BW was a 66-year-old woman who presented for an urgent visit to the general medicine clinic. She reported that she had been having dizziness for the last four days. When pressed, she said it occurred intermittently, being present more than absent. She could not identify any palliative or provocative features, and when asked about associated symptoms she said that she felt “bad and scared” when it was present. The doctor encouraged her, many times, to characterize the dizziness, and she could only say that when she had it, she felt dizzy. Sensible Medicine is a reader-supported publication. If you appreciate our work, consider becoming a free or paid subscriber. Many a medical trainee has been humiliated on morning rounds after proclaiming that their presentation was wanting because the “patient was a poor historian.” Any attending worth her white coat will respond in one of the following ways: “There are no poor historians, just poor history-takers.” “You do realize, don’t you, that the patient is not the historian? You are the historian.” “Did you consider the differential diagnosis of why you were unable to obtain a useful history?” I admit that, going for pith over constructive criticism, I employ the former two more than the latter one. There is a differential diagnosis for the patient who cannot describe the history of their medical concerns. Often, the inability of a doctor to obtain a history is actually a physical exam finding – an extremely non-specific finding, but a finding nonetheless. Psychiatric disease, dementia, and delirium (whose differential diagnosis itself is practically a textbook of medicine) will render a patient unable to provide an accurate history. I can recall dozens of “poor historians'' who became Robert Caro-esque once their hypercapnea, uremia, or alcohol withdrawal was treated. There are three other reasons that obtaining reliable and informative histories might be a struggle. 1.      We think with language The first — the saddest, most troublesome, and probably most common – reason that patients are unable to provide a reliable history is because of their impaired language skills. Not only do we use language to communicate, we also use language to think. George Orwell wrote, “…if thought corrupts language, language can also corrupt thought.”[i] Those of us who failed to master language, usually through inadequate education, are unable to express their health concerns clearly. Sometimes, listening to a patient try to describe symptoms, I get the sense that the problem is more than expressive. BW was not an especially striking example of this for me, she was just one of the more recent. She also presented with a problem for which an accurate history is critical. The history of a patient's dizziness radically alters the differential diagnosis. We teach trainees that the first question to pose to a patient with dizziness is, “What do you mean, dizzy?” We tell the trainee to ask the question and then sit back and listen. More often than not, patients will describe their dizziness in a way that can be interpreted as lightheadedness, vertigo, unsteadiness, or a non-specific feeling of being unwell.[ii] As I interviewed BW, my sense was that she not only struggled to articulate what she was feeling but to figure it out herself. Beyond my frustration in having trouble caring for her, I considered the lifelong impact of leaving people educationally impoverished. Sure, we limit people’s earning potential, but we also limit their internal life and their healthcare. 2.      Anxiety affects how we experience symptoms VG is a patient I have seen for years, from his mid 30’s to his early 60’s. He has a few very mild chronic medical conditions and very severe anxiety disorder. He is a successful professional but struggles with intermittent episodes of health-related anxiety. Our interactions usually begin with an email or a phone call. VG will have be