The waning art of history taking

I remember having senior clinicians tell me the value of a complete history.  As I recall, they told me that at least 90% of diagnoses would come from the history alone.

Of course in the 1970s we had access to automated lab tests and radiologic studies.  We could order tests. 

As my career has progressed those medical giants (here I refer fondly to the senior clinicians who taught me during medical school and residency) have become even smarter.  I now know the importance of a good history.

All medical schools have a course which teaches students the art (and science) of the history and physical exam.  Students learn a long list of questions.

This course is important, but 1^st and 2^nd year medical students do not know enough medicine to properly learn how to take a good history. Taking a history may seem simple, but it requires broad medical knowledge.  Master clinicians alter their history taking in response to the patient’s answers, their body language and observation.  As one performs the physical exam, more questions occur to the clinician.

The history does not end with the admission.  As one collects laboratory results, imaging studies, and clinical changes, more questions become relevant.  History taking represents an ongoing activity, designed to help both the diagnostic and therapeutic process.

How does one become better at history taking?  First, you must take many histories.  You must critique yourself as more information becomes available.  Second, you must think about the process of history taking.

The stimulus for this rant occurred as I was listening to a mystery book.  I love a mystery in which the detective carefully questions witnesses and suspects.  I pay attention to the rhythm and pacing of a good interrogation. 

One thing that I notice in these books is the manner in which the key question is surrounded.  While I know this is the key question, I will get a more honest answer if the patient is not aware of the questions import.

Perhaps history taking just takes time.  Perhaps physicians older than 50 have superior history taking skills to those below 40, just because of experience. 

Even if these postulates are true, I would submit that history taking has such importance that we should invest in helping our students and residents learn these skills more completely than they currently do.