From my notes:

Disease (objective): the organic pathology that afflicts the patient

Illness (subjective): the psychosocial experience and meaning of perceived illness

Taking a thorough patient history is one of the fundamentals of medicine we are being taught as future doctors. For reference, I mean sitting down with patients and interviewing them for a good 15 minutes to a half-hour in an attempt to elicit every facet of their illness and general lifestyle. A good history includes not only every conceivable detail of the progression of the current illness and past medical events, but also the history of any family illnesses and every social habit from alcohol use to religious affiliation to sexual habits. And then to top it off, a review of the body from head to toe, looking for anything out of the ordinary. Ideally all of this occurs before the doctor orders a single test  or begins any sort of physical examination.

The point of a thorough history is to take into account anything that might be relevant in treating the patient. We’ve had sample cases where the key to the whole diagnosis was asking a single, specific question, like whether they have travelled recently or what herbal supplements they might be taking. In other cases, the point has been to highlight socioeconomic factors that might affect treatment, like inability to pay for medication or an abusive relationship. Even when asking questions about the current illness, the most innocuous-seeming details, like when pain or fever is most acute, can hold vital clues.

As we practice which questions to ask, we are also learning how to ask them. We’ve had long discussions about how to phrase certain inquiries (how should you initiate questions about a patient’s sex life?) or how to react to difficult patients (angry, seductive, anxious.) We do some of this  through role playing in small groups or with standardized patients. We hear about some in general terms in large lectures. A few times, they’ve sent us up onto the wards to talk to real hospitalized patients.

It’s harder than it looks. You end up wearing a lot of different hats as you go through the interview. Part of you is frantically sorting through differential diagnoses, trying to make sure you don’t miss any question that might rule something in or out, while another part is trying to listen and react appropriately and empathetically. Meanwhile, you’re attempting to scribble down all the relevant details so that you can give a coherent and comprehensive presentation at the end. You’re also trying to incorporate the volumes of feedback you’ve received from previous attempts, words and phrases to avoid, and questions to remember.

Pictured: medical students practicing interviewing skills

We medical students are like newborn puppies, constantly tripping over ourselves, ending up in a cringeworthy heap. The first time I practiced a sex interview I turned confidently to the student sitting next to me and asked, “Do you have men with sex women or both?” Trying to elicit a family health history from a hospitalized patient, one of my partners jumped in with, “I would assume your parents are dead by now, right?” (Fortunately the subject of the interview and her children, who were still in the room, found this hilarious.)

In the real world, a full patient history is rarely taken by sitting down with a physician for a block of time. Most primary care doctors just plain don’t have enough time. . They usually gather information piecemeal through intake forms filled out by the patient, follow-up questions from the nurse, and whatever they can tease out in a visit. Also these days a lot of medical care is provided by specialists who may have a narrower view of the potential problem or who may be working off information gathered by a referring physician. Of course, there are other times when a full history just isn’t practical, like in emergent situations when stabilization is priority one.

I wanted to write a bit about taking a medical history because illness is complicated and often involves a great deal more than just the most obvious symptoms. Although explicitly the message is that any detail might be vital, the real lesson is that every detail is relevant. And I think it is important for both patients and doctors to realize that. I hope the fact that our medical education emphasizes this so much means good things for the next generation, my generation of physicians.

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