In praise of the history

In medical school, I was taught to TAKE a medical history in such as way that I didn’t MAKE a medical history.

At the time this seemed burdensome and inefficient, another of many unmeetable requirements whose justification was either ‘that’s how I was trained’ or ‘you’ll understand when you have more experience in medicine.’  Well, now I understand. And I no longer chafe (much) at the patience and work involved in letting the patient tell their story, in their own words, and largely at their own pace.

The first thing I came to understand was the value of understanding the patient’s meaning for the patient’s words. I needed to know what the patient meant by sick or numb. When he says my head feels sick, does he mean a headache, confusion, light headed, hearing voices?  When she says her hand is numb, does she means she cannot feel anything, that it is tingling, that it feels cold and wooden, or that it is clumsy? I need to know, because these are very different symptoms with very different implications. I need to know in order to determine what other questions to ask and what exam or testing to do. And I especially need to know the patient’s vocabulary if I am to help them understand what is going on with their body.  This means not interrupting. And it means asking them to tell me more about what ‘sick’ or ‘dizzy’ or ‘sick’ feels like. And it especially means not suggesting to them what I think it should mean. (See below.)

By the end of residency, I had learned how important the history is. It is not a pointless ritual, but in fact is the single most important diagnostic tool the primary care clinician has. If I don’t have a fair idea of what the patient has (or at least a handful of viable possibilities) at the end of the history, I will probably never know. I will have to do every exam and lab test and x-ray known to man and then will be unable to understand what they mean. The history - the story of the patient’s illness in the patient’s universe - is the platform on which everything else rests.

Later I came to realize that the history only makes sense when framed in the patient’s own context. The mild shoulder pain and moderate restriction of motion can be a very big deal for the finish carpenter. The very minimal numbness in the index finger and thumb can be disabling to the fancy stitcher. The brief dizziness can be frightening and dangerous to the roofer. Knowing when it happens, how often, in what settings, and especially what the patient felt and thought and worried about makes a huge difference.

At some point I realized how easy it is to create a false history and how hard but important it is to avoid it. Sometimes this is obvious, as when the patient says they get dizzy when they move, and I say, you mean it seems like things are spinning, and the patient says yes. But it turns out that what the patient was experiencing was orthostatic light-headedness when standing up from a chair - but it was easier and more polite to agree with me than correct me. Sometimes it is more subtle than that. It turns out that it is frighteningly easy to create false memories by asking questions. If I ask the patient about chest pain preceding or associated with their symptoms, the patient may correctly say no - but when asked about it later, incorrectly remember and report chest pain.   

Finally, I have come to believe that trusting the patient to tell their own story in their own way is the first - and perhaps most necessary - step in building the therapeutic relationship. My willingness to let the patient own the narrative signals my respect for his experience. My patience in letting him tell it at his own pace sets the stage for a relationship not constrained by an arbitrary time period. My effort in learning his vocabulary and consistency in using it with him is important to minimizing the sometimes huge differences in culture, education and vocabulary that often is a barrier.  And most important, my willingness to listen conveys a caring and non-judgmental acceptance of the patient.

And so, after a greeting and introduction, I start with: “Tell me what’s going on and how I can help.” Then I wait for the patient to tell me.


 

Links to more on this topic::