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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 findings—some of which are immediately obvious when one first meets the patient—stimulate 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.

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 ...

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