“Every day, I write the book…” Elvis Costello
I write every day, but somehow have not considered myself a Writer. I am a physician, a surgeon. I take care of patients. I operate, I admit patients to the hospital, I consult. I order tests, labs, images; I do physical examinations, I take medical histories. And I write it down.
I gather all of this information, and more than simply recording the list of symptoms, physical findings, and results, I convey the narrative of what has happened, what is going on, the interpretation, the plan. So, maybe I am a writer. A biographer, of sorts, telling the story of every patient I see, at least as it relates to their health or illness. Synthesizing the data, the history, the laboratory and test results, the imaging–into a narrative that not only explains how and why the patient got here, but also what I think is going on (and what is not going on), what it means, and what we are going to do about it (whether that means fixing it or figuring out what else we need to do). All of this are chapters in the story I am telling, to communicate the information, my thoughts and reasoning, my plan to my colleagues. The original, and still primary, reason for the patient chart (whether electronic or paper), the medical record is Telling A Story.
This special “biography”, the history, is an extremely important piece of this story, of caring for patients. All of the testing in the world–labs and imaging and what have you–are really only in support of, augmenting, what is learned in the history, and can not and do not replace it. My wise professors and teaching attendings held to this, and demonstrated it; it has been my experience throughout my own practice and career. They maintained that about 90% of what was really happening with the patient could be ascertained from a skilled, well-done history.
This takes time to do, time to master. And although this percentage may be a bit inflated, so as to impress the young minds under their tutelage, it does not diminish the importance. Most physicians can regale you with stories of taking excruciatingly detailed information in their patient histories as students or interns, only to have the senior members of the team sweep in and in a few questions, not only get far more information, but the crucial clues to the correct diagnosis, the correct next steps. The labs and imaging and testing fill in the gaps, confirm (or occasionally refute) the working diagnosis, re-order the priorities on the differential diagnosis–not calculus, but the working list of possibilities both likely and less likely, that could account for what seems to be going on–again supplementing but not replacing the details in the history. Interestingly, in those cases where the testing seems to refute what is going on, there is almost uniformly some additional detail overlooked or withheld that realigns the history to be concordant with the findings.
Often we think that our Pathology colleagues have the advantage of the most certainty about what is going on or has gone on, under the microscope or on the autopsy slab, but even this discipline to which their fellow physicians look for the most definitive answers is swayed by and depends on the clinical information, the story derived from the history and physical. Our Radiology colleagues appreciate the importance of the context provided by the history, which can make a huge difference in how the image is interpreted. When a patient presents with right lower quadrant pain to the emergency room, and the CT scan shows non-visualization of the appendix, it could be appendicitis. It could also be surgically absent. I was called in on a patient like this, and the history of a prior appendectomy (supplemented by the appropriate scar, though that may not always be present in this era of minimally invasive surgery) not only kept them from the unnecessary surgery, but led down the right track to the appropriate diagnosis. History, and context, count.
Taking a good history is an art. In learning to take a patient history, it was probably the first time I understood why medicine is referred to as an art as well as a science. It is an art that continues to develop and evolve and refine throughout a career in medicine. Taking a good history means you need to sit (yes, sit, borne out by evidence) with your patient, and sometimes but not always with their family or friends, ask your questions, and then listen to the answers. Listening to the answers, being attentive to the demeanor and body language. Attending to the process. Physicians learn techniques to keep the conversation, the process, going–the open-ended questions or the directed ones. Opening up the reticent or reluctant patient; redirecting and focusing the chatty, meandering ones. This balance, teasing out the story and the details and nuance, is the art in the interview, uncovering the history, the story.
Then, combining this interview with the physical exam (another art) and the testing, we set ourselves to the task of telling their story. A narrative capturing the detail and nuance so that it explains to the reader–the colleagues and staff–what is happening, what is the impression or conclusion, and why; what the next steps are, what will happen, what is the plan. Telling the story. This isn’t easy, but this is rewarding. It is how we take care of patients. This is what doctors do every day. This is what I do. The physician as writer.
So, I am a writer, a storyteller, just as I am a physician, a surgeon. This storytelling, by way of the patient histories and record, this communication, is the heart and the art of good patient care. The stories and their telling link the patients and physician, it is integral to the care, the bond between them. My patients, our patients, deserve to have their stories told and told well. Communication is a strong link in the chain of the physician-patient bond, vital to the trust that is forged by that bond. This is a link too important to break.
But, this link has been strained nearly to the point of breaking. We’ll continue in Part 2…
“In the end, we’ll all become stories.” – Margaret Atwood