9.2 Anamnesis
In today's episode, Dr. John Rhee discusses anamnesis, the art of taking a patient’s history. In medicine, anamnesis isn’t just about collecting facts; it’s about listening to the patient’s background, their experiences, and their story. By attending to a person’s history in this way, physicians can better understand not only the roots of an ailment, but also the personality and context of the one who suffers. Dr. Rhee helps us see how anamnesis grounds medical practice in the whole person, reminding us that every diagnosis begins with a story.
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[Intro music]
John Rhee
Welcome to the Hippocratic Society podcast. This podcast is a project of the Hippocratic Society.
John Rhee
In the podcast, we aim to reflect on deeper questions in medicine, all with the aim of rediscovering the ideals that brought us to medicine in the first place in order to better serve our patients and colleagues.
John Rhee
Thank you for joining us and we look forward to engaging with you through this podcast.
Michael Egan
Hi, and welcome back to the Hippocratic Society podcast. My name is Michael and I'm joined again by Dr. John. Re. John, it's great to have you back.
John Rhee
Thanks, Michael. It's good to be here.
Michael Egan
Great. So we are recording an episode today following the episode with Dr. Anthony Weiss about narrative in medicine.
Michael Egan
And so today we wanted to talk about anamnesis.
Michael Egan
John, would you mind telling us to. To begin with what anamnesis is?
John Rhee
Yeah, sure, Michael. So the idea of anamnesis is this calling to remembrance.
John Rhee
And actually it's perhaps most commonly used in more religious terms.
John Rhee
So for the Jewish people,
John Rhee
when they are celebrating the Passover,
John Rhee
there is a whole tradition of the Passover meal.
John Rhee
And during the Passover meal, what happens is that they're not just remembering the events that happened that led them out of Egypt, but rather,
John Rhee
in some sense, they're reliving the events, which is why the Passover meal is supposed to be done in a very particular way.
John Rhee
Staff in hand,
John Rhee
ready to go on a journey. And so there's a significance of reliving the events over in the present moment.
John Rhee
And so in Greek, anna means back,
John Rhee
call to mind, and mnesis, mind.
John Rhee
And the idea is that we are not just remembering back, but trying to relive or call to remembrance in the presence events that have happened in the past.
Michael Egan
Okay, wow. So that is very historical term. And so how does this all relate to medicine? That doesn't seem exactly obvious.
John Rhee
Yeah. So I think the place where perhaps this is most interesting is going back to the episode on narrative. Medicine is that idea of how we listen to patients stories.
John Rhee
And specifically for a trainee who's a medical student or resident or fellow,
John Rhee
the idea of history taking is how we typically get to hear patient stories.
John Rhee
Now, I think that this is also interesting because medicine has a very particular way of listening to patient stories. Right. Because we have a very specific format.
John Rhee
Medical students are very familiar with this particular format, which, as one becomes an attending, you don't follow as strictly, and in some ways you make it your own.
John Rhee
But even then, we tend to have a way in which we gather information and present information. That is one could say is universal. So that any physician who's listening to a presentation of a patient history knows immediately where you are in terms of telling the history of the patient.
John Rhee
Now, as a group, I think that that's very important because it is a way in which there's a familiarity in which information is transmitted. And that's very practically helpful because of the fact that when we're transmitting information,
John Rhee
we want to do it in a way in which the person is expecting to hear certain things at different times.
John Rhee
And so there's a sense in which they also can have a structure in which they're listening to things and therefore be able to be thinking about things like the differential diagnosis or what may be happening to the patient and what may be coming next in the list of things to be able to incorporate information into the presentation itself.
John Rhee
But the other thing that I think is just important to take into account here is that because of the way in which the history is very specifically structured,
John Rhee
it is also not the normal way of hearing people's stories.
John Rhee
Right. I was actually talking with a friend recently whose wife is doing her doctoral thesis. She's a nurse and so she's doing her thesis on specifically the role of how nurse practitioners and their background in nursing also helps them or also makes it more difficult in their role as nurse practitioners and how that she's doing some qualitative work there.
John Rhee
And one of the things that the that is interesting that's coming out from her work is that there's a difference between how nurses and doctors gather histories where nurses tend more towards this story approach to the patient and doctors, because of the training in which the history is structured,
John Rhee
is structured in this very specific way of the chief complaint, the hpi,
John Rhee
the medical history, surgical history, et cetera, medications, allergies.
John Rhee
There's a particular format in which we both gather information and present it.
Michael Egan
Okay, interesting. I can even hear sort of within that format, there's a lot of histories there. So it seems like even in that format there is a lot of variability, I'm guessing, in how it's presented or openness to what the patient could bring into that.
Michael Egan
Is that the case?
John Rhee
Yeah, I think so. Although I would say that because of the fact that there's almost a checklist to go through, and this is a theme that comes up in Hippocratic Society, right.
John Rhee
This idea of trying to break away from just a checklist based approach to things, but because there is a checklist based approach to gathering the information and also presenting the information to a colleague there also tends to be a sense in which when you get the information you want,
John Rhee
you want to move on to the next thing on your checklist to make sure that you get all of the information that you yourself are looking for.
John Rhee
And usually that's very specifically related to trying to figure out the diagnosis for the patient and not necessarily, therefore, with the end of also perhaps knowing the patient as a whole.
Michael Egan
Okay, so I see how this sort of ties into what you were saying before about anamnesis as this remembering, this calling to mind, and as we were talking about in the narrative medicine episode, how important narrative is in stories.
John Rhee
And so where.
Michael Egan
Where is the place for stories in this checklist? How do we balance these two things of getting the information that we need, but also hearing the patient as a whole and who they are?
John Rhee
Yeah,
John Rhee
and I want to make it clear that I'm not trying to dismantle, like, the whole idea of how we take history taking, because I don't think that that's also what we're trying to say here either.
John Rhee
Right. There is an important practical and usefulness aspect of how we gather histories and present it. What I'm just trying to say is that we should also think beyond perhaps just the way in which we typically take histories.
John Rhee
And I still want medical students to understand that, like, in order to be able to become good doctors, you also have to know the checklist mentality in the sense that you have to make sure that you're checking off all the things, like, if you're asking for pain, like, you have to think about OPQRs like T.
John Rhee
Right. That. That there is this, like, sense in which you want to make sure that you're getting all the different elements of pain. And if there's a checklist approach that helps you to be able to get every aspect of the information as you're learning how to take a history,
John Rhee
that is very good.
John Rhee
Right. So I'm not saying that this is bad,
John Rhee
but now, as you're making the history your own, I think that this is the part that's really fun about becoming, like, a senior resident, a fellow, and then an attending, is that you're no longer necessarily constrained by specific rules that you are in your training, and things become more of your own.
John Rhee
And I found that as an attending, that is especially important.
John Rhee
And then also especially as a palliative care attending, I found that as very important because really, ultimately, the diagnosis is just one aspect of caring for the patient.
John Rhee
When coming up with a plan for the patient,
John Rhee
there is much more than the diagnosis. There's A sense in which once you have or are getting close to a diagnosis, like, what is the next steps for the patient to take in terms of their health?
John Rhee
Right.
John Rhee
And the plan really, then, is a true integration not only of the diagnosis, but the whole person,
John Rhee
the context of the whole human being.
John Rhee
And that's why we do have, as a component of the HPI and the history and physical.
John Rhee
The social history.
John Rhee
Now, I think the social history in some ways has been reduced to also a checkbox of asking, like,
John Rhee
do you drink? Do you smoke? Where do you work? Like, very particular concrete information that I remember as a medical student. I wasn't really sure what to ask there in a certain sense, because there was.
John Rhee
It can be both so broad, but also it sometimes seemed untargeted because it seemed like I wasn't really sure how the social history adds to the diagnosis and treatment plan of the patient.
John Rhee
But now that I'm an attending, I see that the social history actually is a key component, maybe even one of the most important components in terms of coming up with the plan for the patient.
John Rhee
Because when we think about the social history, I'm thinking about what are the supports the patient has,
John Rhee
what is the environment in which the patient finds themselves living,
John Rhee
being right,
John Rhee
but also the wider social history of what are the things that the patient is hoping to get to in the next couple of weeks,
John Rhee
what are anniversaries or big events? What is most important to that patient?
John Rhee
So that when I'm coming up with a plan for the patient, I'm really thinking about all of these aspects as we're coming up with a treatment plan. So, you know, one specific example is I'm also a physician in the adolescent and young adult brain tumor clinic.
John Rhee
So we. We see patients generally between 15 and 35, but sometimes even younger.
John Rhee
And one of the things that's been interesting in our field is that there's this new drug that came out called vorasidenib.
John Rhee
And vorasidenib,
John Rhee
not to make it too complicated, but it's an inhibitor of a particular mutation in brain tumors that are more common in younger people.
John Rhee
But you can imagine in an adolescent age range, there's. They're trying to go to school, like college, high school even,
John Rhee
and starting a daily medication.
John Rhee
Both could have side effects, but also we don't know what the side effects are also for things like fertility in the long term.
John Rhee
And so with these things in mind, there are a lot more considerations also in terms of perhaps what and when we should be starting this medication without at least currently clear Evidence that we should start it right away after surgery.
John Rhee
Right. So. Because the trial didn't necessarily do that. And so there's a lot of discussion then that we have with each individual person about, like, understanding the context in which they're living and how to balance these decisions within the context of the life that they're living.
Michael Egan
Okay. So, yeah, so I see very clearly that actually narrative is really key to the diagnosis and treatment. To have a diagnosis and treatment, without some sort of narrative or understanding the patient more fully, it wouldn't really happen.
Michael Egan
But I guess I'm still. Still not seeing perfectly why is a narrative approach so important without.
Michael Egan
I mean, I could imagine sort of just asking the patient, like,
Michael Egan
what's important to you? Or like, you know, I have this treatment plan. What do you think of it? And then they're like, oh, but this wouldn't conflict. Or this would conflict with my other plans, but there could still be a disconnect.
Michael Egan
So, I mean, what is it about narrative that really brings the patient and physician into the harmony that. Where they can see it and the physician can really treat the patient how they need to be treated?
John Rhee
Yeah.
John Rhee
I think the main thing that is at the core of this is that we are embodied beings. Right. So we have a body. We're not just spirits floating around,
John Rhee
that we exist in a particular time and place.
John Rhee
And so our stories also are unfolding in a particular time and place. Right. And so when we are trying to understand a person in their fullness,
John Rhee
then it's not that we're trying to understand every single event that has happened in their life, but at least to be able to understand their story of the evolution of their life or how they've come to where they are now through the idea of a story or the evolution of story,
John Rhee
one can understand their values,
John Rhee
how they've also made decisions,
John Rhee
how they also process their emotions,
John Rhee
find meaning, and have found meaning in different situations.
John Rhee
It offers a much larger context of the patient without actually having to know specifically how they might make decisions at different times. Right. Because if I hear a story of how a person experienced, for example, a particular issue with.
John Rhee
Related to how their mother passed away,
John Rhee
I immediately know without them telling me directly. Because sometimes that could be very emotional or sometimes that could be very hard.
John Rhee
How their perception of, for example, hospice care may be right, in the sense that you get so much more context from a short story from a patient that then you can get sometimes by directly asking people, or sometimes that people don't even really know themselves,
John Rhee
that they haven't yet processed fully. But by listening to their story, you get hints into how they process their values.
John Rhee
I think that there's also an aspect in which stories help us to process and heal. And I've seen that in patients as well, where when they've had some hardship in the past,
John Rhee
the process of telling the story to the physician, who's listening very closely and also offering empathy and sometimes also saying sorry on behalf of all of us. Right.
John Rhee
That you've gone through this hardship, this difficulty in the healthcare system. Right. That that itself could be a healing process.
John Rhee
And so all of those things, I think, are things that are really, really important.
John Rhee
And then lastly, I think that there is an aspect that we talked about already, which is that good history taking also helps us be better clinicians, just better diagnostic accuracy.
John Rhee
And when we are able to spend time, the time with the patient to really hear their story and the evolution of the story,
John Rhee
I think ultimately actually just makes us better diagnosticians and better clinicians in terms of coming up with a plan for the patient.
Michael Egan
Yeah, that makes a lot of sense.
John Rhee
Yeah.
Michael Egan
And so I see it even more fully embraces the physician's role of treating not just the body. And even though we are embodied, as you were saying. Yeah. It is like the whole person and treating them that way.
John Rhee
Yeah, that's right. And I think the other thing is that oftentimes the thing people bring up is that I don't have enough time, that there's not enough time for that.
John Rhee
But there has actually been a study about spontaneously talking, spontaneous talking time of patients in general practice.
John Rhee
And it pointed out that minutes of listening is enough for 80% of patients to recount their concerns. And so it doesn't actually take that much more time to really hear patients stories and their concerns.
John Rhee
And I have found that to be the case in my work as well, that if you get really good at asking questions,
John Rhee
then you could get a lot from a patient and their family, including their stories.
John Rhee
But in the long run, develop a lot of trust from them as well. Because they also,
John Rhee
as they're telling their story,
John Rhee
they're building a bond or a relationship with you that's deeper.
John Rhee
And when it comes time to make harder decisions or decisions that can be just,
John Rhee
yeah. Weigh a lot more on them. What it comes down to ultimately is the bond between the physician and the patient in terms of helping guide the patient in making that decision.
John Rhee
And when the patient feels heard and understood. And also that they've developed a bond with you because they've told you about their story, their life,
John Rhee
they Feel like they're heard and they feel like you know them, then I think in the long run it actually saves time.
John Rhee
Again, that's not why we do it. I don't want to take this approach of like we're doing it to save time. That's not the point.
John Rhee
The point is, is qualitative, not quantitative. Right. But just to ward off some of those concerns that like, okay, maybe you could do it as a palliative care doctor, but I also do it as a neuro-oncologist too.
John Rhee
And my clinic is very busy. Oftentimes could be double booking patients just because it could be so busy. And even in a clinic like that,
John Rhee
I think spending just the beginning part, just like hearing about people's the joys of what they did this summer as we're starting clinic, I think makes a big difference.
Michael Egan
Wow, that's pretty amazing that two minutes for 80% of the patients. Yeah, very not intuitive. You would think that it would take much longer. That's good to hear. And this sort of is touching on practical points.
Michael Egan
So how can we bring this approach to history taking into our clinical practice without, as you were saying,
Michael Egan
taking absurd amounts of time or just asking about irrelevant information like what are the practical things that we can do to bring this in?
John Rhee
Yeah,
John Rhee
one thing is, I think also to. Is more of a conceptual point, but really seeing also ourselves in the context of this idea of a story. I think that also helps because we also at some points in our lives will be patient or are already patients.
John Rhee
And we probably also have had that feeling where the clinician who is asking us about us, like who we are, not just about aspects of our disease.
John Rhee
There's a sense in which we feel thankful or grateful for that, that we sense that the person wants to know us in the context of our illness, that they don't just want to know our illness.
John Rhee
And so just the idea of the story and the narrative humanizes.
John Rhee
And so I think practically this might be different for different people.
John Rhee
But I think coming back to this idea of how can I try to ask these questions in a way in which practically I could get to my next patient too?
John Rhee
Because I have many patients to care for. But how I could touch on something a little bit deeper.
John Rhee
And so sometimes how I do this is like instead of asking like, how are you today?
John Rhee
Which you usually get the same answer, good or okay, right.
John Rhee
Rather, I'll ask, hey, tell me about we're coming to the end of the summer. What was something that gave you the most joy this summer?
John Rhee
And that is One way in which you could hear a bit more of depth of what the patient really did look forward to this summer, what they did that was like, meaningful.
John Rhee
And then asking just a few follow up questions. They're hearing a particular story because usually they'll bring up like, oh, I went to this cabin in Maine and oh, tell me about that.
John Rhee
Oh, you know, it's been a place that my family's been going to every year since I was a little kid.
John Rhee
I remember growing up there,
John Rhee
like fishing with my siblings there. It's a place of peace for me. So going back there this year was something that was, in a certain sense, bittersweet, partly because I love it there and it's all my childhood memories and at the same time, because I wonder, will I be here again next year?
John Rhee
That gives you so much context of even understanding where they are in terms of their understanding of their own illness or prognosis. That gives you a sense of the story in which, okay, there's this place that is like so important to this person.
John Rhee
If I'm thinking about their treatments,
John Rhee
it may be that I incorporate this information into the future of if she's having a hard time or if there's a particular instance or whatever, that bringing this back may be also an important part of her overall plan.
John Rhee
But also I hear themes there about the importance of her family,
John Rhee
the memories with which she grew up with,
John Rhee
perhaps that she is also a nature person. She loves being out in the forest in this cabin.
John Rhee
Right. That there's a lot of context that we gain that's, that's not just,
John Rhee
just, just the story itself. And if we get good at asking questions about,
John Rhee
you know, what are the joys but also the worries that people have or coming into this visit, what's the, the biggest thing that was on your heart this past week,
John Rhee
These are ways in which we could gain a little bit more perspective of that patient's story and be able to know them as a person and not just their illness.
Michael Egan
Wow. Yeah,
Michael Egan
I love that. It's really powerful, but also very easy and practical. Also, I think that touches a lot on a topic that we talk about a lot, about how who you are outside of the clinic affects who you are inside of the clinic.
Michael Egan
And I could easily imagine this same sort of practice being brought to your family or your friends and just asking more intentional questions rather than just, how are you?
Michael Egan
Or how was your day?
John Rhee
Yeah,
John Rhee
yeah, I think that's exactly right, Michael. And so much of my training in palliative care actually just shows me that it's very helpful in my personal life. I'm just trying to go deeper with people.
Michael Egan
Yeah. Well, great. Well, thank you so much, John. This was very, very helpful and we appreciate you coming back.
John Rhee
Thanks, Michael.
Michael Egan
All right. And we'll see you all next time on the Hippocratic Society podcast.
John Rhee
Thank you very much for joining and reflecting with us today.
John Rhee
Keep up with new episodes by subscribing to the Hippocratic Society Podcast.
John Rhee
For more information on the Hippocratic Society,
John Rhee
visit us at hipsoc.org.
John Rhee
The Hippocratic Society is a 501(c)(3) and depends on the generous support of its listeners. And as always, we'll see you next time on the Hippocratic Society podcast.