It’s time to retire ‘poor historian’ from clinicians’ vocabularies

Should we pity the “poor historians” — the individuals or family members who can’t give a clear accounting of their illness or symptoms — or embrace them? They have important stories to offer their clinicians, but can’t tell them. Who is really to blame here? And should the term poor historian ever be part of an individual’s permanent record?

Here’s an example of how this works: One warm summer night, when one of us (Steven) was on call, an elderly man came to the emergency department. He was confused and had a fever with shaking chills. After stabilizing the patient, finding out why he became sick was the central priority for the team. To set the diagnostic cart on the right track, a resident physician interviewed the patient’s wife to gain more information about his condition. The conversation wasn’t illuminating: there was only so much information she could convey through her tears.

The resident left the treatment pod and shook his head. “I don’t know what’s going on with this guy,” he said. “I don’t know anything about him. And his wife was a poor historian, so she couldn’t help much. Let’s just cast a wide net,” he sighed.

Across all training levels, doctors, nurse practitioners, and other clinicians are no strangers to encounters that do little or nothing to clarify murky medical situations. It is seen as the clinician’s job to understand why a person is sick and begin the appropriate treatment. When they aren’t able to do that, caught in the switches translating from patient-speak to doctor-speak, it is profoundly frustrating for everyone involved. In these instances, clinicians sometimes describe the patient — either verbally or in the medical note — as a poor historian. This designation has at least two functions: It’s an expression of frustration at a lack of diagnostic clarity, and a solicitation of forgiveness from their colleagues for lingering clinical ambiguities in the case.

Although the term poor historian emerged in the 1890s to refer to academic professionals studying the past, it acquired a medical meaning in the mid-1900s. The 1950 edition of the “Attorney’s Textbook of Medicine,” for instance, used the term to describe a patient “limited by his disease, by lack of facility in language” due to neuropsychiatric disease.

No longer did “historian” refer to the particular skills of a set of academic professionals. Now, by this logic, every person was a professional — a professional patient — responsible for communicating the recent chronology of their current and past illnesses. In an interesting power move, granting laypeople a limited sort of professional status allowed clinicians to shift blame for uncertainty onto a patient’s alleged deficiencies.

By the 1960s and 1970s, the term poor historian was widespread enough in medicine that some physicians began to advocate against its use. In a 1961 article, a Kentucky physician suggested that the term suggested that the doctor was “himself a poor observer.” A 1978 textbook was far more blunt: “Too often the excuse is made ‘The patient is a poor historian,’ when in fact the physician is at fault.”

These critics flipped the directionality of the power move, arguing that using the term poor historian reflected negatively on lazy or incompetent physicians shirking their professional responsibility to comprehensively gather information, not on the allegedly incompetent patient.

Today, the term continues to be passed down, from one generation of clinicians to the next, achieving meme status within medicine.

While physicians and other clinicians are keen to celebrate tradition, some have argued that the tradition of referring to patients or their family members in this way merits being retired.

The two of us agree, but from a different perspective. We don’t seek to assign blame to individuals on either side of these conversations: Patients offer the stories they can offer, and not getting sufficient information is generally not a sign that clinicians aren’t doing enough, or aren’t effective information gatherers. Instead, we want to identify the dynamics of power inherent in the term as both a symptom and a cause of a sick health care system.

Clinicians have legitimate frustrations about the state of the health care system in 2023. Financial considerations — by health care systems and insurance companies — brusquely affect clinical decision-making on a daily basis, in the form of short patient visits or difficulties with prior authorization. Many clinicians, particularly those lower on the training hierarchy, work long hours. In addition to these daily challenges, layer on the moral injury caused by yawning health care disparities borne disproportionately by vulnerable populations — racism; gun violence; legislative misogyny, homophobia, and transphobia; environmental catastrophe; abuse and neglect; and so much more — and it becomes clear why 63% of physicians in 2021 reported feeling burned out.

Interpersonal challenges inevitably arise between clinicians and patients that tax their coping skills, already inflamed by the system’s injustices. Due to an inability to understand a patient — for any number of reasons — hands get thrown up and the label “poor historian” is applied in exasperation. This is a reasonable human response to the twin irritants of cognitive frustration and moral distress that together threaten a medical professional’s ability to identify the truth and deliver value-based care.

It’s one thing when a clinician thinks the term, or utters it to a colleague in frustration. It’s altogether different when a clinician’s pique gets put into a patient’s medical chart. Then it ceases to be a human response and becomes a clinical judgment, one that can damage the patient’s relationships in the health care system. Future clinicians could read that chart and, when they see “poor historian,” make snap judgments about who the person is even before meeting them for the first time. In an unfortunate sort of irony, clinicians disillusioned by the inequities of the system become agents of inequity themselves.

Clinical interactions between patients and their doctors or other clinicians will always involve some level of confusion or distress: at bedrock, the encounter rests upon one human being bearing witness to the suffering of another. With that in mind, we invite clinicians to reframe fraught moments with patients as opportunities to become more nuanced, empathic historians themselves. These strategies encompass everything from avoiding stigmatizing language such as “compliance” to seeking out opportunities to learn more about social medicine and structurally competent care, and to spending a few minutes to elicit a comprehensive social history structured more like a narrative than a series of checkboxes. With these habits in place, moments of frustration or confusion can become reminders to practice medicine with humility, self-reflection, and earnest curiosity about the experience of another person.

Let us not pity “poor historians”: let us empower them instead.

Steven Server is a historian of medicine and fourth-year medical student at the University of Chicago Pritzker School of Medicine. Samuel Schotland is a writer and historian of medicine, emotions, and capitalism.

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