Commentary by Tobias Vancil , MD
The Incomplete H & P : The Missing “ Family History ”
It is a gross understatement to say that the
last six months has been challenging for us all . As we toil through a worldwide pandemic , many have made sacrifices – loss of time at home , spending countless hours screening patients in drive-thru settings , increased patient care burden , or even loss of job completely . Some live in fear of personally becoming ill due to exposure while others worry about bringing this illness into the home . It is not uncommon to hear about a provider who has been avoiding certain family members who are at increased risk because of age or comorbid conditions . On the other hand , it seems equally as common to hear about extended families congregating all under one roof to isolate together . Regardless of the situation , we have all had an opportunity to rediscover what family means to us .
I hope that people are taking some time for mindfulness and self-reflection amid the current day-to-day turmoil that extends even beyond the pandemic . ( A radio personality was poignant recently in stating : Does anyone remember when the only thing we had to be scared about was COVID-19 ?). I have heard and read many narratives about this reflective process on podcasts , various news outlets and via online contemporary literature ; I have no social media presence , but I suspect I would see more of the same in this arena . Consistently , there is a theme of things taken for granted . Missed summer gatherings with friends , travel to or with family , dinner out with a spouse or even a trip to the park with children . Everything now seems to make us think twice and , as a community , we owe it to each other to take the time to think before we act . Reflection does not have to be melancholy ; it can be frighteningly insightful about
certain behaviors that we likely will never see again . For instance , how was it ever a good idea to share a bowl of nuts at a bar with dozens of other dirty hands ?
One thing that I have taken for granted in my short career is the “ family history .” The quotations are meant to discern my idea from the heading in an H & P template where histories of familial disease are listed . I am referring to the information obtained from the patient ’ s family that can be very valuable to the diagnostic process . Family members can also be integral in helping a patient with medication adherence , delivering after-care following an illness or surgery or in re-directing the disoriented inpatient . This “ loss of family ” struck me most while rounding inpatient with a resident team recently and having few , if any , family visitors present due to COVID precautions . Now , I was not surprised by the lack of family at the bedside – I knew this would be the case – but it just did not feel right . I am also familiar with these changes in the ambulatory setting , but it has not had the impact on my practice that it did in the hospital . It is so often that a family member can add insight regarding the history of present illness . Even more obvious is the common scenario of a patient sugarcoating his or her status hoping for an earlier discharge , only to be corrected when family speaks up about concerns or under-presented symptoms . Of even more importance is the presence or lack of family in terms of disposition . Understanding a cognitive or physical functional status baseline almost always needs family input ; without this , we can have an altered sense of definitive improvement beyond the data obtained in blood work and clinical imaging .
In a short time , we have seen data presented accepting the hypothesis of increased morbidity and mortality associated with depression related to this isolation while inpatient . I am not suggesting a policy change administratively , as these measures are important to control contagion , only wishing to spread light on an easily overlooked aspect of patient care ; it ’ s so easy to not see what isn ’ t there . Really , this is just a reminder to be more diligent in a part of our practice that always has room for improvement : communication . While the phone calls to the family will definitely lengthen a workday , it is what every one of us would expect in return . The look of relief on a patient ’ s face when you offer to reach out to update their loved ones is proof .
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Volume 117 • Number 5 NOVEMBER 2020 • 101