DGIM Generally Speaking

Pages: Notes from the DGIM Writer in Residence

“It is much more important to know what sort of patient has a disease than what sort of disease a patient has,” advised Sir William Osler over a century ago. Though these words are as true as ever, it is increasingly difficult to learn from a person’s medical chart what “sort of patient” he or she is. While attending on the inpatient service, Alaka Ray, MD, a primary care physician in the IMA and Associate Program Director for Ambulatory Training in the Internal Medicine Residency program, wondered if the Social History, in which details of patients’ lives were once carefully recorded, needs more attention.—Suzanne Koven

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	Alaka Ray, Guest Columnist

I have a wooden camel on my desk. It is perched on the lid of an artfully distressed wooden box with a brass clasp. My patients and colleagues assume I bought it during one of my trips to India. I will confess here that the camel’s provenance is somewhat less glamorous: it was found in the trash, a gift from a patient. He initially presented with recurrent dermatitis of his hands, unresponsive to steroid creams of increasing potency. His medical record stated that he was “unemployed” but when I asked him how he spent his days, I learned that he hunted for “treasures” in the trash and then cleaned and repaired them to sell. He was cleaning these objects with harsh solvents. I advised him to wear gloves during his work and the rash never returned. A few months later, I received the camel from him, a treasure he had rescued from someone’s garbage. 

Recently, I attended on the Bigelow service, where I noticed something missing from the residents’ otherwise exemplary case presentations and admission notes: the social history. When it did appear, the “SH” usually contained only a cursory mention of substances used, e.g. “40 pack-year smoking history.”

As a primary care doctor, I need to know who a patient is as a person. What do they do all day? Are they alone or cherished by a large family? I have found these conversations enjoyable, but also essential. The MIT professor will have different concerns about his blood pressure medication than the Chinese herbalist. I understand that in the inpatient setting, it is hard to paint a detailed picture of a patient overnight. However, asking about profession, background, living situation, and social supports can significantly impact the patient’s care.

One morning, we saw a 94 year-old woman admitted with a GI bleed. She had already been scoped and treated and the intern suggested that she might be able to go home the next day. What is “home” for this woman, I wondered. Is she alone? Can she manage? The woman could barely hear or see. She had loving children who were doing their best to support her in the evenings, but she was isolated for most of the day. Her near-blindness led her to cling to the familiar territory of her home despite the obvious advantages of a more supervised setting. As all of this came to light, I saw the interns beginning to glean what the junior resident already knew: that the social history can make or break our best laid plans. If we don’t teach our residents to value it, hopefully our patients will.

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Would you like to share a story from your DGIM experience here, or have a private consultation about a manuscript or about writing in general? Contact me at skoven@mgh.harvard.edu

Read more articles from the Fall 2017 edition of Generally Speaking