Tuesday, February 15, 2011

"Don't You Want to Know What I Used to Do?"

Ms. R, a retired nurse, lives with her husband in Dorchester.  She has two adult children living nearby who she sees regularly.

By the time I get to a patient's social history--almost always elicited last after an exhaustive 25-minute interview--I have about one or two minutes to learn about their marital status and children, who lives with them, other social support, occupation, and hobbies and interests.

With my head spinning from trying to create a coherent narrative from non-chronological, incomplete, inaccurate retellings of current and past medical problems, I often do what a first-year on autopilot would: I skimp.  I rush.  I don't think.  I use standard questions.

"You mentioned your husband.  How long have you been married?"

"Do you live alone or...?" (We give the least agreeable option to normalize it.)

"Do you have children?"

"Do you still work?"

"What did you used to do?"

Those questions usually suffice to sum up a patient's identity for the write-up.  I have his daughter's age, so I cut his ramblings about her college accomplishments short.  He's an avid fisher; it's unnecessary to hear which fish get him most excited.  She's a homemaker; the fact that she's always longed to go back to school doesn't merit a place in the chart.  Tick, tick.  We move on to items I can write down.

It's a nonintuitive balance.  Though we're told to inquire about our "patients as people," their most interesting details get truncated in favor of the bland standard summary.  I suppose this makes practical sense.  But I don't particularly appreciate the sixth sense I've developed to gauge when a patient is getting "off track"--when I know I can stop listening and not miss anything pivotal, when I think about my next question or my last question, when I configure a strategy to guide the patient back to what I need in my write-up.  When it's just not "important" or "relevant."

Some months ago, I interviewed Ms. S, a 94-year-old woman with an ear infection.  Her medical history was fairly uncomplicated, she was incredibly talkative and intelligent, and she laughed a lot.

"You mentioned earlier that you sprained your ankle a few years ago when you were trying to move a table.  Do you live alone?"  Yes.

"Have you ever been married?"  No.


I stopped.  I couldn't ask how long she had been married.  I couldn't ask about when her husband passed away, or what from.  I couldn't ask about her children or grandchildren.  My brain, on autopilot, stumbled to make some sort of transition.  This lady was missing a large chunk of her social history.

She gently asked, "Don't you want to know what I used to do?"

Over 70 years ago, she worked on the atomic bomb (unbeknownst to her at the time).  For thirty years after that, as part of her job with the government, she had traveled around North America, South America, Europe, and Asia.

"I had a lot of boyfriends," she volunteered, unsolicited.  "But if I married, I'd be discharged.  I didn't want to lose that part of my life."

"It sounds like you enjoyed that," I added dumbly.  She rightfully took that as a cue to share even more.  I know most of it wouldn't make the write-up, but this time I listened and made no attempts to guide.

I walked away humbled.  Social history had always seemed so straightforward and formulaic.  Yet this woman had defied the formula, and 70 years later, she seemed happy and complete.

I aspire to that.

Happy Valentine's Day.

Note: Certain medical, social, and temporal details and quotations have been changed to preserve anonymity (while hopefully not altering the narrative and message).


  1. Great story! And what an interesting life she had...

    I heard of one case where inadequate history taking proved fatal. The patient had recovered from a heart attack and the doctor told him he could resume normal activities -- without finding out that they included sky diving.

  2. It is a very important question, one that cannot be answered, or maybe even asked, in the office where the doctor has double and triple booked.
    As a chronic pain patient, I would want you to know what I did, what my life was like, what I lost as the result of my pain and subsequent disability. (I think this would be true of most patients regardless of their disorder/disease.) It is a sad commentary that this early on you are learning how to divorce yourself from the patient, who they were and who they are.

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  4. "You mentioned your husband. How long have you been married?"

    "Do you live alone or...?" (We give the least agreeable option to normalize it.)

    "Do you have children?"

    "Do you still work?"

    "What did you used to do?"
    This question are very important. Great post.
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