The art of eliciting the medical history requires medical knowledge, cultural knowledge, and many “people skills.”  History taking is not science, but rather, art, because it requires interpretation and clarification.  Patients with the same symptoms express them differently.  A major feature of the art of medicine involves learning how to interpret different descriptions of the same phenomenon.

A few examples might clarify these concepts.

The patient tells you that they have chest pain.  At this point, you really know very little.  What are they really describing?  How might they characterize the pain?

A patient comes to urgent care complaining of a sore throat.  The nurse invokes a protocol, gets a rapid strep test that is negative.  The physician reassures the patient.  A week later the patient still has a sore throat.  A careful family physician asks the patient to describe the pain.  The patient then puts her had on a small bulge anteriorly.  The patient actually has thyroiditis.  She did have a sore throat, but not the same sore throat that usually attends an urgent care clinic.

The patient tells you that they have diarrhea.  What do they mean using that term: loose stools, frequent stools, watery stools?

These examples should help us all reflect on careful history taking.  As we read mystery novels, the detective often has to reexamine the “subjective” information.  What did the witness really say; what did the witness really mean?

We must have the same mindset.  We are detectives, and the patient (and family and friends) are the witnesses.  If we ask the proper questions and make certain that we really understand what the patient has experienced, we are much more likely to arrive at the correct diagnosis quickly.  We must not put our interpretation on the words the patient uses, but rather elucidate their meaning.  When we learn to do so, we become artists of the best kind.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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