|Paul Wood (1907 – 1962)|
To take an accurate and relevant history is one of the most difficult and important arts in medicine. Sometimes, a complete diagnosis can be made from the history alone, and not infrequently the possibilities can be whittled down to two or three. A good history should at least indicate the system involved, or it should point unerringly to some group or groups of diseases. A common mistake is the failure to analyse any given symptom sufficiently; in cardiovascular work this applies especially to pain, breathlessness, palpitations, and syncope. The student is usually taught to encourage the patient to tell his story in his own words, and to record them more or less verbatim. Yet such an account may be verbose, irrelevant, inaccurate, and misleading. It is an axiom that the leading question must be avoided at all cost; yet again, an experienced physician must know that the ability to put the appropriate leading question at the right moment, and the intelligent interpretation of its reply, are invaluable. It is not pretended that leading questions may not lead to false information, if the power of their suggestion is not appreciated by the questioner; and it is agreed that much may be lost by failure to allow the patient freedom and time to express his complaints in his own way; but the average patient will not mention half the available information until he is pressed, and the data freely given must be checked as at the bar. For example, in the differential diagnosis between a neural and non-neural somatic lesion, an accurate description of the quality of the pain may determine the issue immediately, yet the majority of patients will volunteer no information concerning the quality of pain, and if asked to describe it will do so inadequately. They may say it is aching or sharp, but fail to enlarge on this, even when urged to do so. In answer to the leading question, “Does it tingle?”, however, they may reply at once in the affirmative. It is essential to realize that the matter does not end there: that such a positive reply to a leading question demands the most penetrating cross-examination, until the questioner is satisfied that the pain really does tingle, and that the patient is not merely saying so because it seems the easier answer. It is scarcely too much to say that the best history-taker is he who can best interpret the answer to a leading question. Appropriate leading questions can only be asked, however, when the proffered history has provided sufficient data upon which to work, and if the physician has sufficient knowledge of the possibilities then entailed.
Paul Wood, MD
Preface to Diseases of the Heart and Circulation, 1957 (Fall 2014)