Doctors' Stories: The Narrative Structure of Medical Knowledge

By Kathryn Montgomery Hunter

A patient's job is to tell the physician what hurts, and the physician's job is to fix it. But how does the physician know what is wrong? What becomes of the patient's story when the patient becomes a case? Addressing readers on both sides of the patient-physician encounter, Kathryn Hunter looks at medicine as an art that relies heavily on telling and interpreting a story--the patient's story of illness and its symptoms.

• Language: English
• Publisher: Princeton University Press
• Release date: Jun 30, 2020
• ISBN: 9780691214726

Book preview

DOCTORS’ STORIES

DOCTORS’ STORIES

THE NARRATIVE STRUCTURE OF

MEDICAL KNOWLEDGE

Kathryn Montgomery Hunter

PRINCETON UNIVERSITY PRESS

PRINCETON, NEW JERSEY

COPYRIGHT © 1991 BY PRINCETON UNIVERSITY PRESS

PUBLISHED BY PRINCETON UNIVERSITY PRESS, 41 WILLIAM STREET,

PRINCETON, NEW JERSEY 08540

IN THE UNITED KINGDOM: PRINCETON UNIVERSITY PRESS,

CHICHESTER, WEST SUSSEX

ALL RIGHT RESERVED

LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA

HUNTER, KATHRYN MONTGOMERY, 1939–

DOCTORS’ STORIES : THE NARRATIVE STRUCTURE OF MEDICAL KNOWLEDGE/

KATHRYN MONTGOMERY HUNTER.

P. CM.

INCLUDES BIBLIOGRAPHICAL REFERENCES (P. ) AND INDEX.

ISBN 0-691-06888-7

ISBN 0-691-01505-8 (PBK.)

1. MEDICAL EDUCATION—PHILOSOPHY. I. TITLE.

R737.H78 1991 90-9072

610'.1—DC20

eISBN: 978-0-691-21472-6

R0

In memory of TSM and LMR

It is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patient himself.

(Sir William Osler)

. .. no ideas but in things—

(William Carlos Williams)

CONTENTS

PREFACE xi

ACKNOWLEDGMENTS xv

Introduction: Interpreting Medicine xvii

PART ONE: MEDICINE AND INTERPRETATION

ONE

Knowledge in Medicine: Reading the Signs 3

TWO

A Science of Individuals: Medicine and Uncertainty 27

PART TWO: NARRATIVE IN MEDICINE

THREE

The Representation of the Patient 51

FOUR

There Was This One Guy . . . : Anecdotes in Medicine 69

FIVE

Writing Up the Case: Charts and Case Reports 83

SIX

An N of 1: Clinical-Pathological Conferences and Syndrome Letters 107

SEVEN

Patients, Physicians, and Red Parakeets: Narrative Incommensurability 123

EIGHT

A Case for Narrative 148

NOTES 175

INDEX 199

PREFACE

ISTUMBLED on the interpretive nature of medicine through my own need to make sense of the knowledge necessary to practice medicine. Although this study grows out of more than a decade of teaching in three medical schools and observing in several more, I began teaching medical students in the company of biologists. I was an English professor, an outsider, on the faculty of the Morehouse Medical School, a new school designed to grow along with its students by adding a year of instruction each year. We had no hospital, no clinic, and therefore no patients. Except for cardio-pulmonary resuscitation, human behavior, and the medical humanities courses I taught, our curriculum was the traditional one established at Johns Hopkins and confirmed by the Flexner Report at the beginning of the twentieth century. ¹ Until quite recently this curriculum prevailed in almost all of the more than 120 American medical schools, and, even after the Association of American Medical Colleges’ report on the General Professional Education of the Physician (GPEP), ² it remains the fundamental pattern. Because there is not much real doctoring in these first two years—students do not see patients until their third-year immersion in clinical work—the beginning faculty included few physicians. With the exception of the pathologists, we were Ph.D.’s: anatomists, biochemists, histologists, physiologists, pharmacologists, psychologists, microbiologists, and one literary scholar.

I had taught for ten years at Morehouse College, which courageously had begun this medical school, and, because it was a small liberal arts institution, I had always known scientists. Several years before, the chair of the physics department and I had taught an experimental course in observation and description. More recently in the freshman honors program, I had offered a course called The Evolution of the Idea of Evolution. A number of my students went to medical school, and soon I was a member of the committee that drafted the faculty’s composite letters of recommendation. From there it was a short step to joining my colleagues engaged in planning a medical school. I chaired the committee that studied the inclusion of the humanities and the social sciences in the curriculum.

The humanities were a new part of medical education in the mid-1970s. My assignment was to design and staff the course included in the curriculum in each of the first two years.³ Drawing on philosophy, literature, anthropology, sociology, religious studies, history, and law, such courses offer first- and second-year students an opportunity to think about and try on the moral and professional lives toward which their education is propelling them. After some initial skepticism—curriculum time is every medical school’s scarcest, most valued commodity—most of those whom medical education labels basic scientists were relatively comfortable with—and some were stimulated by—the presence of such odd people as philosophers, historians, lawyers, and sociologists teaching about medicine. In its third year, having proven itself successful, the school received permission from the Liaison Committee on Medical Education to admit larger classes and to begin planning for the years of clinical instruction. As it happened, I left just before the physicians arrived.

I went next to the University of Rochester School of Medicine and Dentistry. There I found an older, larger, altogether grander place, recognized for the number of scientific research grants it garners in a highly competitive world and for its curricular attention to the psychosocial aspects of illness. I was presumed to be experienced, but though I knew a great deal about medical education, I knew very little about academic tertiary-care medical centers. I did not expect to be comfortable. Here were physicians, subspecialists, superscientists. The size of the school alone—with classes four times larger than the first classes at Morehouse—seemed to promise a certain degree of alienation. Above all, the two last, clinical years of medical school and the presence of hundreds of interns and residents in the adjacent and affiliated hospitals made this not simply a school but a center for clinical research and highly sophisticated medical care.

My first task there, after my teaching, was to understand this strange territory. An education in English literature and literary theory did not promise to be much help. To remedy my ignorance, I went to seminars that reported on clinical research and to weekly grand rounds that concerned an interesting or problematic clinical case. I began with those whose titles I could understand, ones that had a clinical focus. I wanted to know how research into clinical problems was carried out: how were the problems understood and solved? Above all, I hoped to understand how those years of education in the sciences of human biology were preparing students to solve problems in clinical practice.

The research seminars I attended were given by careful investigators who used sound methods and focused on real problems, often with quite important results. Yet the presentations, I noticed, were not quite like a journal article on the same question. Again and again, regardless of clinical discipline—usually near the end of the presentation or early in the question period—I heard an account of the case that had first revealed to the investigator the existence of a clinical problem that was open to research. There was this one guy . .., the speaker might explain, beginning a narrative of the signal case, the instance that had provoked first the investigator’s curiosity and then the research. For grand rounds, I realized, the order is reversed: this weekly ritual in each of the clinical disciplines begins with a presentation of a case, considering first the individual patient who poses a difficult question of diagnosis or therapy, and then moves to a discussion of research, often the speaker’s own, which has led—or should lead—to a clear, more readily made diagnosis or to a new method of treatment.

Whatever the occasion, whether the case was introduced informally in seminars or presented with routine formality in grand rounds, the method of presenting the data of clinical science was familiar to me. The substance was necessarily new—puzzles made up of reported symptoms and observed and measured signs—but the accounts of a patient’s malady and the physician’s diagnosis and treatment were the stuff of my own discipline.⁴ They were stories, narrative accounts of the action and motives of individual human beings, physicians and patients, who, variously, were frustrated by circumstance, rewarded for effort, and plagued by fate. Stories had been the last things I had expected to find in a medical center. Isn’t medicine a science? Aren’t such stories mere anecdotes?

I discovered that the theory and methods of understanding that are traditional to the humanities are useful in understanding what it is that clinicians do. In 1983, with a grant from the National Science Foundation, I undertook a project that has itself been an interpretive activity: the understanding of medicine. Daily for two years and in three hospitals I followed willing colleagues on work rounds, to morning report and professors’ rounds, to sign-out rounds and problem conferences, to morbidity and mortality conferences, and to grand rounds. During that time (and later when I observed elsewhere or returned to renew my observations) I behaved rather like an ethnographer among a white-coated tribe, observing the clinical education of medical students and house staff in internal medicine and surgery. I attended all teaching occasions repeatedly and then sampled them again in subsequent years while I wrote. For two years I was a regular fixture. I was an outsider, far more observer than participant, but then academic medicine is rife with observers. I was known to faculty and residents as a professor in the medical school located in the same cluster of buildings. I had taught at first a few and ultimately most of the third-year students who joined the hospital units for their clerkships. I did not wear a white coat. On those occasions when I went with a group to the bedside, I was introduced by name and title and task ("She’s studying us), and the patient’s permission was sought. My project was understood as a study of the way medicine is taught and learned, and it was generally known (and important in a research institution) that, although my field was literature (wasn’t it?), I had been funded by the NSF. Few were curious about the study’s details or its hypothesis. They assumed (or so it seemed to me) that I was simply around, backstage," getting a preliminary sense of doctoring before turning to what, given the school’s emphasis and the courses I taught, was probably the object of my study: the interaction between patient and physician. They were not entirely wrong.

My focus was on the interaction between physicians teaching and learning to take care of patients, sometimes both at once. I listened for literary phenomena: metaphors, absence of metaphor, jargon and its uses, stories in all their variety, narrative themes. I had questions (refined, as I went, into hypotheses) about how knowledge is acquired and how teaching takes place, about the process of professionalization, the effect of the academic hierarchy, and the almost unquestioned assumption that medicine is a science (and the unquestioned uses of that assumption). I took occasional notes, doodling two or three key words on a styrofoam coffee cup. After rounds, I raced back to my office to make a full entry in notebooks that I indexed as I went along. I tape-recorded sessions of morning report. Only one faculty member and two residents were told that I was particularly listening for stories, and in medicine that word suggests anecdotes rather than routine case presentations. I tried ideas out on these and other informants among faculty, house staff, students. At times the apparently inevitable process of going native set in. I would realize that for the past few days I had been listening like one of them for the telling fact, waiting to clinch the diagnosis. The antidote was to change location or specialty and become a thorough outsider again. I enjoyed the idea that my research involved much the same interpretive process that I was discovering to be essential to the physicians’ understanding of patients.

ACKNOWLEDGMENTS

THE CONSTRUCTION of this account of medical narrative has been enriched by my family and friends and colleagues. Those who know something of the history of attention to patients in American medicine and the investigation of the psychosocial issues that complicate their illnesses and their medical care will recognize the influence of the University of Rochester. While I was still at Morehouse, David Satcher lent me The Clinical Approach to the Patient, an influential guide to the patient-physician encounter by Rochesterians William L. Morgan, Jr., and George L. Engel. Once there, I incurred debts that are numerous and great. Throughout the years of my research, my colleagues were unfailingly helpful, subjecting me to little more than a bracing modicum of skepticism about literature’s place in understanding medicine. I owe my clinical education especially to Robert L. Berg, Lynn Bickley, Cecile A. Carson, Jules Cohen, Christopher Desch, William R. Drucker, David Goldblatt, William A. Greene, Robert J. Joynt, Rudolph J. Napodano, William L. Morgan, Jr., John Morton, Jr., W. Scott Richardson, John Romano, the late Ernest W. Saward, Olle Jane Sahler, Barbara L. Schuster, Seymour I. Schwartz, and T. Franklin Williams. Craig Hohm, then a third-year resident, was my Aeneas during the first year of clinical observation. Lewis White Beck and Jane Greenlaw were dear and unfailing sources of advice and criticism and encouragement.

At other institutions Howard Brody, Eric J. Cassell, Rita Charon, Julia E. Connelly, Daniel M. Fox, William Frucht, Robert Kellogg, Loretta Kopelman, Joseph Margolis, John Stone, Carolyn Warner, and William Beatty Warner variously argued about ideas, read chapters, or took me on rounds. Anthropologists Joan Cassell, Ayala Gabriel, and Grace Gredys Harris provided essential guidance in the methods of ethnographic research. In the faculty study group on social theory at Rochester I learned much that was useful; I am particularly grateful to William Scott Green, Donald Kelley, and Philip Wexler. I learned, too, from the ideas and observations of those who were then students and residents at Rochester and in the summer humanities seminars for medical students funded by the National Endowment for the Humanities at the Kennedy Institute, Georgetown University; chief among them were Holly Anderson, Emily Finkelstein, Stephen Matchett, Barry Saunders, and Brian Zink.

I am indebted to the Hastings Center, especially to Daniel Callahan, Thomas Murray, Arthur Caplan, and Marna Howarth, for the time I spent there as a visiting scholar near the beginning of this project. A two-year grant from the Ethics and Values in Science and Technology program of the National Science Foundation (RII-8310291) funded my research, and a fellowship from the American Council of Learned Societies and a sabbatical from the University of Rochester in 1986–87 gave me a welcome year to write. Ellen Key Harris, Pelin Aylangan, Elizabeth Gajary, and Jennifer Powell helped with research, and Lucretia McClure, librarian of the Edward G. Miner Library, and Christopher Houlihan, its history of medicine librarian, lightened my work. In Chicago I have benefited from a community of scholars from several institutions, especially James F. Bresnahan, my colleague at Northwestern University Medical School, Christine Cassel, William Donnelly, Leon Kass, and Suzanne Poirier. Charles L. Bosk, Julia Connelly, Ellen Key Harris, J. Paul Hunter, Lisa Hunter, Steven H. Miles, Beth Montgomery, and Francis A. Neelon read many of the chapters in draft and made indispensable suggestions. I have learned from presenting some of its ideas informally to members of the Camellia Grill Literary and Debating Society and, beginning in 1983, at meetings of the Society for Health and Human Values and its Association for Faculty in the Medical Humanities.

Long projects have a way of becoming indistinguishable from one’s life, and I am grateful to all those who have shared mine.

A version of Chapter Two originally appeared as A Science of Individuals: Medicine and Casuistry, Journal of Medicine and Philosophy 14 (1989), 193–212. © 1989 by Kluwer Academic Publishers.

A version of Chapter Four originally appeared as ‘There Was This One Guy . . .': The Uses of Anecdotes in Medicine, Perspectives in Biology and Medicine 29 (1986), 619–30. © 1986 by The University of Chicago.

Part of Chapter Six originally appeared as "An N of 1: Syndrome Letters in the New England Journal of Medicine" Perspectives in Biology and Medicine 33 (1990), 237–51. © 1990 by The University of Chicago.

A number of the ideas and phrases in Chapters One and Two first appeared in The Physician as Textual Critic, The Connecticut Scholar: Occasional Papers of the Connecticut Humanities Council 8 (1986), 27– 37. © 1986 by the Connecticut Humanities Council.

INTRODUCTION

INTERPRETING MEDICINE

Students of criminology will remember the analogous incidents in Grodno, in Little Russia, in the year ’66, and of course there are the Anderson murders in North Carolina, but this case possesses some features which are entirely its own. (Sherlock Holmes to Dr, Watson, The Hound of the Baskervilles)

THE PRACTICE of medicine is an interpretive activity. It is the art of adjusting scientific abstractions to the individual case. The daily life of a practicing physician is made up of observing, testing, interpreting, explaining as well as taking action to restore the patient to health. Much of this is routine, the exercise of clinical judgment that has been acquired, first, by a thorough education in human biology and, then, by participation in the care of a myriad of single cases that are narratively described and studied one by one. The details of individual maladies are made sense of and treatment is undertaken in light of the principles of biological science. Yet medicine’s focus on the individual patient, fitting general principles to the particular case, means that the knowledge possessed by clinicians is narratively constructed and transmitted. How else can the individual be known?

Medicine, for all its reliance on esoteric knowledge and sophisticated technology, is not a science. This ought not to be a controversial or even a surprising statement, yet many physicians are likely to find it unacceptable. In the twentieth century, science and the ideal of scientific rationality have played such an important part in medical education and the care of patients that they are now central to our idea of the profession. Scientific advances have given us an almost unassailable confidence in medical efficacy. Epidemiologists and historians of medicine have demonstrated that it was not medicine that improved health and lengthened life in the late nineteenth century but a more productive agriculture, pure water supplies, improved hygiene, and population control.¹ In our own time the incidence of heart disease in the United States has been lowered not by the ingenious techniques of cardiac surgery but by a striking alteration of habits. Yet this epidemiological view of history does not capture our sense of medicine’s importance in our lives. The achievements of public health and preventive medicine are faceless generalities. Our faith in medical science rests on particular cases, which are far more vivid and compelling. We know people, often close to us, who have been saved by physicians. Even those of us who thus far have been healthy have led lives altered for the better by medicine: antibiotics cure infections; microsurgery repairs a damaged knee; syphilis, polio, and smallpox are rare or extinct; pacemakers, artificial heart valves, laser beams, and birth control pills have given us lives different from those our grandparents lived. Not even medicine’s severest critics would be willing to return to the good old days.²

A drawback to such progress, however, is that we have unthinkingly assimilated medicine to other intellectual advances of the twentieth century. We have given our faith to science, and medicine’s importance to us and its twentieth-century success have led us to believe—physicians as well as patients—that medicine is itself a science. The circumstantial evidence is strong. Physicians have spent years learning the minuscule details of human biology. Some of them conduct scientific research. They use intricate machines designed in accordance with scientific principles to detect and treat disease and physical malfunction. They wear white coats as a sign of their professional objectivity. They prognosticate, knowing truths about our bodies that we ourselves cannot (or have not yet begun to) experience. Above all, they are familiar with death and are fearless and rational in its presence. Most of us will learn from one of them how and approximately when our lives will end. In a culture that shrinks from death and has few ways other than medicine of coming to terms with finitude, physicians are set apart by their education and experience. Science serves as the sign of their special knowledge.

Nevertheless, no matter how scientific it may be, medicine is not a science as science is commonly understood: an invariant and predictive account of the physical world.³ Medicine’s goal is to alleviate present suffering. Although it draws on the principles of the biological sciences and owes much of its success to their application, medicine is (as it always has been) a practical body of knowledge brought to bear on the understanding and treatment of particular cases. We seek more from a visit to the doctor than the classification of our malady. We want our condition to be understood and treated. Face to face with a patient, physicians can know disease only indirectly. They depend for its identification on their interpretation of the signs they observe and the story of symptoms the patient tells them. They are barred by ethics and by the chronology of post hoc investigation from many forms of experimental investigation. Instead, like Sherlock Holmes, they must begin with the effects of illness and reason backward to the causes of disease. They cannot offer us a diagnosis, much less cure or palliation, until they have accounted for the symptoms and signs we present to them.⁴ Thus, modern medical practice is founded on an arduous scientific education augmented by formidable diagnostic machinery, but interpretive skill is inevitably required for physicians to work even their everyday wonders.

This distinction between interpretive and scientific knowing is not invalidated by the fact that it is given little attention in medical practice and is seldom made explicit in medical education. The limitation of medical knowing is not a new philosophic insight. Two hundred years ago, the necessary retrospection of medicine’s knowledge—what Sherlock Holmes describes to Watson as reasoning backward along the chain from effect to cause—was described by David Hume and the Marquis de Condorcet, each in his different way concerned with the legitimacy of knowledge that is based on observation and therefore lacks deductive certainty. In his essay Du Degré de certitude de la médecine (1798), Pierre-Jean-George Cabanis, physician and philosopher, recognized that in clinical medicine inductive reasoning is inevitably flawed, but argued nevertheless for the relative, probable, practical certainty that medical therapy might achieve through careful observation, rational classification, and experimental testing.⁵ In our time, the immensity of its relative, probable, and practical success has often obscured our understanding of medicine as an intellectual pursuit or as the exercise of practical wisdom in the face of uncertainty.

Despite its success, medicine’s identification as a science has had adverse effects on both the education of physicians and the patient-physician relationship: the two are not unrelated. Our misunderstanding has led to mistaken expectations on the part of both physicians and patients and, ultimately, to less than optimal care of the ill and to impoverished lives for physicians. It encourages physicians and patients alike to focus narrowly on the diagnosis of disease rather than attend to what is even more necessary, the care of the person who is ill.

Misplaced expectations of medicine have not been solely responsible for the profession’s recent difficulties, of course. Contemporary impediments to the patient-physician relationship have been well described.⁶ The proliferation of technology used in the diagnosis and treatment of disease has driven the physician farther and farther from the presence of the patient.⁷ The knowledge explosion in human biology has meant that a thorough comprehension of any one of its fields could easily occupy a career—and leave little time for the care of patients. The welter of contemporary economic arrangements estranges patient and physician and encourages distrust on both sides; malpractice suits and defensive medicine viciously circle. Underneath it all, however, the mistaken idea of medicine as a body of objective, scientific knowledge that has only to be mastered to bring reliable results impoverishes both medical education and medical practice. It has deprived students of the generative attention of mature practitioners and all physicians of a well founded appreciation of the case-based, skeptical method by which they have achieved so much. About this fundamental misunderstanding, it has seemed to me, something could be done.

What is needed is a conception of medicine, both inside the profession and beyond it, that not only takes account of the physician’s daily work of diagnosing and treating illness but also acknowledges its well-developed narrative method of acquiring and conveying its essential knowledge. Medicine is an interpretive activity, a learned inquiry that begins with the understanding of the patient and ends in therapeutic action on the patient’s behalf. Far from being objective, a matter of hard facts, medicine is grounded in subjective knowledge—not of the generalized body in textbooks, which is scientific enough—but the physician’s understanding of the particular patient. The interpretive task of medicine is made explicit in the language of radiology: You’ll receive a separate bill from the radiologist for the interpretation of the X rays, we are told at the cashier’s window of countless American hospitals. There is a palpable text, the roentgenogram, for a physician to read. But the rest of medicine is little different, for the body, too, is palpable—and palpate it physicians do, looking for lumps and swellings, appreciating the distance the liver extends beyond the rib cage, detecting suspicious tenderness. The interpretation of the individual patient’s physical signs in order to construct a coherent and parsimonious retrospective chronological account of a malady is a methodology that, while thoroughly rational, is distinct from that characteristic of the physical sciences. That physicians are scientifically educated and technologically trained alters not one bit the narrative structure of their practical knowledge. Indeed, the physician’s own subjectivity as well as the subjectivity of the patient is controlled by the fixed conventions of medical narrative.

This study advances such an interpretive conception of medicine, describing the use of narratives by physicians to learn and to teach, to record familiar maladies, and to investigate and report unfamiliar ones. It is not a sociology of medicine. I have focused on academic medicine as it is practiced and taught in university medical centers and reported in the New England Journal of Medicine. As a consequence, I have not written about the political and economic realities of contemporary practice in the United States, important though I know them to be. American physicians are so varied and under such economic and regulative pressure that such a study would be a formidable task, one I am not qualified to undertake. Instead I have been concerned with medicine as it is taught and as physicians believe they should practice it. I have meant to describe medicine’s ways of knowing and its methods of transmitting that knowledge. Clinical medicine is the exercise of practical knowledge, medical education the inculcation of a craft. Despite its reliance on dozens of heavy and expensive textbooks and thousands of scholarly journals, medicine is passed on as a traditional practice: interpretive, diagnostic, concerned with the identification and treatment of disease. The tradition works well in difficult or puzzling cases and is useful in advancing the knowledge of etiology and therapeutics, but it is insufficient for long-term patient care and for the cultivation of interest in the problems of general practice. Scientific advances augment and reinforce the diagnostic tradition; by contrast, chronic illness and dying tend to be uninteresting to many physicians because they do not.

My method has been ethnographic, describing the customs and habits and assumptions of medicine’s teachers and learners as I have observed them. In the academic medical center, medicine takes its most nearly idealized and scientific form, and its culture influences the rest of medical practice. Absorbed and internalized by every physician as student, intern, and resident, academic medicine remains the gold standard of practice no matter how irrelevant it may be rendered by real life in a small-town general practice, an inner-city clinic, or a suburban HMO. There are local variations in custom from one medical center to another and noticeable differences among specialties. But the remarkable thing is the relative uniformity of the culture of academic medicine. Students regularly take residencies at hospitals other than the one associated with their medical school, and their expectation that they will find clinical services much like those where they began their clinical education is seldom challenged. What little variation they find amounts to local color: whether case presenters may use notes or