Okay, I realize you when you read the title for this latest entry you're probably thinking:  "OK, now I'm sure this guy has completely lost it.  Up to this point, it was just a deep suspicion, but now I know he's one card short of a deck..."  All I can say, is "whoa there, Clarence, at least give me a chance!"  In my last journal entry, I pointed out that in Plato's writings one of the key distinctions between the tyrant "slave-doctor" who doesn't listen to his patients and prescribes treatments lickity-split, and the "free-man doctor" who cares for his patients much more thoroughly, is the detailed history that the latter "free-man" physician performs.  So let's talk a little about "the history". And let's talk a little about fishing. 

It's my own stubbornly held contention that there are alot of similarities between taking a good history and going fishing.  Please hear me out:  When I went up to Canada for my first fishing trip,  I was excited.  I read up on fishing, and spent hours pouring over books...I bought the best lures, rods & reels possible, and fitted myself out to the gills.  I mean I was LOADED when I went.  If there was a lure for walleye that existed, it was in my huge tackle box.  I had GPS BEFORE they had GPS.  I had fish sonar...I had every new gadget out there, and THEN some.  I naturally wanted a guide.  And I picked a good one....

His name was Frank, and he was an old Indian, perhaps slightly younger than the oldest Sequoia tree  in California, with a gnarled, weather beaten face to match. Another one of the things about Frank was that (to put it mildly) he wasn't fitted with "the latest gear".  He had a single old rod that looked like it had been hand-cut for him shortly before the Spanish-American war, and a beat up lure or two that looked like they had been hammered with an anvil and  almost bitten in half.  Frank didn't talk much in our boat, but what he lacked in words he made up for in results.  A typical conversation between us went something like this:

 Frank:  We fish over there (he would then point to the location)

 Me:  Why?

 Frank:  Because.

 Me:  How do you know there are fish there?

 Frank:  Because there are.

 Me:  But it looks like all the other places (I would then point out the similarities)

 Frank:  There are fish there. (he takes another drag on his cigarette at this point)

 Me:  Look, I've got sonar, why don't we give it a check?

 Frank:  No need.  Let's go

So off we'd go to another one of "Frank's spots".  The boat would stop, and we'd throw in our lines and the waiting would begin.  The conversation at this point would go something like this:

Me:  I'm not getting even a nibble.  You're spot isn't good, Frank.  We should have used the sonar.  

Frank:  Be patient.

Me:  But I'm not catching anything!

Frank:  Be patient.   

Me:  Whoa, you've got one Frank!  It's huge!  

And Frank out-fished me every time.  With his ancient rod.  I mean he would catch fish faster than he went through his cigarettes (and that was fast).  He out-fished me every time.  Even when I got pissed off at him and went out alone--by myself--(just to show him I could catch fish like him.) he still out-fished me.  

Now what does all this fishing "stuff" have to do with history-taking for the allergist?  There are similarities:  Let's look at how Frank was successful--

1.  He had experience.  Alot of experience.  He knew the lake--every weed-filled inlet of it

2.  He was patient--he knew the fish would bite at "his spots".  It just would take time.

3.  He didn't rely on the greatest hi-tech gear.  He relied on his experience an intuition. (curiosity) 

And so it is with history-taking...truly good history-taking  by a seasoned clinician "who knows the lake" approaches an art-form.  We hear that medicine is an "art and a science" and we see buildings festooned with such signs as "Medical Arts Building" but we allergists give "lip service" to the "art" part of "art and science" when it comes to medicine.  Truly good history-taking takes alot of experience. It's hard work.   And we have to be patient  when doing histories--detailed histories take time, and lots of it.  We also need to trust our mentors or "guides" to help us define and develop our history-taking skills as allergists.     And with taking alot of histories comes experience.  What does experience allow you to do?  Avoid mistakes.  How do you get experience?  By making mistakes.  And just like I couldn't learn the "art" of fishing by reading all the books I had, so you can't learn the "art" of history taking by going to medial school and reading books.  You have to "prowl the lake" under all sorts of "weather conditions" and get experience.  There's no subsitute.  Period. 

Why am I discussing this aspect of Plato's writings?  Because the history is--in my opinion--the single most important tool we have to work with in evaluating a new allergy patient.  Not the prick test.  Not the RAST test.  Not the basophil-histamine release test.  Not our Pulmonary Function test.  It is often with a good history by a seasoned "fisherman-clinician" that we can "catch the fish"--i.e., make the diagnosis.  We can be outfitted with the latest/greatest high-tech lab tools and EMRs, (like my fishing equipment) but they can't make up for good history-taking.  

And what is the true power of history-taking?  Because when you do enough histories, over 20 or 30 years, you begin to see PATTERNS in histories.  And recognizing PATTERNS as we take our patient histories is an enormously powerful tool.  And the next series of entries will discuss patterns I have noted as I have taken allergy histories for nearly three decades.  Patterns that help you see "the big picture" and have a thorough idea of what's going on with the patient, even before doing allergy testing.  Patterns that allow us, like Frank, to cryptically point to a given spot on the lake, and say, "fish here".