Patient Stories, Doctor Stories, and True Stories: A Cautionary Reading

^Patient Stories, Doctor Stories, and True Stories: A Cautionary Reading Nancy M. P. King and Ann Folwell Stanford Over the past twenty years, medicine and medical education have increasingly—and commendably—emphasized the importance of treating the whole patient and the importance of listening to stories as ways of understanding patients and their illnesses more fully.1 This emphasis has allowed physicians to rethink what can (and frequently has) become primarily a technical practice and to return to the healer's values once characteristic of general practitioners but newly recognized as effective across specialities. As Arthur Kleinman observes, talking with patients about their particular experience of illness becomes a kind of "witnessing ," an encounter that helps patients "to order that experience" and one that "can be of therapeutic value."2 What George L. Engel first termed in 1977 the "biopsychosocial model" of health and illness is slowly replacing the biomedical model as the dominant explanatory model in Western medicine.3 This model permits and encourages physicians to take into account the many critical factors in patients' lives and health that go beyond the purely mechanical or chemical. Howard Brody, Arthur Kleinman, Eric J. Cassel, and many others have argued that factors such as stress and social support, economic realities, the psychological impact of illness, and the like can all be addressed in the care-giving relationship through this model, and that attention to such factors can significantly affect health.4 In many respects, the biopsychosocial model is a medical breakthrough; in other respects, it reflects timeless knowledge of the relationships among mind, body, and the healer's art.5 For patients, the explanatory model adopted by their care-givers delimits the care-giver's intrusion into private realms. In many cultures, for example, healers have access to patients' dreams, family quarrels, and spiritual lives without necessarily being afforded the full range of Literature and Medicine 11, no. 2 (Fall 1992) 185-199 © 1992 by The Johns Hopkins University Press 186 STORIES: A CAUTIONARY READING physical intimacy characteristic of Western medicine. In American culture , few, if any, people have as much license with the patient's body as the physician, yet the American notion of privacy—especially psychic privacy—is extremely strong. The biomedical model takes physical intrusion , no matter how great, as a given; the biopsychosocial model seeks to add to that a corresponding mastery of nonphysical information about patients. This extension of the physician's "reading" of the patient, from the patient's body alone to the patient's psychic and personal life as well, can be just as invasive as access to patients' bodies. For some patients, nonphysical intrusions are much more invasive than their physical counterparts. It is therefore necessary to ask whether this kind of reading is compatible with respect for the autonomy of patients. We believe that, although seeking the "whole story" is not inherently paternalistic , unless careful attention is given to the gathering and interpreting of information, the process can simply become paternalism in modern dress. The attempt to understand patients' stories is similar to the interpretive difficulties readers encounter in literary texts. What (and how) does the story "mean" and how do we know? In this essay, we attempt to map out some of the ethical issues that arise in obtaining information about patients, particularly when using methods predicated on a biopsychosocial model. We are especially interested in the problematic arena of interpreting or reading such data. We adumbrate these issues in our own readings of two literary texts—one that demonstrates possible misreadings , and thus abuses, inherent in what we are calling a monologic encounter, and one in which the encounter begins to move from monologic to dialogic and hints at the rich possibilities of the latter.6 Obtaining Information: Patient Stories and Moral Conflict A well-liked and respected family physician describes to friends one of the ways he learns about some of his patients: he obtains invitations to their homes and, once there, seeks the bathroom, getting "lost" on the way. This enables him to see as much as he can of the house and to examine the contents of the bathroom and medicine cabinet. He thus gathers information about...