A patient’s social history isn’t just checked-off answers
Ms. R., a retired nurse, lives with her husband in Dorchester. She has two adult children living nearby whom 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 go on autopilot: 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 off his ramblings about her college accomplishments. 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.
As medical students, we’re taught to inquire about our “patients as people.” In reality, 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 can think about my next 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.”
Today 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 broke your arm a few years ago when you were trying to lift a box. 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?”
More than 65 years ago, she had helped work on the atomic bomb (though she didn’t realize it at the time). For 20 years, as part of her job with the government, she’d traveled around North America, South America, Europe and Asia.
“I had a lot of boyfriends,” she volunteered. “But if I married, the rule was I’d be discharged. I didn’t want to lose all those perks.”
“It sounds like you enjoyed that,” I added dumbly. She rightfully took that as a cue to share even more. I knew most of it wouldn’t make the write-up, but this time I just 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 65 years later, she seemed happy and complete.
I aspire to that.
Yurkiewicz just completed her first year at Harvard Medical School in Boston and is author of the blog This May Hurt a Bit, where this essay first appeared. She can be reached at firstname.lastname@example.org.
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