Narrative Based Medicine: Dialogue and Discourse in Clinical Practice (review)

Trisha Greenhalgh and Brian Hurwitz, eds. Narrative-Based Medicine: Dialogue and Discourse in Clinical Practice. London: BMJ Books, 1998, xvi + 286 pp. Paperback, $35.95.

From the title and the baroque frontispiece showing a grave physician observing an indolent, perhaps lifeless child, it is easy to imagine that this text contains a series of essays written by and for literary critics and medical sociologists. In actuality, most of the twenty-nine essays in this rather eclectic collection are written by clinicians of one type or another and are intended for readers with little practical experience in discourse analysis. Indeed, as the two co-editors reveal in the final chapter, neither has any formal training in narrative analysis, nor any special training in literature.

In addition to serving as a handy resource for clinicians and medical educators, this volume appears to have two primary objectives: 1) to demonstrate the diagnostic and therapeutic value of narrative; and 2) to demystify scientific or evidence-based medicine (ebm) without arguing in extremis that positivist and interpretive/hermeneutic approaches to knowledge or patient care are irreconcilable. These arguments are set forth best in two essays: an illness autobiography or pathography written by the renowned paleontologist Stephen Jay Gould (chapter 3); and a more philosophical essay written by Trisha Greenhalgh, one of the co-editors (chapter 24).

Gould retells the story of his diagnosis with an abdominal mesothelioma, a rare and deadly cancer that is generally related to asbestos exposure. Although Gould is curious to learn more about his affliction, his physician disingenuously remarks that there is little in the medical literature worth reading. Gould soon learns why. Searching the medical literature he discovers that the median mortality for patients with this disease is eight months. However, after recovering from the initial shock of this discovery, Gould uses his knowledge of statistics and variation to create a more comforting, more hopeful scenario. He discovers that he possesses all the characteristics that would allow him to be on the right half of the curve (e.g., relative youth, good health care, early discovery) and that the curve is strongly right-skewed with a long tail. He may, in fact, have many years of good health in front of him. Unlike many other mesothelioma sufferers, he is also aware that the clinical trial he is participating in may ultimately shift the whole distribution to the right, increasing the median mortality and the right tail significantly.

While Gould is clearly a champion of scientific medicine and recognizes the dilemma of physicians who believe that the scientific information they possess may undermine the patient's outlook, the essay contains important lessons for those spellbound by evidence-based medicine. Gould's story not only highlights the primacy of interpretation and context, but also serves as a reminder that patients will obtain information and form judgements about their condition, that failure to be frank with patients will simply undermine their trust, that a naive understanding of statistics may cause more harm than good, and that ebm should serve patients as well as doctors. Above all, Gould demonstrates to his physician that even a dire medical predicament may have a silver lining.

In the latter essay, Greenhalgh, who in other venues has written essays in support of evidence-based medicine, attempts to deconstruct ebm by arguing that what physicians do is actually quite different than what they think they do. She begins by noting the failure of medicine to obtain reproducible results, one of the cannons of positive science. Citing Sackett, a leading proponent of ebm, Greenhalgh notes that whenever the diagnostic acumen of different physicians is measured, there is always significant disagreement. Even for routine clinical procedures, clinical agreement occurs only about fifty percent of the time. Thus, argues Greenhalgh, "[T]he evidence itself supports the claim that doctors do not simply assess symptoms and physical signs objectively; they interpret them by integrating the formal diagnostic...