“The patient is a 72-year-old male admitted for chest pain. He is a poor historian who states his pain began several months ago….”
“Stop. Tell me, Doctor, who is the historian?”
Over the years the term “poor historian” has become increasingly distasteful to me. Originally, I assumed it meant a patient suffering from dementia, aphasia, or some other physical ailment impairing his or her cognitive or communicative abilities. However, the abnormal neurological findings supporting this label were all too often missing. I gradually came to realize that the term “poor historian” really referred to a patient who was unable to present a medical history in a form the resident could easily digest and record in the time allotted to collect it. That was when I realized that we had it backwards: The patient isn’t the historian at all; the doctor is.
What is the function of a historian? Not just to scribe events as they occur or record a simple timeline. The historian sorts and organizes the past, identifying the important and meaningful events from the trivial, and then interprets the story in order to explain the circumstances of the present. This retelling is rarely done well by persons living the events. The best histories, then, are usually written by historians who have a distanced and more objective view.
“Doctor, you are the historian. Your job is to collect the data, sort and organize it, and present it in the history of present illness in such a fashion that it clearly supports and explains your differential diagnosis.”
When I use this little tangent, my goal is threefold. First, I hope to encourage the learner to begin critical thinking and analysis immediately during the interview. Instead of raking in every detail, the medical historian should immediately begin looking for recognizable patterns, weighing the relevance of data, and reorganizing it from a lay perspective to a medical perspective. Second, I want to reinforce the goals of the medical interview beyond data collection. The interviewer must also develop a therapeutic relationship with the patient, and this cannot be done by “grilling” the patient for every detail of his or her medical history. The skilled interviewer must work on developing trust and a rapport with the patient while simultaneously obtaining the critical data. This implies a totally different style of interview that includes open-ended questions, pauses, silence, and active listening, to allow the patient to tell the whole story to his or her own satisfaction. Finally, I hope to encourage a little humility and empathy toward patients who may not be “ideal.” Learners must keep in mind that the same stresses that make them short-tempered in the middle of the night also plague their patients. Physicians cannot deliver compassionate care if they do not feel sincere compassion for their patients.
“Doctor, you are the historian….”
The little smirk I see on the senior resident’s face doesn’t discourage me; in fact, I find it heartening that one brief teachable moment will be remembered for the years to come and hopefully has changed behavior a little for the better.
Jeffrey Tiemstra, MD