We cannot understand our patients’ bodies if we do not understand something about who they are as human beings,
“Social history: doesn’t drink, doesn’t smoke.” The reality of residency is that we cut the corners we think we can get away with.
In medical school, we were taught that when presenting a patient, we should provide a thorough social history, with information about our patients’ family structure, occupation, living situation, drug use, diet, exercise, sexual history, travel history, financial stresses, and more. But in residency, with all the added responsibility and exhaustion, gathering a thorough social history can feel like a superfluous luxury we just don’t have time for.
I’ve known for some time, at least intellectually, that I cannot truly care for my patients if I do not try to understand them as full human beings. However, that humanistic understanding has, up until recently, felt separate to me from my clinical reasoning. For most of medical school and much of residency, I felt like I could either understand the patient as a person or manage the disease, but to do both in the same moment wasn’t feasible. I felt like I had to choose.
I’ve realized though that the two aren’t so separate. I’ve learned that the social history—understanding my patient in their social context—is so often critical in diagnostic reasoning and clinical management.
Social history as story
When I talk to my patients, I am listening for a story. I am trying to understand what is happening in their bodies and in their lives—pathophysiologically, socially and emotionally. I don’t believe we can fully separate our humanity from our physical being. That is the nature of embodiment, and the premise of the biopsychosocial approach to medicine. When I talk to my patients, I weave back and forth between exploring symptoms and learning about their context. That integration allows me to listen for the components of a story: setting, characters, plot.
Setting—what is this patient’s environment?
I admitted a disheveled patient from the emergency department with horribly controlled diabetes. “Where did you sleep last night?” I asked. “Grand Central,” he told me.
In clinic I met a patient with HIV, diabetes, and severe depression. “Where do you live?” In a shelter, he said. I learned he had a room to himself and an assigned case worker there. It was a place he could reliably go back to, a place he could call home.
These two patients are considered, at some cursory level, “homeless.” Getting granular about the setting of their lives was key to understanding their diabetes and formulating a treatment plan that might work.
Characters—who else is in this story?
“Do you live with anyone?” I like to ask all my patients. It’s so hard for me to picture someone’s life, and how they came to medical attention, without a sense of the other characters in the story.
“My wife said I had to come,” is a common response from the stoic, Vietnam and Korean War vets I care for at the VA. I’m reassured that these men have their wives looking out for them, prodding them to get that cough or that belly pain checked out.
“I’m a bit of a loner,” one patient told me. He had been off his HIV medications for months. He could hardly eat, could hardly walk without becoming profoundly short of breath. His isolation gave me insight into how his disease might have progressed, and made me worried that he would languish at home, alone, after discharge.
The social fabric of my patients’ lives likely has more impact on their long-term health than the vast majority of interventions I can offer in the hospital. How can I understand how my patients became ill or how I can help them heal without understanding this context?
Plot—what was it like before?
Stories have beginnings, middles, and ends. I’m often meeting my patient squarely in the middle of the story, when crisis has really set in.
I strive to understand what their lives were like before they became ill. This may have been weeks ago, or years ago. “What was your life like before you became sick?” I sometimes ask.
“I had a normal life; I was an accountant at a hotel” a young man told me. As we talked more about this normal life, his eyes welled up with tears. The toll his multiple surgeries and chronic wounds were having on his life was becoming apparent to me.
As I try to understand the rhythms of a story, it often doesn’t make sense to separate the clinical from the social. They are integral to each other.
Putting the story together
We often begin the assessment portion of our presentations with “putting it all together…” It is here that I try to tell a cohesive story, that weaves the human story with pathophysiology.
I do not believe we can understand our patients’ bodies if we do not understand something about who they are as human beings, and what their lives are like. As I write this, I worry that sounds so obvious. But if it were obvious, we would not relegate the social history to a few lines in the second page of an admission note. If it were obvious, we would tell the history of present illness as a story about a human being.