Chapter 1. History and Physical Examination - Art and Science

9/17/2015
The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e >
Chapter 1. History and Physical Examination: Art

and Science
Faith T. Fitzgerald, MD
History and Physical Examination: Art and Science: Introduction

The medical history and physical examination are not separate entities, but necessarily continually enrich one
another at every point. The patient's history leads the skilled doctor, even as he or she is eliciting it, to think of
things to look for on physical examination, and physical findingssome of which are immediately obvious
when one first meets the patientstimulate further historical questions. This fluid oscillation, the ongoing
back-and-forth between these two pillars of diagnosis, is, perhaps, the most difficult thing for students of
medicine to grasp because it is learned only by evaluating real patients. Standardized patients do not have
true physical findings that match the history or may have physical signs not in the script. The techniques
and some findings of physical examination can be described in books, seen on video, heard on audio, and
demonstrated on simulacra or on well people, but the essential clues given by the physical findings in
subsequent real patients, and their intertwining relationship with the history, cannot.
The medical history, say venerable clinicians righteously, is the core art of patient care. They continue to cite
references that maintain that the patient's history provides the diagnosis in 85% of cases. That often-quoted
figure of 85% is in doubt, however, because many of the histories now given by patients and taken by doctors
are in actual content a compendium of data from the laboratories and radiology suites from previous visits to
their doctors and admissions to hospital. So, for example, patients bring folders of laboratory studies with them
to consultants' offices; house staff and students present patients with chief complaints of fever, leukocytosis,
and mitral vegetations on echo; and a first concern given by a patient in clinic may be high cholesterol. It is
hard to escape the implicit conviction that laboratory and technologic data are more objective, and therefore
more scientific, than the subjective information gathered by listening to a patient tell his or her story.
Furthermore, the wondrous advances in technologic diagnosis appear to justify the reverence in which the
results they generate are held.
Developing Skill in Listening and Looking

Without a careful history, without knowing patients' stories of what happened to them and their unique
circumstances and personality, the practice of medicine becomes neither art nor science. Consider what
opinion we would have of a bench investigator who plated known microorganisms upon an unknown medium.
Would we credit a geneticist who intercalated even the most intimately analyzed base pairs into an otherwise
unknown genome? The study of the patient begins with the history, a history taken by a skilled listener too, for
it is only the skilled listener who can hear the vocal inflections that suggest the importance of things to the
patient. It is only she who can read the nonverbal clues that illuminate the meaning of the words. It is only he
who can understand not only what is said but the often vitally important information gathered when things go
unsaid by patients. It is only she who from the first moment can integrate the history and the physical
examination so that they make sense, as in a patient who complains of anxiety but who has on first glance the
bulging eyes and tremor of hyperthyroidism or the patient who moves slowly and stiffly, speaks monotonically
http://accessmedicine.mhmedical.com/content.aspx?bookid=500&sectionid=41026543
1/3
9/17/2015
and softly, and has minimal facial expression who tells you he has trouble swallowing, which are common
symptoms of Parkinson's disease. In the first case, the examiner would make a mental note to ask for a history
of weight loss and a family history of thyroid disease and, on the physical examination, would seek confirming
signs, such as a rapid pulse and an enlarged thyroid gland. In the second case, the historian would ask about
other parkinsonian risk factors and seek physical findings of resting tremor, cogwheel rigidity, or abnormal
gait. The complete physical is not a list of things to do by rote; it is a search for things directed by the
history. That is what makes it interesting for the doctor, as well as good for the patient.
The ability to take a good history cannot be acquired by lecture or syllabus, standardized patient exercises,
CD-ROM, or even texts such as this one. It is an experientially acquired art, learned over time with each
successive patient story and the careful observation of what follows from it. It is often frustrating for students
and junior doctors who want to know what the so-called good history should include. They mistake structure
for substance. The good history varies depending not on how one orders its component sections (such as
present illness, review of systems, and the like) or on mastering the current jargon and multiple acronyms that
more often obscure than facilitate understanding, but on the story that the patient needs to tell and the doctor
needs to hear, so that they together may go further along the path of understanding what to do next. Like any
artand like sciencethe ability to do a patient assessment builds on the practitioner's past and requires
practice. Knowing what to emphasize and what to discard, what question to ask next, and how to direct the
discourse (subtly and without markedly influencing or altering its content) is difficult, and the lessons are
never-ending. The only way to learn it is to do it, with real patients, again and again and again.
More Than the Facts

Here we are, doctors in the 21st century, equipped with truly miraculous tools of diagnosis and therapy, and
patients complain about us. Even the best educated, or especially the best educated, go to quacks. They do not
trust us. Why? Perhaps it is because the greatest afflictions of our patientsfear, despair, fatigue, and pain
may have no objective findings. No laboratory result or image can portray them. Only through the history
and the evidence of their bodies do patients tell us how they need our help and how best that help can be given.
Patients have also told us time and again in surveys that their greatest discontent with physicians of our era is
that they do not listen. This has been markedly worsened, it appears, by the increasing demands of the
electronic health record systems, which are wondrous and very useful but cannot be the main focus of any
good doctor's attention during the patient visit. An increasingly heard lament of patients is that the doctor
concentrates less on them than on putting data into computers and that all the patient sees is the doctor's
back as he or she types the patient's story in formulaic language onto screens.
The history is more than the elucidation of the facts of the case, more than a construct of symptoms. It also
tells the tale of the reaction a unique human being has to those symptoms and their impact on the patient's
mind and life, their family, and their hopes. Listening to patients is more than an ingathering of indications for
further studies or filling in the required spaces in the electronic health record. It is, in and of itself, a major
therapeutic act, and the physician, himself or herself, is a potent therapeutic instrument. In conjunction with
the laying on of hands that follows in the physical examination, the meeting of doctor and patient fulfills some
primal need of vulnerable and often fearful people to be attended to, cared for, and cared about.
The history and physical examination also gives doctors much of the richness of their professional lives.
Decades from now, a physician in retrospective reverie about his or her career in medicine will not remember
the chemistry panels, the MRI results, or even the majority of the medical scientific facts of their past practice
(just as well, since so many of these facts will have changed). What they will remember and tell to their
potentially bored students are the stories of their patients, about who they were and how they acted, and what
their physical examinations showed that surprised or confirmed history-generated hypotheses. If endurance in
memory is any indication of the importance of events, it is the history and physical examination, that story of
how the patient responded to duress both in spirit and in body, that is existentially most important to both
doctor and patient.
2/3
9/17/2015
The 20th century poet T.S. Eliot once wrote, Where is the wisdom we have lost in knowledge? Where is the
knowledge we have lost in information? Laboratory studies and imaging are, without doubt, essential and
informative; knowledge, however, comes only with their integration with the patient's story as told by history
and physical examination; wisdom is what doctors acquire when they recognize this truth.
McGraw Hill
Copyright McGraw-Hill Global Education Holdings, LLC.
All rights reserved.
Your IP address is 69.175.168.85
Silverchair
3/3

Chapter 1. History and Physical Examination - Art and Science

Uploaded by

Copyright:

Available Formats

Chapter 1. History and Physical Examination - Art and Science

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Chapter 1. History and Physical Examination - Art and Science

Uploaded by

Copyright:

Available Formats

9/17/2015

The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e >

Chapter 1. History and Physical Examination: Art

History and Physical Examination: Art and Science: Introduction

Developing Skill in Listening and Looking

More Than the Facts

You might also like