Taking a satisfactory history – it’s one of the cardinal skills in the practice of medicine.  Lack of skill in taking a history distinguishes the competent physician (and other medical practitioners,) from the wannabees who covet the title of “Doctor” but cannot do the work.

Taking a good history involved a prolonged period of shutting up and listening.  I find that most people cannot tolerate shutting up and listening for more than 10 seconds, and they demonstrate great struggle and anxiety when doing so.  Watch the patient in the room – the iPhone comes out within ten seconds of being asked to sit quietly while I go about a task.

There is little difference between a “medical history” and the professional practice of history.  Everyone lives in the now, and when the Model T and the biplane were made, people didn’t view them as though through some sepia haze.  They were part of the Immediate, the Now, and they had no inkling that these modern devices would some day become as quaint as the Palm Pilot of the nineties.

History is the skill of perceiving the past as though it were now, and conveying by word and demonstration so that others can share that perception.

I was well and thoroughly trained in taking a history, in examining the patient, and in constructing a coherent oral monologue that could tell the story of the patient, emphasizing clues and themes that brought the a professional listener to share an understanding of the present, and how to progress into the future of the care of the patient.

I also learned how to write a medical note, which is simply a written form of that oral monologue, addressed to myself and colleagues, to mark the status of the patient at a certain time.

These are nearly extinct skills.

What passes for these skills today is not the passive, focused listening to the patient, but a recitation of canned questions attached to check boxes.  We gather a block of trivialities called the “Review of Systems” which is a collage of unremarkably normal assertions that distract from the main concern.  People are trained how to examine the patient -; they are not trained how to look.  People are trained to leap towards a certain diagnosis – they are not trained to think about the patient.

And they all are gathered into an indigestible gush of symbolic data, now called the medical chart.  Once upon the day, a medical note could be covered with one’s hand, and still be exceptionally competent.  No more!  All that is needed now is to regurgitate a lengthy gabble which might deter criticism.  It’s all about dodging the blame.

There was a time when doing what we do was considered beneath contempt.  That time has largely be forgotten.  I feel it is my duty to take a history of what was, and what once was standard and correct; and when what we have now was once unimaginable.

This is the horror of dystopias – that they may someday become real, and even worse, routine; and finally, that any alternate path becomes unthinkable and even wicked.  We are there.

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