Beyond fixed procedures: meshing anamnesis with physical examination

As we enter this conversation, the doctor has just received information from the ambulance team that handed the patient over to the medical team. The doctor is an experienced young man and the patient is a middle-aged man with no significant medical history. Under the transportation to the hospital he has complained about severe stomach ache and diarrhoea and he has had several intense stomach cramps. The patient has a very low pulse rate, which is discussed several times during his stay in the ward. When he arrives he is still in great pain and he has difficulties breathing, which impedes his speech and his power of concentration. The medical team initiates the diagnostic task and works with an abdominal patient hypothesis.

Transcript 6.1²¹ ikke været det har ikke været sådan noget (.) vandligt

17. 04:39:20, D: nej

29. 04:53:90, D: har du ondt heroppe i brystet (touching) 30. 04:55:50, ps. (1.0)

31. 04:56:50, P: ne:j .h

32. 04:57:20, D: nej (.) har du udstråling til armen (touching) 33. 04:59:00, P: ne:j det synes jeg ik[ke

 21 PM is an abbreviation for paramedic; ges is an abbreviation for gesture.

41. 05:14:80, D: der tværs over o:kay (.) ja men vi bestiller et EKG for en sikkerheds skyld men mit umiddelbare indtryk er at det i:kke er noget kardionalt (.) men nu må vi jo lige se

42. 05:22:60, PM: ja

43. 05:23:00, D: der er også visse point må man sige til noget abdominalt 44. 05:26:00, PM: (xxx)

1. 03:55:80, D: PLEASE POINT AT YOUR STOMACH WHERE IT HURTS 2. 03:57:80, P: °°.h°° 19. 04:42:90, D: but that is the stomach right

20. 04:44:00, P: yes 27. 04:51:60, D: and the one shoulder (.)↓o:kay 28. 04:52:90, ps. (1.0)

29. 04:53:90, D: do you have any pain up here in the chest (touching) 30. 04:55:50, ps. (1.0)

31. 04:56:50, P: no: .h

32. 04:57:20, D: no (.) do you have any pain radiating to the arm (touching)

33. 04:59:00, P: no: I do not think [so

34. 04:59:70, D: [any difficulty breathing (.)

35. 05:01:50, P: when it cramps then eh (.) [then eh I have difficulty breathing fully

36. 05:02:80, D: [when it cramps

37. 05:05:10, D: yes (.) and then it spreads up out to the shoulder on the backside

38. 05:08:20, P: yes

39. 05:08:80, D: okay (.) try to point with your finger where it hurts the most 40. 05:12:70, ges: (P points)

41. 05:14:80, D: across there o:kay (.) yes but we order a EKG just to be sure but my immediate impression is that this is no:t something cardiologic (.) but now we will wait and see

42. 05:22:60, PM: yes

43. 05:23:00, D: there are some points you must admit to something abdominal 44. 05:26:00, PM: (xxx)

45. 05:28:10, D: yes

46. 05:29:00, P: it is freezing man (.)

47. 05:31:50, D: yes (.) we will get you warm again 48. 05:33:10, ps. (2.1) (D covers P with the duvet) 49. 05:35:20, D: please put your legs down

50. 05:36:30, ps. (2.5)

51. 05:38:80, D: did you have any fever at home (.)

52. 05:40:30, P: yea:eh just f I sat and sf yes (.) I was sweating like hell

Right after the doctor has greeted the patient, he asks him to show specifically where it hurts: PLEASE POINT AT YOUR STOMACH WHERE IT HURTS, line 1. The history taking is immediately initiated in a way that requires the patient to use a whole-bodied approach that enables precise identification of the real-time medical problem. As the patient locates his pain with his hand, he responds with an embodied deictic rather than with a linguistic category such as “the chest”, “breast”, “upper body” or “the right side”.

The answer turns out to be tricky as the original starting point (abdominal medical issues) now is expanded to incorporate further symptoms and hence even more possible and complex cause-effect relationships. Thus, the moment the patient touches his chest is identified as an event pivot that prompts the doctor to clarify, re-evaluate and determine whether the patient suffers from one or the other medical condition. Specifically he tests the two hypotheses 6 times during the next excerpt (see figure 6.2)

Figure 6.2: Embodied procedures in hypothesis generation

The figure shows how the doctor tests two competing hypotheses as he relies on embodied expertise. As he re-evaluates the medical situation he meshes physical examination and history taking. This process is defined as a clarification task, methodologically identified as a breakthrough phase in which the doctor links new insight with non-local information, real-time perceptions and medical expertise.

First, the doctor double-checks that the patient is sure about the location. He poses a

counter question IS IT UP ↑HERE (line 3). The emphasis on the ↑HERE, and the rising intonation indicate an element of surprise. As the patient confirms, the doctor acknowledges this new information and a lapse of 3.3 seconds emerges (line 6) and the doctor freezes. The remarkably long lapse indicates a cognitive puzzling and marks a transition phase in the interactivity trajectory. Before the lapse, the patient and the doctor engaged in history taking. However, as the doctor after a first validation test (see figure 6.2), realises that the situation is not as straightforward as assumed, the realisation serves as an affordance for re-evaluation. During the 3.3 seconds the doctor’s cognitive puzzling has consequences for how he continues the task performance. After the lapse a different strategy is enacted and the doctor meshes history taking with physical examination to validate and generate hypotheses about medical issues. As the doctor meshes the two tasks he is able to contrast the patient’s narrative with perceived information achieved through physical examination.

The doctor tests the patient’s localisation of pain area a second time by giving him the choice to articulate which body part (the chest or the stomach) is related to his pain (line 7). When the doctor explicitly asks the question he also uses his own medical expertise to identify and locate the specific areas that define the areas of the stomach and the chest respectively by pointing specifically to each area with his fingers (see picture A and B below). When the doctor selects concrete areas of the body and demarcates them through touch, he also allows the patient to relate the area of touch to the area of pain in real-time, rather than relying on pure memory.

The doctor relies just as much on the information he sees and senses as what he hears. To paraphrase Foucault (1973), he uses ‘the ear of his finger’ in direct perception of the patient’s symptoms. The information he perceives by gazing at the patient’s deictic gestures and locations of touch, prompts him to work with two competing hypotheses concerning two medical scenarios, with two different patient categories: the abdominal patient as initially hypothesised, and the cardiologic patient as hypothesised through the interaction with the patient. As the doctor now works with two competing hypotheses, he systematically investigates which one seems more evident than the other. As will be shown below, he does this by (a) using the patient a cognitive resource, (b) using his own body encompassing touch, gesture, voice, gaze, and posture to gain comprehensive information about the patient’s medical condition, (c) meshing examination and anamnesis, and (d) explicating reasoning during the task performance.

General procedures in the diagnostic process dictate structural steps; for instance to complete anamnesis before examination, and to follow general guidelines for information retrieval. According to this procedure, the first step is to welcome the patient. However, this doctor barely introduces himself before he meshes anamnesis, with examination.

Picture C illustrates how the doctor examines the patient’s stomach as he tests the medical claim a third time: YOU DO NOT FEEL ANY PAIN DOWN HERE IN THE STOMACH. He examines the abdominal wall with his fingertips in order to identify possible abdominal tenderness. The patient is encouraged to explicate his experience as the doctor compares it to medical measurements (the result of the palpation). The doctor is experienced and this

shows in his adaptive behaviour. First, he relies on what he perceives in situ and he is able to adapt to the situation by meshing two tasks, as this proves useful according to the situation. However, no procedure in the ward accounts for the function of meshing tasks;

rather they dictate an action hierarchy, for instance following protocols and procedures for the abdominal patient and the cardiac patient, respectively. Further, such procedures are saturated with what Linell (2005) defines as the written language bias. Communicative procedures within the anamnesis process are developed with an exclusive focus on verbal information retrieval, for instance which questions to ask in a pre-defined sequential order.

In the following, it is exemplified how the doctor both relies on standard medical procedures as he asks standard questions and guides the patient’s narrative and how he also relies on inter-bodily dynamics as he uses gaze, touch and gestures as crucial means in anamnesis. While the doctor’s embodied task performance is functional and effective, it is rarely discussed comprehensively in educational programmes or protocols.

As the doctor is not yet convinced of which of the working hypotheses should be excluded, the highest priority in the diagnostic task is to clarify which body part the medical condition relates to. This prioritisation is seen in the way the doctor balances multiple constraints in the situation and specifically in (a) the way he guides the patient’s narrative, (b) how he relies on standard procedures to clarify cause-effect relations, and (c) how he circumvents fixed procedures by relying on embodied resources and inter-bodily dynamics. By so doing, the doctor adapts to the situation by initiating what appears to be the most efficient move in order to achieve the goal as efficiently and precisely as possible without losing sensitivity and without performing in a recipe-like fashion.

When the patient embarks upon a narrative concerning his intake of Pinex, (line 10+12), the doctor interrupts, changes the subject and tests the medical symptoms in relation to previous medical conditions: YOU HAVE HAD A LOT OF DIARRHOEA right. And again later on: but that is the stomach right as he touches the domain of the stomach with his fingers to relate his question to a physical area that can be felt immediately by the patient (picture E). The patient confirms that his diarrhoea relates to problems with the stomach.

And the doctor then explicates what appears to be a medical inconsistency as he comments: now you are saying that you have pains in the chest (line 21) (figure 6.2, Picture F).

Again, the patient uses his hand to locate where it hurts as he utters: it (.) cramps up here, (line 22). In what follows, the doctor repeats and puts emphasis on the: up here, (line 23).

Rather than referring to a distinct part of the patient’s body (up there), the doctor puts himself in the position of the patient. By touching the patient’s chest as he utters up here he minimises the distance between them, because he meshes the patient’s explanations with his own perceptions through touch. Finally, the doctor validates the seriousness of the patient’s chest pain symptoms by asking a few standard questions as he touches the physical body areas to underline the movement of pain, the directions of pain and the precise location within the body part (see picture G, H and I).

Picture G– time: 04:58:10 Picture H – time: 05:00:00

l. 32, D: no (.) do you have any pain l. 34, D: [any difficulty breathing (.) radiating to the arm

Picture I – time: 05:14:10

l. 40, (P locates the area with his hand)

This embodied strategy affords a dynamic, interactive and participatory behaviour from the patient as the doctor asks the patient, not to tell, but to show where it hurts (line 1 and 39).

It is complicated to articulate the feeling of pain and its exact location, thus other strategies

– such as pointing and touching - can turn out to be helpful.²² Interestingly, the patient does not immediately recall the location and it takes him a moment to identify the right location (see picture I). For 8.5 seconds the patient moves the tip of his fingers back and forth on his stomach to narrow down the area. Because he is able to use his body actively in the diagnostic process, the relevant location is prompted through actions (a felt place) rather than through pure mental simulation. Touching is a means for enacting non-local experience as real-time perception is linked with bodily experience (Noë, 2004; 2010). The patient identifies not only the area of pain, but also the direction and movement of the pain he perceives. This approach equips the doctor with valuable information, since horizontal pain movements are related to some cases of illnesses and not to others. The approach is useful and provides the doctor with vital information that makes him change his current hypothesis once again. Initially the abdominal hypothesis that originated from background information from the paramedical team was replaced with the cardiac patient hypothesis that was generated on the basis of the patient’s localisation of the pain in his chest. Finally, after gaining further insight in the patient’s narrative combined with physical examination, the symptoms point in the direction of an abdominal medical condition (see line 41).

Rather than being an unreliable patient, it is common that the average patient is not aware of the exact boundary between physiologically defined body parts, as for instance the exact domain of the stomach and the chest, the sternum and the ribs etc. Thus, rather than relying on verbal language as the only means for history taking, the doctor draws on his experience and uses his body as a coordinating tool. Such whole-bodied approach is useful in reaching efficient and relevant information about the patient’s medical situation. However, standard procedures in diagnostic tasks are biased by the view that language is the primary tool for representing information. This doctor actively searches for answers by relying on inter-bodily dynamics. As the patient is an integral part of the cognitive system, the diagnostic process is characterised by joint interactivity rather than individuals engaging in question-answer sequences. This approach enhances efficiency and coordination in the diagnostic process and it leads to a useful result: as the patient locates the pain across the stomach, the doctor perceives just enough information to reach a preliminary decision and move on, (line 41). The doctor orders an EKG, as he has not been able to eliminate the possibility of cardiac problems, even though he is convinced that the medical condition relates to abdominal issues. The breakthrough leads to a new, broader cognitive focus. The doctor asks general questions and initiates obligatory examination procedures.

However, as there are standard procedures that must be followed - some information is always needed - others are optional. When the patient grabs the doctor’s arm as he utters that he is freezing (see picture L), the doctor is prompted to check the patient’s                                                                                                                

  22 There are examples of guidelines that include the use of gestures, for instance in a chapter on palpation:

”Ask patients with abdominal pain to point to the area of greatest pain. Then reassure them that you will try to minimize their discomfort and examine that point last” (Ferguson, 1990:474). However, in such interpretations gestures are used as a means for sequential information gathering rather than dynamical possibilities for coaction.

temperature, he relies on his own body temperature to decide if the patient’s temperature is critical. However, his first attempt is constrained by the latex gloves he wears (see picture M), and he immediately uses the backside of his wrist to perceive the warmth directly (see picture N).

Picture L – time: 05:31:40 l. 46, P: it is freezing man (.)

Picture M – time: 05:39:50 Picture N – time: 05:41:10 l. 51, D: did you have any fever at home (.) l. 52, P: yeah just f I sat and

In standard cases, healthcare practitioners rely on material equipment when measuring medical values. Indeed a thermometer is, in principle, more precise than a wrist, but this doctor uses a less precise, yet less time-consuming approach as he uses the temperature of

his own body to gauge the temperature of the patient’s body. By so doing, he avoids wasting time to get hold of a thermometer, just so he can continue the flow of interaction without interruptions. The doctor’s behaviour indicates an efficient prioritisation of the relevance and function of medical nested tasks in relation to the overall goal. In this case, it seems important at first to state whether the patient has a fever or not. However, immediately after this activity, the doctor needs to listen to the patient’s lungs, which involves the use of his stethoscope. During this task, he starts thinking aloud and he rephrases the medical puzzle related to the patient’s low pulse rate, in a way that leads to valuable results.