The need for a careful and thorough history and how to obtain one

www.MarylandClinicalDiagnostics.com

COURSE 2

Nelson Hendler, MD, MSFormer Assistant Professor of NeurosurgeryJohns Hopkins University School of MedicinePast president-American Academy of Pain Management

Concepts for Diagnosis• A diagnosis allows “predictive analytics.”• “Predictive analytics” is essentially pattern

recognition, i.e. recognizing a pattern of symptoms, or behavior, a “clusters of events,” and then predicting what else can be associated with these “clusters of events.”

• I noticed the headlights on my car were left on over night, and the car won’t start. I should-1) add gas 2) charge the battery 3) change the solenoid 4) get new spark plugs

Evidence Based Medicine• “Outcome studies” or “evidence based medicine”

measure how good your “predictive analytics” were.

• This is based on longitudinal studies, to determine the accuracy of diagnosis, and if the proper treatment was selected, based on outcome, or the results of treatment.

• My car won’t start-what else is associated with it?• It just clicks-change the solenoid• Nothing happens or just whirrs- change the battery• It turns over but sputters- add gas

Pattern Recognition and Outcome Studies lead to Predictive Analytics

• My car won’t start, and the lights were left on overnight, and it whirrs when I turn the ignition key – a cluster of symptoms, history and signs.

• Based on experience, from doing a variety of treatments for this condition with the associated symptoms, I know that charging the battery is going to produce better results than changing the solenoid

• I charge the battery, and the car starts-Evidence Based• I can now predict what treatment works for the set of

symptoms of a) symptom of not starting b) history of lights left on c) sign of a whirring engine

The value of a thorough historyIn Israel, a swallowing disorder questionnaire couldpredict findings on oral physical examination 85%

ofthe time (1).In Canada, a questionnaire could predict who

would have abnormal ankle X-rays 98% of the time (2)

In the US, a questionnaire could predict which patient with back or neck pain would have medical test abnormalities 95% of the time (3)

(1) Cohen JT, Manor Y. Swallowing disturbance questionnaire for detecting dysphagia. Laryngoscope. 2011 Jul;121(7):1383-7

(2) Stiell, IG, Greenberg, GH, McKnight, RD, Nair, RC, McDowell, I., Reardon, F, Stewart, JP, Maloney, J.: Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA, March 3, 269 (9):1127-32, 1993

(3) Hendler, N. and Baker, A., An Internet questionnaire to predict the presence or absence of organic pathology in chronic back, neck and limb pain patients, Pan Arab Journal of Neurosurgery, Vol. 12, No. 1, pp: 15-24, April, 2008.

Various Educational Institutions Recognize a Thorough History

provides Proper Diagnosis• The value of a diagnosis is ---• It allows a physician to explain symptoms and signs• It determines the source of the illness- the pathophysiology• Once the pathophysiology is established, from the

diagnosis, the physician can then select proper tests to confirm the diagnosis

• With proper confirmation, specific treatments, based on experience, can be used which give a predicted outcome

Training to Take a Thorough History This study evaluated the impact of a training program in

communications skills on subsequent diagnostic efficiency. Videotaped history-taking interviews conducted by groups of specially trained and control groups of students were rated for their diagnostic efficiency by two medical practitioners. Students in the trained group had shown greatly increased skills in interviewing and interpersonal effectiveness as a result of their training. A comparison of ratings given by the two experimentally naive, independent observers revealed that trained students were significantly better at eliciting full, relevant data from patients--they were diagnostically more efficient, but took no longer than their control group counterparts to elicit the information. Further research with the medical interview rating scale will clarify the skills required of medical students in interviewing and diagnosis and facilitate remedial training for students who show poor interview skills.

Evans BJ, Stanley RO, Mestrovic R, Rose L., Effects of communication skills training on students' diagnostic efficiency, Med Educ. 1991 Nov;25(6):517-26.

Teaching History Taking Skills Since clinical training often fails to equip medical students with essential

history-taking skills, more effective teaching methods required to be developed. As previous work had suggested that training which included televised demonstrations of history-taking and practice with simulated patients might be superior to traditional methods, it was decided to evaluate this experimentally. Thirty students beginning the Oxford Clinical Course were randomly selected and allocated to a traditional or one of two experimental courses. Both experimental courses used television and simulation but differed in the way the history-taking demonstrations were presented. After completing these courses, each student was asked to take a history from a simulated patient. Rating of the videotapes of these interviews showed that the two experimental groups obtained much more information and used many more of the required skills than students assigned to the traditional course. The experimental students were also rated more favourably by the simulators and recorded more data in their case histories. It is concluded that these short courses were practical, very effective, and could be augmented by a self-teaching programme in history-taking skills.

Maguire GP, Clarke D, Jolley B. An experimental comparison of three courses in history-taking skills for medical students, Med Educ. 1977 May;11(3):175-82.

Teaching History Taking Skills • Communication is an important component of patient care. Traditionally,

communication in medical school curricula was incorporated informally as part of rounds and faculty feedback, but without a specific or intense focus on skills of communicating per se. The reliability and consistency of this teaching method left gaps, which are currently getting increased attention from medical schools and accreditation organizations. There is also increased interest in researching patient-doctor communication and recognizing the need to teach and measure this specific clinical skill. In 1999, the Accreditation of Council for Graduate Medical Education implemented a requirement for accreditation for residency programs that focuses on "interpersonal and communications skills that result in effective information exchange and teaming with patients, their families, and other health professionals." The National Board of Medical Examiners, Federation of State Medical Boards. and the Educational Commission for Foreign Medical Graduates have proposed an examination between the. third and fourth year of medical school that "requires students to demonstrate they can gather information from patients, perform a physical examination, and communicate their findings to patients and colleagues" using standardized patients.

• Teutsch C. Patient-doctor communication. Med Clin North Am. 2003 Sep;87(5):1115-45.

Teaching History Taking Skills • One's efficiency and effectiveness in communication can be improved through training,

but it is unlikely that any future advances will negate the need and value of compassionate and empathetic two-way communication between clinician and patient. The published literature also expresses belief in the essential role of communication. "It has long been recognized that difficulties in the effective delivery of health care can arise from problems in communication between patient and provider rather than from any failing in the technical aspects of medical care. Improvements in provider-patient communication can have beneficial effects on health outcomes". A systematic review of randomized clinical trials and analytic studies of physician-patient communication confirmed a positive influence of quality communication on health outcomes. Continuing research in this arena is important. For a successful and humanistic encounter at an office visit, one needs to be sure that the patient's key concerns have been directly and specifically solicited and addressed. To be effective, the clinician must gain an understanding of the patient's perspective on his or her illness. Patient concerns can be wide ranging, including fear of death, mutilation, disability; ominous attribution to pain symptoms; distrust of the medical profession; concern about loss of wholeness, role, status, or independence; denial of reality of medical problems; grief; fear of leaving home; and other uniquely personal issues. Patient values, cultures, and preferences need to be explored. Gender is another element that needs to be taken into consideration.

• Teutsch C. Patient-doctor communication. Med Clin North Am. 2003 Sep;87(5):1115-45.

Teaching History Taking Skills • Ensuring key issues are verbalized openly is fundamental to effective patient-

doctor communication. The clinician should be careful not to be judgmental or scolding because this may rapidly close down communication. Sometimes the patient gains therapeutic benefit just from venting concerns in a safe environment with a caring clinician. Appropriate reassurance or pragmatic suggestions to help with problem solving and setting up a structured plan of action may be an important part of the patient care that is required. Counseling around unhealthy or risky behaviors is an important communication skill that should be part of health care visits. Understanding the psychology of behavioral change and establishing a systematic framework for such interventions, which includes the five As of patient counseling (assess, advise, agree, assist, and arrange) are steps toward ensuring effective patient-doctor communication. Historically in medicine, there was a paternalistic approach to deciding what should be done for a patient: the physician knew best and the patient accepted the recommendation without question. This era is ending, being replaced with consumerism and the movement toward shared decision-making. Patients are advising each other to "educate yourself and ask questions". Patient satisfaction with their care, rests heavily on how successfully this transition is accomplished. Ready access to quality information and thoughtful patient-doctor discussions is at the fulcrum of this revolution.

Teutsch C. Patient-doctor communication. Med Clin North Am. 2003 Sep;87(5):1115-45.

Teaching History Taking Skills • Recognizing that skilled history-taking is in danger of

becoming a lost art, the American Board of Internal Medicine calls attention to the urgent need for internal medicine residency programs to ensure that these skills are taught and assessed. Although the Board's certification examination contains standardized items that test the physician's ability to use information from a patient's medical history, the written examination cannot assess the physician's ability to elicit that history. The Board believes that history-taking skills will become even more crucial as health care delivery changes, requiring more cost efficiency without sacrificing quality. By highlighting the skills of effective history-taking and strategies for assessment, the Board offers specific recommendations for its promotion as a key element of quality patient care.

Schechter GP, Blank LL, Godwin HA Jr, LaCombe MA, Novack DH, Rosse WF. Refocusing on history-taking skills during internal medicine training. Am J Med. 1996 Aug;101(2):210-16

Teaching History Taking Skills • Though most medical schools administer comprehensive clinical skills

assessments to identify students who have not achieved competence, the types of problems uncovered by these exams have not been characterized. METHOD: The authors interviewed 33 individuals responsible for remediation after their schools' comprehensive assessments, to explore their experience with the problems students demonstrate and strategies for and success with remediation. RESULTS: Respondents perceived that technique problems in history taking and physical examination were readily correctable, but that poor performance resulting from inadequate knowledge or poor clinical reasoning ability was more difficult to ameliorate . Interpersonal skill deficiencies, which often manifested as detachment from the patient, and professionalism problems attributed to lack of insight, were most refractory to remediation. CONCLUSIONS: Poor performance in comprehensive assessments often indicates underlying deficiencies in cognitive ability, communication skills, or professionalism. The challenge of remediating these deficiencies late in medical school calls for earlier identification and intervention.

Hauer KE, Teherani A, Kerr KM, O'Sullivan PS, Irby DM. Student performance problems in medical school clinical skills assessments. Acad Med. 2007 Oct;82(10 Suppl):S69-72

Conclusion-Teaching History Taking• Time consuming to teach and learn• Labor intensive to teach and learn• Without training, lots of inter-rater variability• Doctors are rushed, so less likely to spend time• Insurance doesn’t reward long time with a patient• Failure to take adequate or accurate history leads

to bad medical diagnosis• Variables include not only the skills of the doctors,

but the communication skills of the patient• Doctors tend to rely on tests rather than history

How failure of taking a careful history interferes with making a diagnosis

• If a patient complains of pain in their thumb, and the doctor takes an X-ray, and sees a vise clamped on the thumb, the diagnosis is established, and the treatment is clear..remove the vise.

• If a patient complains of pain in their thumb, and the doctor sees no broken bones or compression, on X-ray, then he doesn’t have a diagnosis nor a treatment.

• But if a doctor asks “How did the pain start?” and is told “When I repetitively hit my thumb with a hammer” then the cause of the pain is established. The X-ray is needed only to see if the repetitive hammer blows chipped or broke a bone, which leads to one treatment, or if the tissue is just bruised, which leads to another treatment

Real-life Problems with Taking a Thorough History

• Not enough time to take a history• Interruptions by phone, or staff• Loss of train of thought-tired-distracted• Forgetting to ask questions• The patient has communication problems, i.e.

hard of hearing, English is not the first language, fear of the doctor, not understanding the questions, lack of knowledge of their body, forgetting symptoms

Specific Problems with Chronic Pain• Patients focus on the severity of the pain,

which is of no diagnostics value, since pain is a totally subjective experience

• Doctors don’t ask the right questions, because they are not trained in history taking from chronic pain problems

• Key questions are the location of the pain, how the pain first occurred, the type of pain which is felt, what makes it better, what makes it worse, and is it constant or intermittent.

Interpretation of the Answers• A throbbing, pounding pain is indicative of a

vascular problem. • Numbness is indicative of sensory nerve damage,

of either compressive nature, compromised vascular flow, or metabolic nature, such as diabetes, or poisoning.

• A constant pain predicts a compressive nature to the cause.

• An intermittent pain predicts a mechanical component to the source of the pain.

• Location predicts the nerve causing the pain, etc.

www.MarylandClinicalDiagnostics.com Diagnostic Paradigm

• Research has shown that 40%-80% of chronic pain patients are misdiagnosed (1,2,3,4,5,6,7,8,9,10,11)

• 1) Dellon, A.L., Hendler, N., Hopkins, J.E.T., Karas, A.C., Campbell, J.N.: "Team Management of Patients with Diffuse Upper Extremity Complaints." Maryland Medical Journal. Vol. 35, No. 10:849-852, October, 1986.

• 2) Long, D., Filtzer, D., BenDebba, M., Hendler, N.: "Clinical Features of the Failed-Back Syndrome." Journal of Neurosurgery. Vol. 69, pp. 61-71, July, 1988. • 3) Hendler, N., Kozikowski, J., Schlesinger, R., Schlesinger, J.: "Diagnosis and Treatment of Muscle Tension Headaches." Pain Management. Vol. 4, No. 2:33-41, March/April, 1991. • 4) Hendler, N., Zinreich, J., Kozikowski, J.: "Three-DMCDnsional CT Validation of Physical Complaints in `Psychogenic Pain Patients." Psychosomatics. Vol. 34, No. 1:90-96,

January/February, 1993. • 5) Hendler,N.,Kozikowski,J.:" Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation." Psychosomatics.Vol.34,No.6:494-501,November/December, 1993. • 6) Hendler,N. Kozikowski, J., Morrison, C., Sethuraman,G. "Diagnosis and Management of Sacroiliac Joint Disease." Journal of the Neuromusculoskeletal System.Vol. 3, No.4:169-

174, Winter, 1995. • 7) Hendler, N., Bergson, C., Morrison, C.: "Overlooked Physical Diagnoses in Chronic Pain Patients Involved in Litigation, Part 2." Psychosomatics. Vol. 37, No.6: 509-517,

November/December, 1996. • http://www.slideshare.net/DiagnoseMyPain/overlooked-diagnoses-in-chronic-pain • 8) Hendler, N.: “Differential Diagnosis of Complex Regional Pain Syndrome.” Pan Arab Journal of Neurosurgery. Oct., 2002 pp. 1-9.• http://www.slideshare.net/DiagnoseMyPain/crps-rsd-overdiagnosed-71-of-time • 9) Hendler, N. Overlooked Diagnoses in Electric Shock And Lightning Strike Survivors, Journal of Occupational and Environmental Medicine, Vol. 47, No. 8, pp. 796-805, Aug. 2005. • http://www.slideshare.net/DiagnoseMyPain/electric-shock-and-lightning-survivors-misdiagnosis • 10) Hendler, N, Murphy, ME, Romano, T. Chronic Pain Due to Thoracic Syndrome, Acromo-Clavicular Joint Syndrome, Disrupted Disc, Nerve Entrapments, Facet Syndrome, and

Other Disorders Misdiagnosed as Fibromyalgia. Abstract 1086 Poster presentation, American Psychosomatic Society, Portland, Oregon, March 10-13, 2010. http://www.psychosomaticmedicine.org/misc/meetingAbstracts.shtml, page 91, 2010,

• http://www.slideshare.net/DiagnoseMyPain/fibromyalgia-abstract • 11) Dellon, AL, Andronian, E, Rosson, GD, CRPS of the upper or lower extremity: surgical treatment outcomes, J. Brachial Plex Peripher Nerve Inj, Feb 20: 4 (1):1, 2009)

Diagnostic Paradigm• The Diagnostic Paradigm test

(www.MarylandClinicalDiagnostics.com) has a 96% correlation with Johns Hopkins Hospital doctors’ diagnoses, so the patient will get a diagnosis which is virtually similar to one from a Johns Hopkins Hospital physician (19).

• 19) Hendler, N., Berzoksky, C. and Davis, R.J. Comparison of Clinical Diagnoses Versus Computerized Test Diagnoses Using the Mensana Clinic Diagnostic Paradigm (Expert System) for Diagnosing Chronic Pain in the Neck, Back and Limbs, Pan Arab Journal of Neurosurgery, pp:8-17, October, 2007.

http://www.slideshare.net/DiagnoseMyPain/diagnostic-paradigm-pan-arab

Diagnostic Paradigm Test Development

• The Diagnostic Paradigm is based on data collected over 17 years.

• After a retrospective analysis of 15,000 patient files and prospective testing, the Diagnostic Paradigm was developed

• This is virtually impossible to replicate in terms of sample size, length of data accumulation and expertise of the doctors.

• This test is available at www.MarylandClinicalDiagnostics.com

The Diagnostic Paradigm & Treatment Algorithm

• The test consists of 72 questions with 2008 possible answers.

• The test takes 5 minutes of secretarial time to access the program for testing

• It takes the patient 20 to 60 minutes to complete.

• The test is available in English and Spanish• Results are available 5 minutes after the test is

completed.

Evidence Based Medicine-Outcome Studies• The value of the test from the team at Johns Hopkins Hospital is

documented by outcome studies. This is true “Evidence Based Medicine.” As an example, most workers compensation insurance carriers report that if a person is out of work for two years or more after an injury on the job, the return to work rate is less than one percent. Using the Diagnostic Paradigm from www.MarylandClinicalDiagnostics.com, in a group of patients out of work for an average of 4.9 years, one clinic was able to achieve a return to work rate of 19.5% for workers compensation patients, 62.5% for auto accident patients, and in both groups, a 90% reduction in the use of narcotic medication, and a 45% reduction

in doctor visits (25,26). • 25) Hendler, N.: "Validating and Treating the Complaint of Chronic Back Pain: The Mensana Clinic Approach." Clinical Neurosurgery. Vol. 35,

Chap. 20:385-397, eds. Black, P., Alexander, E., Barrow, D., et. al., Williams and Wilkins, Baltimore, 1988. • http://www.slideshare.net/DiagnoseMyPain/validating-the-complaint-of-pain-13871037 • 26) Talo, S., Hendler, N., Brodie, J.: "Effects of Active and Completed Litigation on Treatment Results: Workers' Compensation Patients Compared

with Other Litigation Patients." Journal of Occupational Medicine. Vol. 31, No. 3:265-269, March, 1989. • http://www.slideshare.net/DiagnoseMyPain/effect-of-types-of-litigation-on-rtw

Outcome Studies• The www.MarylandClinicalDiagnostics.com methods

resulted in improved medical care and cost savings, ranging from $20,000 to $175,000 for various cases. Research from Johns Hopkins Hospital itself showed that the hospital achieved a 54% reduction in workers compensation costs if they required that the injured workers limit their medical care to only Johns Hopkins Hospital physicians. (27,28,29). Thus, these outcome studies support the assertion that the use of the www.MarylandClinicalDiagnostics.com tests improve medical care and reduce health care costs.

• 27) Stanton-Hicks, M., Baron, R.,Boas, R., Gordh, T., Harden,N., Hendler, N., Koltzenburg, M., Raj, P., Wilder,R.:"Complex Regional Pain Syndromes: Guidelines For Therapy." The Clinical Journal of Pain, Philadelphia,14: 155-166, 1998.

• 28) Long, D, Davis, R, Speed, W, and Hendler, N, Fusion For Occult Post-Traumatic Cervical Facet Injury, Neurosurgery Quarterly, Vol. 16, No. 3,pp. 129-134, September,2006. • http://www.slideshare.net/DiagnoseMyPain/cervical-fusion-for-misdiagnosed-headache-and-whiplash • 29) Bernacki, E, and Tsai, S, Ten years' experience using an integrated workers' compensation management system to control workers' compensation costs. J. of Occupational

and Environmental Medicine, 2003, 45:508-516• http://www.slideshare.net/DiagnoseMyPain/bernacki-j-occ-enviro-med •

Treatment Algorithm• Rank ordered test based on least invasive, least

expensive testing, increasing in expense and complexity to most invasive, most expensive.

• All testing selected as the result of “evidence based medicine,” so there is a rationale for picking a test.

• Follows a diagnostic and treatment protocol which was proven to be effective, based on years of research with retrospective and prospective studies.

Bayesian versus Boolean Logic• Experience (Bayesian) versus binary thinking• Boolean logic is binary- “on-off,” or “yes-no”

type of branching diagram. …In Boolean logic:• Each possibility gets an equal weight.• Is the tire flat? Yes-No• If flat, is there a leaky valve stem? Yes-No• If valve stem is not leaky, is there a cut side

wall? Yes-No.• If no cut, is there is a nail in the tire? yes-no• Repair the nail hole and drive away.

Bayesian Logic• In Bayesian logic:• Each outcome gets a weighted answer• Is the tire flat? Yes-No. • Have you has a flat in the past? –Yes-21 of them• Rank order the cause of previous flat tires. • 18 were due to a nail in the tire, 2 were due to a

leaky valve stem, 1 was due to a cut sidewall.• Look first for the nail in the tire. Most likely.• Repair the nail puncture, and drive away

Ease of Use of Test versus Training • Training for medical students and residents is

expensive and time consuming• Many physicians in training, as well as those in

practice, have not been well schooled in how to obtain a thorough history

• There is no chiropractic school nor medical school in the country which has a course specifically designed to teach about chronic pain.

• The www.MarylandClinicalDiagnostics.com tests compensate for both of these deficits.

CPT Codes for billing for the test• Use the three following codes to report

services for the Diagnostic Paradigm and Treatment Algorithm:

• Use code 96102-52 –”psychological testing by technician” for technician time to set up test

• Use code 96103 for “psychological testing by a computer, “ for the period of time the patient spent taking the test

• Use code 96101-52 for “psychological testing, interpretation and reporting by the psychologist or physician”

Authors of Missed Diagnoses Papers, and Diagnostic Paradigm

• Donlin Long, MD, Ph.D. former chairman of neurosurgery Johns Hopkins Hospital, founder and Director of the Pain Clinic, Johns Hopkins Hospital, professor of neurosurgery, Johns Hopkins University School of Medicine

• James Campbell, MD –professor of neurosurgery, Johns Hopkins University School of Medicine, past president, American Pain Society

• Reginald Davis, MD – former chief resident in neurosurgery, Johns Hopkins Hospital, assistant professor of neurosurgery, Johns Hopkins University School of Medicine, chief of neurosurgery, Greater Baltimore Medical Center

• John Rybock, MD, assistant professor of neurosurgery Johns Hopkins University School of Medicine, assistant dean for academic affairs, Johns Hopkins University School of Medicine.

• Nelson Hendler, MD, MS, former assistant professor of neurosurgery-Johns Hopkins University School of Medicine, past president, American Academy of Pain Management

• Lee Dellon, MD, PhD.-Professor of Surgery Johns Hopkins Universitry School of Medicine

• Mats Gronblad, MD, PhD-professor of physical medicine and rehabilitation medicine, Department of Physical Medicine and Rehabilitation, Helsinki University Central Hospital, Helsinki, Finland

Contact Information• Nelson Hendler, MD, MS, CEO• Maryland Clinical Diagnostics• Former Assistant Professor of Neurosurgery• Johns Hopkins University School of Medicine• Past president -• American Academy of Pain Management• Phone 443-277-0306• Email DocNelse@aol.com • www.MarylandClinicalDiagnostics.com