"Taking In" a History

. . . when a patient comes to me for examination and begins to talk to me about symptoms, how she suffers, and what her trouble is . . . I am listening to her story, and while listening, I am seeing in my mind’s eye the combinations of systems which go to make up the whole of that body structure. I am concentrating on her story, trying to determine through the description given to me the structural alterations which have occurred to produce the symptoms described.
                                        -- A. T. Still

“Taking a history” initiates the formal gathering of data that opens the mainstream doctor/patient encounter known today as an office visit. When a patient sees their physician, for a particular medical problem, the doctor asks a series of questions attempting to delineate the problem and identify the issues that will then be assessed during the physical exam portion of the office visit. From the data garnished from the history and physical exam, the doctor organizes the information and arrives at a diagnosis. Based upon the diagnosis, a treatment is offered. This structured approach to evaluation and management of disease is the standard in the American medical model.

Andrew Taylor Still, was a gifted clinician. He had an uncanny ability to bring together divergent elements of a history and physical exam into a holistic understanding of the true cause of the dysfunctions that lead to disease. He “listened to” and “concentrated on [the patient’s] story” to obtain a history. Dr. Still also said that we must, “Listen patiently to the patient’s story of how his health began to fail . . .”

He did not just inventory data like some form of clinical taxonomist. He listened patiently. He did not hurry the process. He explored how a patient’s health began to fail, rather than just documenting the presence of disease. He integrated the information he received into what he called a “mind’s eye” view of the “combinations of systems which go to make up the whole of that body structure.” The mind’s-eye image is an interpretation; it is a felt diagnosis. It is an interactive diagnosis where Dr. Still was feeling and seeing the diagnosis in his consciousness. He was prioritizing the pertinent mechanical dysfunctions created by disorders in structure, or anatomy. He was seeing the whole of a patient’s body structure. By “seeing . . . the whole of that body structure” he was also experiencing the patient holistically. To experience the holism inherent with our patients is to connect with the essence of what originates healing.

E. E. Tucker, DO, an early Osteopathic pioneer, once said of Dr. Still that “He did not ‘think’ of a patient’s sick body, but he felt it . . . He got a real sense of it’s state.” Having a mind’s-eye impression of a patient’s abnormal anatomy and its disordered function, as taught by Dr. Still, was a sensual diagnosis processed outside of organized thought. When Dr. Still felt and sensed, what he called the “connected oneness of the whole person,” as he described holism, he was experiencing the diagnosis so he could then better understand it and treat it. When we as clinicians do not feel “connected oneness” in our patients, we are identifying the causes of a lack of functional holism, which is a manifestation of disease.

Before medicine formally codified the patient encounter into a history, physical exam, diagnosis, and treatment -- or what we also call the SOAP note (Subjective, Objective, Assessment, and Plan respectively) -- physicians of all types used a similar, though unnamed, format in the assessment and treatment of disease. Dr. Still did not organize his specific clinical style into a designated method. From his writings we can presume what he did. Dr. Still, first and foremost, “listened patiently to the story,” he performed a physical exam, he identified the most accessible cause (which is a diagnosis), he gave an Osteopathic Treatment, and then he “let it alone” to allow Nature to do the work of healing.

During the listening phase, or history, he was seeing the whole structure and function of the patient. He was getting an impression as to whether the patient was functioning holistically or was acting as a collection of parts with inadequate physiologic communication, and therefore insufficient abilities to self-heal. He was not just plugging data into a list of possible differential diagnoses in order to just name a disease. While he was listening, he was beginning to identify the cause, or causes, of how a patients “health began to fail,” and then he combined that evidence with the confirmatory details of the physical exam to arrive at the whole story of the reason for that patient’s disease or illness.

Medical semantics calls the history the “subjective” aspect of an office visit. Subjective is defined medically as being experienced only by the patient. It is used to describe a medical problem that is perceived to exist only by the patient and is not recognizable by anyone else. Being subjective also implies feelings or opinions rather than facts or evidence.

In my practice of Osteopathy, the “listening phase” of an office visit is extended throughout the entire time spent with my patient. Listening begins when I first greet the patient and gain my first impression of who they are and what is “happening.” With established patients, I am listening for what is new or different compared with when I saw them last. I am observant and aware. Before I even ask a verbal question, I am gaining information via sight, smell, and sound. I am using other-sensory perceptions to discover non-linear material by methods that some may call intuitive. I am actively listening for what is said and what is not said. Tone and attitude tell me more than the details of words. I am constantly looking for non-verbal clues that will give me unfiltered information. I am looking in between the lines of what is said to gain a clearer perspective on the totality of a situation rather than focusing on the details of statistics.

Osteopathic listening continues through the hands-on treatment phase. Osteopaths are trained to listen with their hands using other-sensory perceptions that function far beyond the traditional five senses. I am continuously taking in information, processing it, allowing a minds-eye image to appear, and then effortlessly applying a treatment. In reality, the listening phase of an Osteopathic Treatment, only ends after the patient leaves face-to-face contact with me.

“Listening to a story” feels much different than “taking a history.” Listening, in the way Dr. Still teaches in the quote opening this essay, is a receptive action. It is an afferent process involved with receiving rather than an efferent action involved with doing. The Osteopathic process of allowing for the development of a mind’s-eye image is really a diagnosis, or a working diagnosis if realized during the history.

Rather than just take a history, I prefer to “take in” a history. The taking in of a history is congruent with Dr. Still’s style of listening and concentrating upon the patient’s story, while at the same time appreciating the presence or absence of holism in structure and function. Taking a history insidiously implies that we grab or seize someone’s story. In the formalized medical model, it also implies a separation between doctor and patient. By taking in a history, we are receiving a story. We are actively listening, concentrating, and integrating our patient’s story into our consciousness.

Many studies of Western trained allopathic physicians indicate that doctor frequently interrupts a patient within one minute of the start of a story during an office visit. The common complaint of many patients is that they feel rushed and ignored by their physicians. If a fellow human being is offering his or her story to us and we take it, or grab it, by rapidly introducing our agenda, we disrupt the healing process that begins by the sharing of a story. Grabbing a story is a form of invasion. When we share our story with a fellow human being, we are exposing ourselves. True healing requires a sense of vulnerability by the patient. And, true healing requires humility and respect on the part of the receiver of the story.

People can experience a significant catharsis when they are allowed to unveil their story in an uninterrupted manner. I allow a patient to reveal their story, unbounded, for as long as necessary. When a patient is allowed the opportunity to express themselves, to an open-minded and attentive Osteopath, they rarely need more than 15 minutes to tell their story -- as long as it is uninterrupted. In select cases, I have listened, without interruption for 60 minutes. Conscious listening in these select cases is the treatment, and it is highly therapeutic. This process of unbounded listening and receiving is more like gathering in a story rather than grabbing a history.

In a traditional medical encounter, the subjective portion of the office visit is separate from the objective part. The objective, or physical exam, is the stage where details are elicited by the physician. Objective is defined medically as signs observed by someone other than the patient and is based upon what can be measured. The data elicited during the objective exam are perceivable by the senses of the doctor. Being objective is also based upon facts rather than thoughts or opinions, and exist independent of the patient’s perceptions.

The taking in of a history in an Osteopathic practice is inextricably linked to the creation of a working diagnosis by having a mind’s-eye image of what is normal and what is abnormal. The taking in of a history involves “thinking Osteopathy.” Harry Chiles, DO once said, “If one can think Osteopathy then one can practice Osteopathy.” The process of “thinking Osteopathy” is understanding the principles of Osteopathy combined with knowing normal anatomy. By “seeing in my mind’s eye the combinations of systems which go to make up the whole of that body structure” and by “determin[g] . . . the structural alterations which have occurred to produce the symptoms described” I am using my Osteopathic way of thinking to bring together complex clinical details that allow me to best help my patient.

I am “thinking Osteopathy” at every portion of an office visit. I am “thinking Osteopathy” when my hands are on the patient and when I am sitting face-to-face with them in conversation, listening to their story. In an Osteopathic office visit, we acknowledge the need for an independent verbal history and an allopathically oriented physical exam that often begins and office visit.

However, most of the time spent in an office visit with an established patient for example, is devoted to an intricate and seamless exam/diagnosis/ treatment process -- following the taking in of a history. Exam, diagnosis, and treatment interweave and are interdependent in an Osteopathic Treatment. This process of exam/diagnosis/ treatment occurs dozens of times during a 30 minute Osteopathic Treatment in my office.

Taking in a history is not only receptive; it demonstrates a very active engagement, or participation, on the part of the Osteopath. To “think Osteopathy” is to utilize the principles of Osteopathy in a clinical setting. “Thinking Osteopathy” is in reality applied philosophy. When we take in a history, while at the same time “thinking Osteopathy,” we offer our patients the gift of our attention, it demonstrates our unalterable respect, and it provides them with the unique healing perspective of Osteopathy.

Steve Paulus, DO