In all of medicine, it is important to understand that there are only three sources of diagnostic information: patient history, physical examination, and laboratory studies.
While patients overwhelmingly assume that diagnosis derives from lab tests, experienced physicians will tell you that about 75-80% of the time diagnosis derives from the patient history. Moreover, a meaningful medical history will be comprehensive, and not limited to the most obvious symptom of the moment.
The Health Appraisal Center at Kaiser Permanente in San Diego had a unique experience in developing these processes. Over the course of 30 years, we applied them to 1.3 million individual adult patients who came through the HAC for comprehensive medical evaluation.
In 1998, we incorporated trauma-oriented questions, based on what we were learning from the Adverse Childhood Experiences (ACE) Study. This is how the health appraisal system worked, and how we integrated ACEs into our practice:
After an adult joined Kaiser, she or he could opt-in to participate in the health appraisal process. Eight-one percent did. Each patient who opted in was sent a comprehensive bio-psycho-social questionnaire to fill out at home.
The questionnaire included a review of body systems, psychological questions, a family medical history, a history of past medical, surgical, and psychiatric treatment, a listing of medications, a social history, and questions relating to the patient's expectations and needs from the examination. Accompanying the questionnaire was information about what would happen during the evaluation. MaleQ.pdf FemaleQ.pdf
The patients handed in the completed questionnaire on arrival, and it was fed into a digital scanner to pick up all “yes” answers and reformat them into a “review of systems” layout. (These days, it would be more efficient for a patient to fill out an online questionnaire. This would still provide the privacy and security to fill out a long questionnaire at home. It is important to avoid the distraction and loss of privacy from sitting in a busy waiting room and to provide the time necessary to reflect on the questions and answers.)
At the first visit to the Health Appraisal Center, the questionnaire was collected and passed through a digital scanner, extracting and reformatting all Yes answers. Patients then watched a 10-minute video showing what was going to be done during the rest of the visit, and how to perform certain tests properly. They then entered a series of small testing rooms where various measurements, tests, and procedures were carried out over the next hour and 20 minutes. This was a high volume operation in which about 250 patients were seen each day -- six people were scheduled every 10 minutes, over seven hours. Staff members were available to answer any questions. The tests and measurements included:
- Urine collection
- Eye tests – distant and near visual acuity and tonometry. Diabetics had retinal photographs taken.
- Height, weight, temperature, pulse, blood pressure
- Pulmonary function measurements
- Hearing test
- Chest X-ray, mammogram, EKG (determined by sex & age)
- Blood draw for total cholesterol, HDL, creatinine, fasting glucose, VDRL, TSH, CBC, serum iron saturation
- Patients over 50 years old were given a packet of Hemoccult slides to bring in at second visit.
Between the first and second visits, a Framingham Study-based health-risk analysis was generated from the test results and the report mailed to the patient. Attached to this blog post is a copy of an anonymized but real case (PHPLetter.pdf).
For the second visit, an examiner – a nurse practitioner or a physician assistant – reviewed the medical history with the patient, reviewed the results of the prior lab studies, and did a complete physical exam, including retinal exam, rectal, pelvic, and neurological exams. Depending on age, patients were scheduled for either a 30- or 45-minute appointment.
The examiners worked under the continual on-site guidance of supervisory physicians. The basic goal of the second visit was to conclude if the patient was well, ill, or at risk.
The second visit began with the examiner reviewing the lab results with the patient. The Mrs. B case [MrsB.pdf] illustrates a typical medical history output from the scanner and represents what we knew before even meeting this patient.
In other words, we knew in advance where we needed to go and where we didn’t need to go in terms of this patient. Obviously, further annotations to the patient history were made in the exam room.
Training to integrate ACE questions for this work was simple and brief and consisted of meeting a few times each with groups of a half-dozen examiners, giving them all a copy of the same patient's history, and posing two questions:
- "How do you put these few pages of laser-printed history together intellectually and diagnostically?"
- "What are you going to say after you say 'Hello'?"
In other words, how are you going to move from the social nicety of introducing yourself to a stranger to inquiring about things that most people aren’t comfortable discussing? The second was the more difficult question, but every one of the 28 examiners soon became quite proficient, several remarkably so.
It turned out that asking, listening, and accepting are a powerful form of doing that appears to provide great relief to patients. A common interchange was for the examiner to remark, "I see on the questionnaire that ...... (your father killed himself / you were raped / you were frequently beaten as a kid). Can you tell me how that has affected you later in your life?"
It took patients only a minute or two to describe how their childhood trauma affected them later in life. Their responses were to the point and usually helpful to understand what might be done.
It took a few months for the staff to get used to working routinely with this level of information. There’s no question that it’s easier to respond to the symptom of the moment than to understand why that problem exists, especially if the problem is chronic. Our 28 examiners became comfortably proficient in the task of understanding people's lives as well as their biomedical bodies and symptoms.
What we learned was that a well-devised comprehensive medical questionnaire that is filled out privately, at home, can collect and legibly record a depth and breadth of patient information that is quite remarkable and, in the hands of willing and capable users, can have a profound and beneficial impact on patient care.
However, physicians and other caregivers are not flocking to this approach. The responses I’ve heard to why ACE questions can’t be incorporated into medical practice include:
- "There's no time."
- "You can't ask questions like that. Patients will be furious and no one will tell you the truth anyway."
- "Insurance won't cover it."
- "If I wanted to be a damned shrink, I'd have been a shrink!"
Our huge experience with this trauma-oriented approach in 440,000 adult patients has shown these responses to be superficially appealing but incorrect. A number of notes of thanks have been received from patients. Here's an interesting letter written by a woman named Connie Valentine about what her doctor didn't ask and hence didn't know. It was published in the Kaiser Permanente Journal anonymously, because the journal editors were reluctant to use her name even though she wanted her name used. She also published it under her name on ACEsTooHigh.com.
There’s one more response I’ve heard that does need an answer: “What do I do with this information?”
It depends. At the very least, people have a major release from unconscious stress that affects their lives, often profoundly. They share the worst secret of their lives, and the people they share this with understand and accept them in spite of it. After all, what determines doctor office visits is not just illness; it’s also anxiety about disease.
Lest anyone think this is some theoretical point to debate, it is important to understand that several years ago an outside data-mining firm tested the incorporation of this medical questionnaire with its trauma-oriented questions into the comprehensive medical evaluation of 125,000 adult patients over a two-year period. To our surprise, they demonstrated this single change coincided, during the year subsequent to evaluation, with a 35% drop in doctor office visits and an 11% decrease in emergency room visits. These were, of course, preliminary findings, but interesting enough that the concept should be tested.
During the entire ACE Study, in which 17,000 people participated, we never had a patient become profoundly disturbed by the questions. Neither did anyone have a mental breakdown or even become angry when we incorporated the ACE questions into the general questionnaire. Some may well have entered false “No” answers, but the number of “Yes” answers was overwhelming.
And if there were people who were obviously depressed or talked about suicide, we referred them to a psychiatrist, just as we would refer someone with a cardiac problem to a cardiologist. Earlier, we had a psychiatrist who had an office in the Center. Pretty soon the examiners found that, rather than risk a patient refusing to see a psychiatrist, it was a lot easier to ask a patient: “Can I introduce you to Dr. Schannon? He’s just down the hall. He’s had experience with this, and may be able to help you.” This was enormously successful, and the response from patients was overwhelmingly positive.
At the end of the health appraisal process, there were three possible outcomes:
- If well, the patient was through with the entire process, and told to return for another appraisal in one to five years, depending on the patient’s age.
- If ill, arrangements were made to see the most appropriate type of physician if there was not already an ongoing doctor-patient relationship.
- If at risk for common problems, the patient was entered into one of several risk abatement programs.
Finally, there was one more part to this health appraisal process. In addition to properly conceptualizing each patient in the medical record, we considered it part of our goal that patients have an accurate general understanding of the nature of their problems and of their significance. So, we mailed a letter of summary several days after the second visit. This letter -- SABIRLOS.pdf, attached to this post -- provided a list of diagnoses, with each diagnosis associated with one or more paragraphs explaining its significance and implications.