Can I listen to your history or must I take it?

“You will have 15 minutes to take a full medical history,” the moderator says in a plain, mechanical voice. We stand at our assigned exam room doors ready to embark on a mission that will be recorded, reviewed, and graded as part of an OSCE (objective structured clinical examination).

“You may begin!”

I knock, enter, and make a b-line to the soap dispenser — check. I take the history in record time and leave feeling both accomplished and guilty.

Whether the encounter is standardized or not, the idea of taking someone’s history, their story has continued to trouble me. I must admit that I am new to this side of the medical encounter, but I continue to feel unsettled. I never realized that my clinicians were taking note of my hygiene and placing my observations in the subjective section of their SOAP note while their observations receive the “objective privilege.”  Now on the other side, I find myself quickly trying to establish rapport so that I can extract the information I need to match the patient’s story to one of the masterplots of pathology I have been taught.

As in most other parts of medical school, I am looking for answers. We are taught to listen carefully to the patient’s story so that we can take it, interpret it, run the right tests, and provide the patient with information. Some of this interpretation makes sense to me. The patient is not the only moral player in the medical encounter. We all falter from time to time as historians. Patient narrators, or physician narrators for that matter, should be listened to with an eye for reliability. In acute encounters for mild illnesses I think both parties are often satisfied with this this approach.

I think my discomfort arises with more chronic diseases, disabilities, and preventative medicine which seem to place more weight on the future. Physicians may work to become co-narrators with their patients, but patients hold the pens for their lives. The medical interpretation may conclude that the patient needs to do “x” to achieve a better quality of life because “x” has been shown to reduce the risk of [insert scary outcome] in study “y.”  The logical side of me says, “Yes, that makes sense.”

But what if this patient has a different future in mind? No problem, we have been taught and continue to practice how to motivate patients to make healthy changes — and so my discomfort grows.

I cannot help but feel at times that medicine is too concerned with answers and control. The intentions are sincere, but accounts from individuals with serious, chronic illnesses and disabilities have suggested that these medical interpretations can be quite hurtful. Perhaps the medical future is a realm better suited for the right questions rather than answers. Are the next chapters going to feature a miraculous struggle to some higher state of physical health or perhaps a spiritual journey toward enlightenment? Who knows? I would rather follow patients into that unknown as an ally, suggesting different paths informed by evidence-based medicine but always offering support.

I often criticize these thoughts of mine with questions of time constraints — that all sounds great if every physician had the time to do so. True, listening to a story takes longer than taking one. It may require physicians to share this approach with their medical teammates. Perhaps as a team of professionals we can take the time to understand each unique story and offer individualized suggestions when the patient leads us to that next fork in the road.

Eric J. Keller is a medical student.

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  • ninguem

    Don’t forget, the PATIENT is not the historian.

    YOU (the physician) are the historian.

    • DoubtfulGuest

      Thank you.

    • guest

      Oh my gosh, that’s so true!

  • ninguem

    Edward Gibbon wrote The History of the Decline and Fall of the Roman Empire.

    Gibbon may have written about Marcus Aurelius or Julius Caesar.

    The historian is Gibbon, not Aurelius or Caesar.

    There may be something we do not know in history. Maybe no one was there to record it. We may know a meeting took place but no one reported what was said. Maybe the accounts conflict between various sources. The historian reports that stories conflict or for various reasons the story is suspect. Maybe what a general told his captors, interrogated after losing a battle, conflicts what the same general wrote in his memoirs 30 years later.

    It is important for the historian to report WHY a story may be suspect.

    A patient may not be able to tell a story because of many things, including but not limited to

    - dementia
    - delirium
    - low intelligence and understanding
    - language barrier
    - stupor or coma
    - other psychiatric disease

    or a story may be suspect because of secondary gain issues, or the patient’s story may be in conflict with known events, or a police report, or in conflict with family member reports……surely many other reasons….

    The patient is not “a poor historian”. The physician is the historian. The history may well be limited because of……..any of the things mentioned above. The physician reports that the history is limited, and WHY the history is limited. The reason for the limitation is of itself a useful piece of information.

  • DoubtfulGuest
    • ninguem

      ^^^…….What DG said……or linked…..^^^

  • DoubtfulGuest

    I really enjoyed the post, too, and I didn’t mean to discourage this student in any way. Lovely story about your dad and his doctor. I’m very sorry for your loss.

    Dr. n. makes an important point. Another factor for the list is that the patient is just uneasy and out of their element in a doctor’s office. It doesn’t take a psychiatric disease for that to happen. I would have liked it if, for example, the first neurologist I saw would have considered the possibility that fatigue was affecting my ability to give him a complete history. He didn’t have to bark at me, it didn’t have to feel like a police interrogation. He didn’t have to shut down lines of questioning because it sounded fishy…just a bit more open-endedness and sensitivity would have made it all clear.

  • Rob Burnside

    Occasionally, I had a problem with “Chief Complaint.” Thinking now of a long-ago patient who presented with a screwdriver lodged in his chest, complaining of a headache. Me: “Do you know you have a screwdriver stuck in your chest?” Patient: “Yeah, but my head hurts more.”

    Turns out he had a history of epilepsy, passed out, and impaled himself on a tool he was using when the seizure occurred. There was no evidence of head trauma. He was postictal when we found him. Chief Complaint: “Headache, with Impaled Object.” It’s all in how you look at things, I suppose.

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