Last week, I was listening to the cases that were admitted by the overnight resident. By the time he presented the third case, I became annoyed after I repeatedly heard the dreaded phrase “poor historian.” This particular patient wasn’t forthcoming with his symptoms. He was vague with what was going on. “He couldn’t provide an accurate history.” The patient was a homeless man who came to the emergency room feeling unwell and coughing up blood. He had a rip-roaring pneumonia.
I stopped the resident and told him bluntly “the reason the patient can’t give a history is because he is very sick! You too would give a poor history, if you had strep pneumonia bacteria coursing in your blood. ”
The resident had also incorrectly used the term. The historian is the by definition, the one who takes the history. The resident had done a poor job and had blamed the patient for his own deficiencies.
In Jayshi’s Patel JAMA’s piece “The Things We Say” he recounts his own experience with this term.
Later, when I ignored the term and began to pay attention, I concluded encephalopathy, dementia, depression, frustration, anxiety, and anger were reasons why patients did not provide an accurate history. In fact, there was always a reason why the patient wouldn’t or couldn’t provide a history. I learned that a patient’s inability to provide a history should not limit my ability to correctly obtain one.
Whenever I hear the phrase poor historian, I try to teach that there are always ways to get a thorough history. There is collateral history we can take from a patient’s family and friends. There are written notes by the paramedics who are usually the first to the scene. There are old medical charts and electronic records we can peruse. We can examine the patients and phrase our questions in ways they can understand and respond to. Rather than grilling the patient, “we can use open-ended questions, pauses, silence, and active listening, to allow the patient to tell the whole story” writes Dr. Tiemstra. The historian isn’t just a scribe – they are the person who organizes the past events and details, and reorganizes the story in a way that makes sense.
When I went to see the patient in the emergency room, I saw a man who was lethargic and breathing hard. “I feel sick doc,” he said in a weak voice. There was nothing more needed to be said. He had given me an accurate history.