“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.
