Every Patient Tells a Story Read Online Free PDF

and family. But the odds are overwhelming that the patient won’t have much of an opportunity to tell that story.
    Doctors often see this first step in the diagnostic process as an interrogation—with Dr. Joe Friday getting “Just the facts, ma’am,” and the patient, a passive bystander to the ongoing crime, providing a faltering and somewhat limited eyewitness account of what happened. From this perspective, the patient’s story is important only as a vehicle for the facts of the case.
    Because of that “facts only” attitude, doctors frequently interrupt patients before they get to tell their full story. In recordings of doctor-patient encounters, where both doctor and patient knew they were being taped, the doctor interrupted the patient in his initial description of his symptoms over 75 percent of the time. And it didn’t take too long either. In one studydoctors listened for an average of sixteen seconds before breaking in—some interrupting the patient after only three seconds.
    And once the story was interrupted, patients were unlikely to resume it. In these recorded encounters fewer than 2 percent of the patients completed their story once the doctor broke in.
    As a result, doctors and patients often have a very different understanding of the visit and the illness. Survey after survey has shown that when queried after an office visit, the doctor and patient often did not even agree on the purpose of the visit or the patient’s problem. In one study, over half of the patients interviewed after seeing their doctor had symptoms that they were concerned about but did not have a chance to describe. In other studies doctor and patient disagreed about the chief complaint—the reason the patient came to see the doctor—between 25 to 50 percent of the time. This is information that can come only from the patient and yet, time after time, doctors fail to obtain it. Dr. George Balint, one of the earliest writers on this topic, cautioned: “If you ask questions you will get answers, and nothing else.” What you won’t get is the patient’s story, and that story will often provide not only the whats, wheres, and whens extracted by an interrogation, but often the whys and hows as well.
    Moreover, the interrogation model makes assumptions about the elicited symptoms and diseases. And while these assumptions might be true for most of the people with those symptoms, they may not be true for this particular individual. The great fictional detective Sherlock Holmes talks at length about the difference between the actions and thoughts of the individual when contrasted to the average. Holmes tells Watson that while you may be able to say with precision what the average man will do, “you can never foretell what any one man will do.” The differences between the average and the individual may not be revealed if the doctor doesn’t ask.
    “It is much more important to know what kind of patient has the disease than what sort of disease the person has,” Osler instructed his trainees at the turn of the twentieth century. Even with all of our diagnostic technology and our far better understanding of the pathophysiology of disease, research suggests this remains true.
    So getting a good history is a collaborative process. One doctor who writes frequently about these issues uses the metaphor of two writers collaborating on a manuscript, passing drafts of the story back and forth until both are satisfied. “What the patient brings to the process is unique: the particular and private facts of his life and illness.” And what the physician brings is the knowledge and understanding that will help him order that story so that it makes sense both to the doctor—who uses it to make a diagnosis—and to the patient—who must then incorporate that subplot into the larger story of his life.
    If getting a good history is so important to making an accurate diagnosis, why are we so bad at it? There are several reasons.
    First, most