I agree with most aspects of Dr. Donnelly's essay on questionable language of medical case histories [1]. Dr. Donnelly wonders why the seven practices (or maladies) continue despite extensive criticism. He cites two main reasons: that sickness is considered a matter of disordered biology and, accordingly, that physicians adopt the viewpoint and methods of natural scientists. Thus, he states that a conventional, biomedically oriented history of present illness just reflects the facts and that more attention should be paid to the patient's personal experience. In discussing the remedies to correct the language maladies, he suggests that a two-perspective history of present illness be incorporated-the biomedical perspective (disease) and the patient's perspective (illness). Both perspectives should appear in the medical case history as two separate narratives, from admission to discharge and in subsequent outpatient clinic visits.

Although such practices are probably used worldwide, they do not necessarily reflect what physicians do. In fact, large amounts of the patient's experience of illness are treated in off-the-record physician-patient talks. Thus, the problem is that the patient's perspective may not be transcribed but rather just discussed. In my opinion, an important reason that this sort of information is not recorded in the case histories is that, especially in a hospital setting, physicians simply do not have the time to do it. Most clinicians just get to the point; for that reason, we write "a 55-year-old patient" instead of "Mr. John Jones, a 55-year-old self-employed architect who lives with his architect wife ... ." Although the patient has his or her own ideas, feelings, and fears, he or she is in the hospital because a physiologic function is failing. Thus, when time is precious, the case history may describe the patient's illness primarily in terms of disordered biology because that is the main reason for hospitalization.

To save time, I suggest that such otherwise important information be tape-recorded. A two-perspective history of the present illness can be easily acquired in this manner: the hard history (biomedical perspective) and the soft history (patient's perspective). For example, the hard history entry would state, "sixth hospital day: do not resuscitate according to patient's decision"; the soft history would state, "sixth hospital day: today Mr. Jones has been told of his diagnosis and prognosis; he prefers only supportive measures at the end-of-life days." The soft history could be periodically updated as needed according to psychological events or changes. It could also be used in out-patient visits; for example, the cassette could be played back just before the patient comes to the office to remind the physician of the patient's perspective of illness, and an update could be recorded just after the patient's visit. In any case, each medical case hard history cassette would have to be accompanied by a corresponding patient's perspective cassette.

The more tools that can be used, the more prepared we will be to deal with patients' illnesses and perspectives.