Listen to the patient history taken by my partner last night while admitting:
HISTORY OF PRESENT ILLNESS: Mr. B is a very pleasant 60-year-old male with extensive past medical history who presented for evaluation of extreme weakness. The ambulance reports that the patient had a witnessed fall while walking to the store to purchase some cigarettes. He states that he is currently homeless, but compliant with medications and follow-up with the clinic. He did not report any syncopal episodes, or chest pain, but does report significant shortness of breath.
It’s just the beginning of a story really, or perhaps the end of a long and complex story of a difficult life. Like any story, it conceals as much as it reveals, a mystery. This snippet already lets the doctor start sifting through medical possibilities, thinking of other questions to ask, or tests to run. The focus on the patient’s story has led to the modern methodology of “narrative medicine,” with its attendant conferences, schools and papers. Narrative medicine is nothing new really; the doctor’s job has always been to listen to the patient and to be a witness, and to show empathy by somehow connecting to the story that the patient tells. Even the most technical of the subspecialties listen to patient stories: surgeons, electrophysiologists and interventional radiologists. And those of us in more holistic specialities, we have made this our bread and butter. For better or worse, doctors are often evaluated by patients nearly entirely based on our ability to listen and empathize.
HISTORY OF PRESENT ILLNESS: Mr. X is a 70-year-old man without known cardiac history who was transferred here for management of ventricular fibrillation arrest. This morning the patient was loading boxes into a truck and went back into the house. His daughter heard a crash and found the patient on the floor, unconscious and unresponsive. The history was obtained from the patient’s family and daughter who lives with him. Per brother’s report, patient had been complaining of left shoulder pain for the last few weeks. He does not seek medical attention and has not seen a doctor for many years. Apparently 5 years ago he saw any eye doctor who told him that he needed to see a primary care physician based on the findings in his eyes.
In this case, Mr. X does not tell his own story. In fact, in some sense, none of us may ever tell our own stories. People use the cultural baggage that they inherit in order to make sense of the events of their lives, and this “baggage” actually determines the course of the story. Nowhere is this more evident than in medicine. We are a culture currently obsessed with “health” and medical advances. All my patients have filtered their health experiences through a myriad of lenses before I hear about them: grandmother’s herbal tea, House MD, and so so many others. We all tell filtered stories, and the physician’s job is to be the literary critic and detective.
Taking relatively undifferentiated symptoms, and preconceived notions, and weaving these into a medical story is the skill that distinguishes a master clinician. At its best, it is what makes primary care so exciting, because nowhere else are we exposed to raw stories prior some other clinician’s interpretation.
If we wish to know about a man, we ask “what is his story – his real, inmost story?” – for each of us is a biography, a story. Each of us is a singular narrative, which is constructed, continually, unconsciously, by, through, and in us… (Oliver Sacks)
When I have medical students on my service, we often spend time reviewing pathophysiology, but even more time may be spent teaching how to construct the patient’s story. Medical students quickly learn to assemble “facts,” such as blood pressure, symptoms and lab values. But not until they start to create a plausible narrative with the facts do they become doctors. Sometimes this is called the art of medicine, as opposed to science, but it is also true that “scientific reasoning often makes use of causal narratives.” (Solomon) In some ways, doctors function as the close readers of books, matching patterns against what we have already read.
Alas, as clinicians there is a hard edge to our stories. The stories the patient tells, and then the ones we tell, do not always harmonize with actual events. Even more concerning are the selective memories that we hear every day, the downplaying of drug use, and the dissembling in order not to alarm family members.
Humans are… in general susceptible to the ‘narrative fallacy’ in which the attempt to weave experience into a coherent story results in the omission of facts, or even in their (intentional or unintentional) distortion or fabrication.” (Solomon)
Doctors are not immune to the narrative fallacy. In fact, in order to ‘package’ a patient into a “History and Physical,” “Progress Note,” or one of the other codified narratives that physicians use for communication, we are required to commit the narrative fallacy by assigning a diagnosis. We cannot complete a patient assessment of any kind without constructing this story. And the story must fit one of the accepted and routinized narratives that scientific medicine has authorized in its repertoire. In other words, we have to assign one or more diagnoses, and these diagnoses are always the conclusion of the story that we construct.
This narrative urge ties directly to the case-based, practical, knowledge of the doctor. Physicians are not scientists, we are a humanistic profession and would starve without a constant diet of stories. However, perhaps not all illnesses should fit a narrative. Chaos and its acknowledgement might serve medicine’s interest from time to time. But I’m unlikely to let that happen; it’s what I am paid to do, commit the narrative fallacy. I’m hooked. There are three patients waiting in the emergency department. Let me tell you about the first one…
Charon, Rita. Narrative Medicine: Honoring the Stories of Illness. Oxford University Press, 2006.
Solomon, Miriam. Making Medical Knowledge. Oxford University Press, 2015.
Sacks, Oliver. The Man Who Mistook His Wife for a Hat. Touchstone, 1998.