note imparts an advantage to the writer, which thereby benefits the patient. Likewise, computer generated order sets, while convenient, have created a form of intellectual atrophy. This point was eloquently made one night while I was in the ICU and a resident was struggling to assist a medical student in writing (for practice) a set of admission orders. It wasn’t until a preloaded set of orders were brought up and viewed that the task could be completed. 

All along our personal medical odysseys we’d been told or read — probably both — that most diagnoses can be made based solely upon a thorough history. At the very least, a thorough history will assist in formulating a workable differential diagnosis for your patient. Indeed, as I reflect upon my prior clinical experiences as a clinician, that statement still holds true.

And it’s not just the history of the present illness (or chief complaint) that is vital. A patient’s entire history is of paramount importance. Indeed, all aspects of a patient’s history should be known and reviewed when appropriate — at the very least at the time of their annual exam or any event prompting hospital admission.

Obviously, for me, the described incident reinforced the significance of a patient’s entire history, a lesson never forgotten. Now, reflecting on the current state of EHR and that histories are now patient-generated documents, perhaps this new way is somehow better. If that is truly the case, then just how is it better? The answer to that question is uncertain, but what is certain is the complete context of a patient’s history is now at risk of being lost or overlooked in a sea of data and bytes. Admittedly, many of the inherent flaws with EHR cannot be avoided. However, I urge you to resist the temptation to scroll past the history in your quest to stay on schedule. Better yet, listen to your patient tell their history before you synthesize it and only then enter it into their H&P.

What important lessons have you learned about the H&P? Share your experiences in the comment section.

Lloyd Holm is a retired obstetrician who lives in Cottage Grove, Minnesota with his wife, Gretchen. He has authored two novels and a children’s book and his writings have appeared in the Omaha World Herald, The Female Patient, Iowa Medicine, Contemporary OB/GYN, Hospital Drive, the American Journal of Obstetrics and Gynecology, and Obstetrics and Gynecology. While a member of the teaching faculty at the University of Nebraska Medical Center in Omaha, he received the Dean's Award for Excellence in Clinical Education and The Hirschmann Golden Apple Award. Dr. Holm was a 2021-2022 Doximity Op-Med Fellow, and is currently a 2022-2023 Doximity Op-Med Fellow.

All names and identifying information have been modified to protect patient privacy.

Illustration by Diana Connolly

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