The Craft of a History

I have a vague recollection of the first history I took as a young clinician. I was anxious, confused and lost among a sheaf of papers I had prepared. I don’t remember the history, but I do remember that the poor volunteer patient and I suffered our way through my 100 questions.

I eventually got better at receiving a history. I memorized my review of systems, created lists of questions to distinguish related diagnoses, and by the time I went off to residency, I was facile enough to create and test hypotheses while keeping up a conversation.

It was not until my first year of residency that I had the chance to observe a history taken by someone who was really good at communication. My internal medicine residency included a monthlong psychosocial rotation. In that rotation, I watched Bob Smith, MD, MACP, take a history, and it was like nothing I had seen before. He started with open-ended questions, then he steered the patient to address his hypotheses with repeated words and nonverbal cues, such as leaning forward or “tell me more” hand motions. He was quick, thorough, and the patient did nearly all the talking. Near the end, Bob had a few closed-ended questions to tie down his hypotheses, a quick summary and a final open-ended question to provide the patient with a chance to add anything. It was history-taking as a tightly honed craft.

During that rotation, I came to understand a desultory history as a diagnostic clue of its own. We read sociologist/philosopher Arthur Frank’s The Wounded Storyteller, an exploration of what it means to be sick and what illness does to a person’s story. The easiest clinical stories follow a straightforward plot: I was fine, then I got sick, and now with this treatment I will be better. A patient’s story is often more complicated, and histories can be meandering tales.

This was an important realization for me. I started using the structure and linearity of the story as a diagnostic clue, and my frustration with patients who told unmoored narratives disappeared when I came to understand their stories as a part and parcel of their condition. Good communication creates better clinicians and better patient outcomes, which is the whole point.