Thread by @medicalaxioms

Proposal: We call it a “history and physical.” We abbreviate it “H&P.”

In fact, it is 3 things, not 2.

It should be called “H,P&TAB.”

History, physical, and therapeutic alliance building. 1/

I did this recently. I sat with a patient. I listened while she told me how she got sick.

I checked her body for clues.

Then we took some time to shoot the shit. Talked about life and jobs and the time she worked for this real famous movie star. 2/

This last step was as essential as the first two.

She is pretty sick. I needed to ask her to do some hard stuff she hasn’t wanted to do in the past.

I needed to talk to her about life and death.

I couldn’t do that before I knew her as a person and she knew me. 3/

I almost always do this. The harder the medicine is going to be for the patient, the more time and energy I spend on this third part of medical care. 4/

It takes a long time for doctors to learn this essential step—the TAB—because we never mention it.

We don’t teach them this in the name of the activity.

It is “hidden curriculum.” 5/

Well made plans that the patient won’t follow because they don’t even know you and have not reason to trust you are useless.

We all know this from experience. Both as doctor and patient. 6/

If we started calling it “HP&TAB” it would be a lot easier to say, “... and what did you two talk about in addition to your history collecting and abdomen mashing?”

“Who is this person? What matters to them? What did you share about yourself?”
6/

It may sound like I’m proposing my least favorite thing in medicine—one more thing.

Like adding a 5th vital sign (🙄🙄🙄) or drawing a family tree.

I’m not. 7/

I mean even in the fasted 2am ER admit, I do the TAB part of the HP&TAB in passing.

- Who drove you here? I have 4 daughters.
- Who lives at your house? Oh what’s your dog’s name?
- Where do you work? Oh yeah I worked in a factory for awhile... 8/

Some might suggest this is “personal information.” This is 100% true. You might not write the details in the chart.

If we included it in the name of the activity “go do an HP&TAB in the new lady,” we would remember it is an essential step.

Not touchy freely. Essential. 9/

Residents who work with me seem to notice 2 things:
- the job seems easy without a lot of conflict and disagreement with patients
- I have a lot of fun

Both of these things come from the TAB.

I know these patients and they know me. Now we can get some stuff done. 10/

Or maybe we aren’t going to get anything done. Sometimes that what you learn as you build the therapeutic alliance.

This lady doesn’t want all this diagnosis and treatment.

Which is fine. Now we know, there won’t be any conflict. 11/

Residents are also sometimes surprised how direct I am:

“If you prefer to die drinking, we are happy to arrange that. If you’d like an alternative, I know how that is done.”

My directness comes from knowing the person I am talking to. 12/

And them knowing me. I am not a bullshitter. 13/

Anyway, Medicine is hard when you treat the patient like a science experiment in a glass box to be poked, prodded, dissected and H&Ped upon.

It gets easier if you HP&TAB your way to an understanding of who this cat is and what makes him tick. 14/

And share enough of your story so they know you aren’t a robot.

🤖🤖🤖

15/

It’s a lot more fun to pick up stories as you go.

To chat with people and hear who they are. Let them know who you are—a real person beyond your MCAT and USMLE score.

Two people brought together sick and healer. Meeting in a very personal and vulnerable situation. 16/