A Country Doctor Writes:

“Listen to the patient, he is telling you the diagnosis.”

William Osler

Sir William was right, but listening for the diagnosis when patients speak isn’t quite as straightforward as it may seem. This is particularly the case in the fifteen minute universe of American health care today.

In America we call it “history taking”. Our use of the word “history” somehow implies that there is something very objective about it. This has led people in the medical field to even delegate the listening to and documenting of patient histories to non-professional office staff.

In Sweden we used the word “Anamnes”, derived from the Greek words “ana” (back again) and “mimnesco” (remember). “Anamnesis” is found in Plato’s teachings about memory. There is a subjective quality to the use of the word “anamnesis” for patient or case histories, as the word in English can also mean, simply and non-medically, “recollection”.

Taking a patient history or anamnesis can require a fair amount of finesse.

Sometimes a patient comes in with a diagnosis already in mind. He or she will outline their differential diagnostic thought process and resist getting into what the actual symptoms are, as if they’ve moved beyond that stage. They act as if they wish I would please catch up with where they are. My usual reaction and tactic in such situations is to let go of any seeds of frustration I might feel and declare my inability to skip over any steps in the diagnostic process. I usually say something like “I’m a little slow…” in order to not seem to be challenging my patient’s preliminary efforts.

Other times, I run into patients who offer neither symptoms nor interpretation, but tell convoluted narratives about what others have said about them and what happened years ago that might have set the stage for whatever may be happening now, although I haven’t yet become the least bit aware of any of their present symptoms. Before I became aware of the condition now called alexithymia, I would easily become frustrated with this kind of narrative. Now I am more able to consider this kind of “anamnesis” a warning sign that my patient truly might be unable to recognize and describe both emotions and physical symptoms.

I worry about the idea of delegating listening to someone else; even a highly trained colleague could obtain a slightly different history, and every clinical decision is to some degree based on nuances that go beyond the mere “facts” of the case. It often seems that the way a patient’s history and his demeanor appear congruent or dissonant can move the diagnostic process forward quite dramatically.

I also worry about the therapeutic consequences of eliminating or abbreviating the listening process. I couldn’t count the times a patient has seen a well respected specialist who delivered technically excellent care and come back telling me “he didn’t even listen to me”. Patients have again and again told me that they value simple listening in me and other health care providers they see.

This ties in with something I read recently about the difference Between Care and Cure.

My wife ordered a book a few weeks ago by Henri Nouwen, called “Bread for the Journey”. It was published posthumously and contains daily reflections. Nouwen is perhaps best known for his writings about the “wounded healer”. This morning over coffee, Emma asked me to look at today’s reflection, titled “Care, the Source of All Cure”:

“Care is something other than cure. Cure means “change”. A doctor, a lawyer, a minister, a social worker – they all want to use their professional skills to bring about changes in people’s lives. They get paid for whatever kind of cure they can bring about. But cure, desirable as it may be, can easily become violent, manipulative, and even destructive if it does not grow out of care. Care is being with, crying out with, suffering with, feeling with. Care is compassion. It is claiming the truth that the other person is my brother or sister, human, mortal, vulnerable, like I am.

When care is our first concern, cure can be received as a gift. Often we are not able to cure, but we are always able to care. To care is to be human.”

Nouwen was absolutely right. I think the way we take each patient’s history, the way we elicit their stories and recollections – their “anamnesis” – is at the very foundation of “care” in health care.