Are We Shortchanging The Family History?
What happens when a patient’s family history falls through the cracks? A leading podiatric educator recalls an incident that happened early in his practice. A patient underwent extensive ankle surgery and had a myocardial infarction on the operating table while he was under general anesthesia. The patient survived and the DPM found out later that the patient had a long family history of heart disease. “From then on, I was very diligent in obtaining the (family history) information from all patients,” he emphasizes. Another podiatrist recalls a significant discovery when obtaining the family history of a 20-year-old patient who presented with an Achilles rupture. It turns out his brother and father had a history of deep vein thrombosis (DVT) with surgery. Accordingly, the DPM notes that subsequent tests on the patient revealed a hypercoagulation problem. Then there is the perhaps more disturbing question to ask: Just how accurate is the information you are getting from patients? A recent article in The New England Journal of Medicine (NEJM) cited a survey of over 4,000 people on family health history. Only 30 percent of those polled had obtained health information from relatives in order to develop a family history. No one disputes the importance of the family history, particularly when it comes to diabetes, heart disease and cancer. According to the Centers for Disease Control and Prevention (CDC), studies have shown that having a “first-degree relative” (a parent, sibling or child) with one of these diseases can “at least double” a patient’s risk of developing these diseases. There is a consensus among the DPMs whom I spoke with that the family history is critical to guiding the diagnostic workup and arriving at an appropriate treatment plan. One podiatrist emphasizes the importance of obtaining an “orthopedic history” as well. He notes that family orthopedic conditions ranging from high ligamentous laxity and painful flatfoot to equinus and hallux valgus have “been implicated in inherited similar conditions.” One DPM, who works at a prominent research institution in the profession, says they are in the midst of developing a comprehensive, interactive history form for the foot and ankle. He cites the work of the prominent arthroscopic surgeon Lanny Johnson, MD, who developed a similar form seven years ago for those who have a history of knee pain. The DPM says Dr. Johnson’s questionnaire helped accurately diagnose knee injuries without an examination in over 90 percent of the patients. Another recent development is the launch of the Web site www.hhs.gov/family. This Web site from the Department of Health and Human Services (DHH) reportedly helps people gather and organize pertinent information so they can store their family health history on their own computers. While these developments are promising, perhaps the biggest obstacle is raising awareness among patients. As one podiatrist points out, “many patients are reluctant to provide a detailed family history because they can’t understand why you need to know about their brother’s diabetes, their mother’s cancer or their dad’s heart attack when they are just having foot surgery.” Clearly, the significance of the family history to individual health needs to be promoted better. Perhaps the CDC could provide educational posters that could be placed in waiting rooms or promote family history awareness through television ads. There is an old saying that you can’t go too far in the future if you don’t know or learn from the past. I can’t think of a more accurate application of this universal wisdom given the preventive value of the family history.