"Is There a Person in This Case?"

r<* j*¡* "Is There a Person in This Case?" William Frank Monroe, Warren Lee Holleman, and Marsha Cline Holleman The clinical case report serves a fundamental role in patient care and medical education by organizing knowledge about a patient into a standardized form. Whether written or oral, the form is fixed and consists of the following elements: the chief complaint, followed by a history of present illness, past medical history, social history, family history, review of systems, physical exam, results of tests, assessment, and plan. To question or suggest altering the case report would be regarded by most physicians as trying to fix what's not broken. Yet some critics are challenging the worth of this sacrosanct form. We agree with those who argue that the case report uses and legitimates deleterious, even degrading , terminology, that it encourages hasty categorizations and excludes the voice of the patient. The form also emphasizes description (often numerical data) at the expense of storytelling and biomedical objectivity at the expense of empathy. In short, the case report has become the story of a mechanistic entity, a biomedical body. It seems fair, then, to modify a locution of Stanley Fish and ask, "Is there a person in this case?"1 There are ways to render the story of a person in addition to the story of a body.2 Promising suggestions for improvement have come from writers who apply insights from literary criticism and interpretation theory to the case report.3 The primary benefit of such critical theory is its revisioning of the patient as a cultural text rather than a biomedical body. Yet the cognitive, analytical mode delimits the value of critical theory for physicians, nurses, and other health-care professionals. By casting the patient as a text, the interpretive paradigm does not render the patient as a person. Thus, in the hope of building on the insights developed through literary criticism and interpretation theory, we want to suggest a performance paradigm, a way of thinking about patients and cases that would enrich and enliven the notion of textuality and narrative Literature and Medicine 11, no. 1 (Spring 1992) 45-63 © 1992 by The Johns Hopkins University Press 46 "IS THERE A PERSON IN THIS CASE?" re-presentation. Minds may know and be known by cognitions. But persons are enacted rather than known, enacted by performances with a story in mind. Before turning to recommendations, however, we should review the recent criticisms of the case report. I. Review of Recent Criticisms Deleterious Terminology Kenneth Burke says that "a way of seeing is also a way of not seeing."4 The way physicians see their patients and talk about their professional practice will necessarily preclude other ways of seeing, acting , and interacting. Thus an attentive concern for the language of the case report is crucial. Much has been said about the use of overtly hostile terms such as gomer and dirtball.5 Though these and other derogations are scrupulously edited from formal case reports, there are a number of less overtly offensive expressions that similarly undermine the physicianpatient relation and yet appear routinely. Even locutions such as "the patient complained of . . .," "the patient denied . . .," "the patient admitted . . .," "the patient is noncompliant," and "the patient failed therapy" can have deleterious consequences.6 Such language is a more tactful and accepted manifestation of the physician's desire to distance the patient and may bespeak the very antagonism communicated by overtly hostile terms such as gomer. Without intending to do so, the physician implies that the patient is a complainer, a malingerer, even a hypochondriac. Admittedly, to say "the patient denied having frequent headaches" is quite different from saying "the patient denied having anal intercourse" or "the patient denied heavy alcohol use." The latter statements suggest that the physician doubts the veracity of the patient and may imply that the physician suspects the patient of behavior that is medically or morally objectionable. To eliminate such connotations, the physician ought to substitute neutral expressions for the offending ones: "the patient reported," rather than "complained of"; "the patient stated that he [or she] did not [or does not]," rather than "denied"; the patient's "chief concern" or "worry," rather than "complaint." The term noncompliant, again, suggests an antagonistic relationship between physician and patient and casts the patient as a child or ward and the physician as a domineering parent or sovereign.7 Physicians should find ways to describe patients in the case report that Monroe, Holleman, and Holleman 47 enhance rather than erode the patients' responsibility and competence: "the patient disagreed with . . ."; "the patient did not understand [why] . . ."; or "the patient placed a higher value on χ than on y." "The patient failed therapy" suggests that the patient is at fault for not getting well. It also suggests an attempt by the physician to avoid or transfer blame, a reluctance to accept the role of comforter as well as healer, and a hubristic refusal to admit that the physician is a catalyst to the healing process rather than the causa sui. To call the patient "a poor historian" also assigns blame. This label provides a handy excuse for not uncovering relevant information and may also signal an irritation with patients whose stories are not easily translatable into the standard case-report form.8 Physicians may also seek to assign responsibility to the patient because they lack the requisite patience, diligence, or interpretive skills to be good historians themselves. When patients cannot or will not respond, as a result of, say, dementia or intoxication, physicians can avoid placing blame by stating their perceptions as directly as possible in the case report. For example: "The patient appeared to be intoxicated. I could not decipher his words, which were incoherent and barely audible ." If patients become, in the minds of their doctors, complainers, liars, or failures, then therapeutic care will surely imitate language. If patients are depicted as distractions or as intractable opponents in a conflict of wills, then we should not be surprised that lab reports are preferred to personalized patient histories, that paperwork, charts, and tests take precedence over bedside care. With such language the patient —rather than the illness—is designated the problem. We do well to remember that the language we use to render patients has the power to "commodity" physicians and medical care as well as patients, transforming physicians into ombudsmen and gatekeepers and making the practice of medicine a business or a technology rather than a healing profession. Objective Description at the Expense of Narrative The preference for the objective (the test) to the exclusion of the subjective (the history) has become solidly embedded in the culture of modern hospital practice. Also entrenched is the scientistic bias that history and narrative are inadequate or unreliable modes of communication about the biomedical conditions of patients. Description, especially when buttressed by quantifiable data, is more scientific, somehow more 48 "IS THERE A PERSON IN THIS CASE?" medical, than narrative: description (data) is "hard"; narrative is "soft." This bias is supported by the unexamined assumption that objective data are not only essential but also sufficient for the optimal diagnosis and treatment of an illness.9 The quest for objectivity should not be abandoned , but physicians should seek ways to acknowledge the full humanity of both their patients and themselves. Certainly individual feelings , beliefs, values, and desires are important in patient care, and these elements cannot be adequately rendered by the mode of description. There are human costs exacted by medicine's de facto marginalization of narration, and an actual case can be used to underscore them: The physician of a young man bedridden with AIDS ordered an MRI brain scan after the patient reported a constant headache. The scan showed no abnormality. The pain continued. More tests were ordered while the young man remained in the hospital. Two weeks later the physician happened by and discovered that the patient lay in bed with his neck completely flexed. He suggested that the patient adjust his posture. In 24 hours the patient's headache resolved.10 A thorough history, taken before the tests were ordered, could have saved the patient considerable time, anxiety, and money. Certainly, collecting clinical data is part of the culture of modern medical practice, but the physician is probably also motivated by the fear of missing something and the sense that there is no time to waste before running some tests. Perhaps the impulse to test and even to hospitalize are motivated by desire for the absent narrative. Tests, then, and their charted results, can be seen as substitutions made necessary by medicine 's narrative silence. The testing itself, however, far from a benign aspect of professional work, wastes a great deal of time —time that is the terminally ill patient's most precious resource. The case illustrates the deleterious nature of our overreliance on objective and quantifiable descriptions, especially as it manifests itself in a penchant for "running a few tests." We have cultivated a scientistic bias that presumes that history and narrative are inadequate modes of communication about the conditions of patients. Put more philosophically , we could say that medical professionals, by ignoring the case report's potential to function as a collaborative performance, repeat and reinforce the subject-object dichotomy that has vexed Western culture at least since Descartes. In an effort to be scientific rather than performative , physicians often reduce persons to objects and enhance the illusion that they can understand and care for their patients, to borrow Monroe, Holleman, and Holleman 49 the words of Ursula K. LeGuin, "without bias, without participation, without imagination and without moral concern."11 The result of an exclusive reliance on scientistic, abstract language is to render or "screen" a sick person, in Burke's sense, as merely a specimen or exemplum of a type of disease.12 A particularly candid junior medical student, when asked "What is a patient?" replied, "Some lab values on a chart." Distortions, Biases, Exclusions A third criticism, recently articulated by Laurence B. McCullough, is that the case report consists of abstract language masking as concrete.13 Physicians like to think of themselves as just-the-facts empiricists who are careful not to jump to conclusions. Instead, they often reduce persons to patients or even to instances of diseases and ignore many of the particularities that make each person's illness unique. We hear a person pigeonholed as an "obese black female, diabetic with hypertension" and immediately assume that she has poor health habits, is uneducated, passive, and not motivated to lose weight. Abstract language, used exclusively, abstracts the person out of the case. Physicians, then, ought to pay closer attention to that which is unique and resist the temptation to define patients as instances of general disease categories. The particular history, individual situation, and even the personality, or character, of a sick person should be acknowledged as important and rendered responsibly in the case report. Including observational and narrative material that is particular (and thus unlikely to be quantifiable) does not undermine the objective validity of the case report: a patient's demeanor, attitudes, affiliations, commitments, beliefs, values, desires, and expectations can all be considered without dismissive , pejorative, or demeaning language. Concrete descriptive details and specific, emplotted narratives should be included, not only out of respect for the patient as a person, but also because they may improve the patient's outcome. Consider the case of a man with groin pain who believes that his illness is a punishment from God for committing adultery . His version of the etiology, however unscientific, will almost certainly play a role in his recovery. Therefore, his beliefs and his narrative ought to be included, without condescension, in the case report. Many physicians exclude beliefs they regard as superstitions when rendering an illness; instead of describing the illness of a particular person, they use pseudoscientific, abstract-as-concrete language to shape and define the patient. 50 "IS THERE A PERSON IN THIS CASE?" Biomedical Brevity A related and final criticism makes use of literary theory to point out that case reports invariably involve interpretation, though we often presume that only facts are reported. In "Righting the Medical Record," William J. Donnelly observes that case reports are usually terse, empirical "chronicles" rather than fuller, fleshed-out "stories."14 These brief chronicles are presented without affect or interpretation, and in a "Mr. Spock mode" typically associated with the communication of hard facts and scientific data. Suzanne Poirier and Daniel J. Brauner note that during the delivery of the case report, the face and voice of the physician become expressionless. His speech is frequently rapid and businesslike. He uses passive verbs, avoids first-person references, and seldom names the patient.15 Donnelly argues that even such a bare-boned case report requires selection, interpretation, and ordering of information.16 H. Tristram Engelhardt shows that medical language is not merely descriptive and explanatory but also evaluative, that it shapes the social reality of the patient.17 McCullough goes further in claiming that not only the social reality, but also the individual reality, even the individual identity of the patient, is shaped by the physician's language.18 Because case histories are, in Donnelly's view, "made," not "taken," he asks physicians to view their task, not as the collection of medical data, but as the making, the construction, of a story.19 Furthermore, to make patients' stories good stories, physicians ought to incorporate the patient's own language into them. Physicians should encourage patients to express themselves in metaphorical as well as flat, literal language—to say, for example, "It feels like someone is pinching the inside of my shoulder joint with a pair of tweezers," rather than simply, "My shoulder hurts." Physicians ought also to elicit and describe the patient's feelings regarding his or her sickness.20 Larry and Sandra Churchill, as well as Donnelly, lament the fact that the contemporary style of case reporting systematically distorts or even excludes the patient's own account of his or her condition .21 Donnelly, however, does not consider the potentially problematic legal status of storified patient accounts. Without a large body of familiar precedents, vivid patient accounts may be interpreted in unpredictable ways by third parties. This concern does not justify ignoring the patient's story, but it does suggest the need for caution, for a thorough integration of the patient's characterization of his or her illness with the physician's, and for an analysis of the legal precedents, if any, regarding the status of self-diagnostic pronouncements by patients. Monroe, Holleman, and Holleman 51 Finally, Donnelly does not offer a full theoretical justification for the use of stories in a situation in which problem solving, not narration, is the primary objective. Howard Brody, concurring with Joanne Trautmann , argues that storytelling itself is a healing art.22 In other words, the stories exchanged between patients and physicians can actually exacerbate or relieve suffering. Richard Selzer has also made the point that the poet, not the surgeon, is "God's darling" because his words have the capacity to heal.23 If we agree that stories can help not only in diagnosis but also in the process of healing itself, then a rehabilitated case report would serve this healing process better. II. Rehabilitating the Case Report The Patient as Text The metaphor of interpretation or hermeneutics is useful for bringing to the case report new vocabularies and new modes of analysis: once the patient is seen as a text, he or she can be interpreted by using any number of methods familiar to literary critics but novel to physicians. Rita Charon, for example, wants doctors to learn better how to understand , interpret, and write patients' stories, and she suggests that physicians study literary criticism and contemporary narratology. Charon argues that such study would help physicians by teaching them to become better, more capable and confident interpreters of patients' accounts of illness.24 We need to move carefully, however, as we consider alternatives to or enhancements of the traditional case report. The underlying problem is not solved merely by substituting literary or philosophical vocabularies for familiar biomedical terms. A physician who wants to become a better storyteller can spend time more profitably by reading stories than by reading literary theory or hermeneutics. Specialized knowledge, whether in the literary or biomedical realm, will not help physicians temper their role as experts, and the experience of illness—its intransigent reality—is often obfuscated by expertise. Common images of physicians —adventurers, detectives, heroic warriors, experimental scientists —imply that a medical encounter is an opportunity for discovery, conquest, or victory. Such images evince the need for excitement, acquisition , and competition, for the chase and the capture. Imaging medicine as an encounter between physician-reader and patient-text does 52 "IS THERE A PERSON IN THIS CASE?" not fundamentally change the relationship between the active physician and the passive patient. No longer a battlefield or uncharted terrain, the patient-as-text still waits to be analyzed and interpreted, plumbed for meanings deemed biomedically significant by the physician. The notion that a text has a discoverable, verifiable meaning has fallen into disfavor; now critics routinely discover textual disunities and discontinuities rather than harmony and organic wholeness.25 Some methodologies borrowed from literary interpretation suggest that a text is indeterminate, that the unfettered reader freely and imaginatively constructs the text.26 There would seem to be manifest dangers for physicians who would appropriate such deconstructive approaches, which typically show a text dismantling itself, and apply them to patients.27 Another school of critics insists that both the reader and the text are remarkably unfree, merely the products of institutional patterns of power and control. These politicized theorists speak of "the loss of the subject" (that is, the self) and see individuals as places, or loci, where power within a particular society is "negotiated."28 If a theory that so explicitly denies the autonomy of individuals were applied to medicine, the status of patients as human beings, as ill persons, would certainly be threatened . So these models of textual production and interpretation do not seem to offer ready help to the practicing physician. In fact, conceiving of the patient as a text may reinforce rather than dismantle the very subject-object dichotomy that already vexes physician-patient relations and makes mutual understanding and healing more difficult. With the textual model we risk once again transforming the person who is sick into a specimen—a butterfly under glass —and thus an appropriate object for study, analysis, and interpretation. Literary theory can be a subtle, arcane, and overwrought enterprise, and physicians would serve themselves and their patients well by approaching it with skepticism. The Illness as Text An alternative metaphor construes the illness, not the patient, as a text. The patient then becomes the joint author of the text, sharing that more powerful and privileged role with the physician. After all, the knowledge that a physician receives from a patient about illness influences the physician's judgments and affects his decisions.29 And both physician and patient are engaged in the process of healing. This metaphor of illness as text should be extended to the case report itself. There have, in fact, been recent efforts to incorporate the properties and powers Monroe, Holleman, and Holleman 53 of narrative into the case report, notably by James Hillman and David Barnard.30 Currently, however, personal or subjective judgments cannot be included in the case report without risking peer criticism and even litigation.31 We need to develop routines and forms that acknowledge the essential role of storytelling and frank discussion in medical practice. "Many treatment decisions," as Willard Gaylin says, "involve values and attitudes as well as medical judgments."32 If physicians are to move beyond a narrow interest in "the disease in the body in the bed," they must, according to Michael J. Hyde, "expand their appreciation of the patients' narratives to include what these narratives are saying about 'the person/ "33 To this end, the case report could be viewed as a text that has been composed by several authors: the initial report, consisting of the narrative collaboration between physician and patient, and the "second draft," including revisions, emendations, and validations by colleagues from various disciplines to whom the initial report is presented . Intermediate drafts of the case report, understood as essential to the open process of brainstorming and synthesis, could remain privileged and fiduciary if necessary. Admittedly, such collaborations take time, that most precious medical commodity, and are not practical for every occasion. The health-care team may elect to move expeditiously and postpone additional drafts when necessary. We may heed, without allowing ourselves to be tyrannized by, the urgent. An additional difficulty with using collaborative case reports in clinical practice arises from the fact that multivocal narratives , even after being put down in writing, are more idiosyncratic, anecdotal, and metaphorical than the current, denarrativized case report. These difficulties notwithstanding, the inclusion of insights and interpretations from psychologists, social workers, chaplains, and medical anthropologists should be more frequently utilized to help the physician and patient better understand the illness, the "text," which they must face together. To this end we endorse the multivocal medical record evaluated in this issue's "Charting the Chart—An Exercise in Interpretation (s)" (pp. 1-22). We ask a great deal of the case report as a narrative form: that it select, interpret, decipher, analyze, synthesize, communicate, and generally support the healing process. Only a comprehensive model of the case report, one emphasizing its joint or multiple authorship, can do justice to the complex and crucial activity of adequately rendering— literally re-presenting—a sick person in language that is neither pejorative nor deleterious. 54 "IS THERE A PERSON IN THIS CASE?" Narrativizing the Case Report Oral presentations of cases to one's peers and superiors only rarely become collaborative narratives. Genuinely collaborative case conferences have been implemented in geriatric care by Poirier and Brauner. They report that after a usually impersonal case-report presentation by a resident physician, questions posed by other members of the geriatric team elicit responses concerning family situations and dynamics, the physician's and the patient's attitudes, and ethical, legal, economic, and historical issues surrounding the patient's illness.34 This give-and-take usually provokes what Clifford Geertz would call a "thicker" description of the patient, one embedded with stories.35 If the geriatric-team model proposed by Poirier and Brauner were generalized, the case report could be reconceived as a collaborative performance: that is, it could enact the salient and immediately relevant beliefs, values, desires, motives, symptoms , images, and virtues of the patient and the physician and, more importantly, give the patient a script with which to perform his or her own recovery. And, despite the fact that personal stories and subjective judgments can open the door to peer criticism and even to litigation, there have been other efforts to narrativize cases and to focus more attention on the subjective experience of physicians. Hulmán, for example, argues that the psychoanalytic case report is nothing other than a story, a narrative that can be appreciated as poiesis, a work of art.36 Constructing a good case report, he suggests, requires precisely those skills associated with storytelling. Arthur S. Elstein, Lee S. Shulman, and Sarah A. Sprafka observe that physicians usually depend on logical analysis to do their problem solving,37 but David Barnard, as we noted above, does attempt to utilize the powers of storytelling for the field of medicine. Barnard's pioneering effort functioned, as Kathryn Montgomery Hunter observes, to "widen the narrow, stereotypic compass of the medical case history" by introducing the patient's subjective experience and by rehumanizing the medical narrator.38 Working with a physician, Barnard made frequent visits to the home of an elderly man suffering from amyotrophic lateral sclerosis. The medical attention was focused upon the husband, but his wife, who cared for him at home, died first, exhausted by her ordeal. Both experienced great hardship in the last years of their lives. Ironically, Barnard's effort to be more subjective and provide a fuller, more empathie narrative was met with animated criticism and anger by Eric Rabkin. Rabkin argues that Barnard's well-meaning attempt to construct a smoothly written narration ignores the historical Monroe, Holleman, and Holleman 55 reality that two people did in fact die and that Barnard and his physician colleague could have intervened to prevent the premature death of the wife. Rabkin suggests that Barnard was more concerned about getting the story than in helping the patients. In other words, by constructing a story about the "torment and shame and fear" of Paula and Maurice Baker, who become merely characters in a medical "case," Barnard commits , in Rabkin's view, an act of dehumanizing appropriation.39 In Barnard's defense, it should be pointed out that he and his colleague rendered what most physicians would consider to be appropriate care and that Rabkin's concerns are aided by the benefit of hindsight . Rabkin's insinuation that Barnard reaps inappropriate literary benefit from the Bakers' suffering and death seems, in our view, to discount Barnard's humane intentions for his home visits to the Bakers and his laudable motive of using narrative to foster empathy among physicians. Furthermore, this kind of literary benefit—that which depends on the suffering of others—is garnered by reporters generally, especially professional journalists. Consider, for example, the way the career of Arthur Kent was boosted by the Persian Gulf conflict. And Janet Malcolm has suggested that the relationship between journalist and human subject is implicitly and unavoidably adversarial.40 It is just such adversarialism that we hope to minimize; yet a certain violence, in the Derridean sense, will be present in any rendering. Realizing that representation does violence may release physicians from a sense of futility and guilt in their writing about patients. Our point is that the traditional case report is just one form of rendering and that physicians should consider its strengths and weaknesses with the same critical attention that has been focused on Barnard's more subjective, narrative presentation. We also believe that physicians should experiment with such alternative modes of reporting, especially in educational settings—and be willing, as Barnard was, to endure the inevitable criticism from peers. It would seem easier not to take such a risk, to rely on the current denarrativized methods of rendering patients. The neglect, or what we might call the repression, of narrative no doubt has its source and motivation in the biomedical triumphs of clinical practice. The successes of pharmaceuticals and biomedical technology have been astounding and have encouraged physicians and patients to anticipate curative intervention following certain diagnosis. These successes represent the rhetorical power of the doctor's techné, the special abilities and armamentarium of the medical practitioner. It is this techné that most sharply distinguishes the doctor from the patient, and it is convenient to imagine that it is precisely this distinguishing capability that patients purchase 56 "IS THERE A PERSON IN THIS CASE?" with their fee, insurance, and payments to health-maintenance organizations (HMOs). Physicians have therefore learned to rely on the objective , descriptive test—which the doctor owns and sells—to the exclusion of the subjective, narrative history, which in some sense always remains the possession of the patient. But the repression of narrative leaves signs and traces that can be discerned in our compulsive preoccupation with the running of tests and our collective investment in the technology that makes such repetitive, chronological testing possible. III. Persons and Performances Both Barnard and Donnelly, then, advocate a shift to a fuller, more flexible, and more inclusive narrative than we find in the current model of the case report. Barnard marshalls the powers of narrative to create empathy and understanding, while Donnelly suggests shifting from chronicle to story to make physicians better interpreters — more skilled, sensitive, and balanced. Both want to get the voice of the patient into the medical record and suggest narrative as the most effective means of doing so. Yet voice suggests the need to add the function of performance to that of narrative. The paradigm of patient as text or patient as story can be enriched by the notion of performance, and the case report, in turn, can be revisioned to render patients as persons more adequately. Narrative theory and rhetorical criticism provide insights that are useful for understanding the practice of medicine and medical encounters as the performances of persons. The notion of presenting one's self is found throughout classical rhetoric, notably in Aristotle's delineation of the rhetor's "ethical appeal."41 Kenneth Burke, Erving Goffman, Wayne C. Booth, Clifford Geertz, Victor Turner, and other contemporary theorists who emphasize the social construction of reality as well as the action of literary texts provide additional arguments, both direct and indirect, for utilizing the concept of performance.42 Through temporal performances, Turner and Geertz suggest, communities and persons are made, modified, and maintained. A communication theorist, Dwight Conquergood, argues that the performance paradigm properly emphasizes "qualities that are particular, participatory, dynamic, intimate," and takes proper stock of "precarious, embodied experience." Adding performance to the paradigm of the physician-patient encounter helps to repair the Cartesian split, which devalues the particular "experiencing body situated in time, place, and history."43 Since, as we are arguing, the case report should also address embodied persons situated spatially Monroe, Holleman, and Holleman 57 and temporally, a performance paradigm can illuminate the encounters, processes, and purposes of medicine such that they are revealed as essentially patient-oriented. Bringing the notion of performance to the text paradigm also suggests, quite simply, that we improvise our lives and our very selves in negotiation with others. In the mutual playing and sharing of roles, as Geertz says, "the deeply different can be deeply known without becoming any less different."44 Thus, enlivening the text paradigm with the notion of performance may offer additional insights for the practice of medicine and the utilization of the case report. Booth's rejuvenation of the neglected critical metaphor of texts as friends is also helpful and germane.45 A text that becomes a friend is implicitly an agent and a performer. Texts are properly interpreted, but friends are, simply and properly, befriended.46 The trope of personification implied by the friendship analogy is also endorsed by Warwick Wadlington. He claims that we always personify when we read, and that we do so because, by definition, "only persons can act."47 The paradigm of interpretation, on the other hand, often implicitly casts the text in a passive role: the inert text must in some sense wait on the interpreter to reveal its meaning, which is presumed by the paradigm to be more or less fixed and hidden. If the work of the physician, even the diagnostic work, is conceived as purely interpretive, then we risk textualizing persons. Interpreters work on texts, texts are objects, and objects are incipient commodities. Thinking of medicine and medical interactions as reciprocal performances—which depend, to be sure, on interpretations—takes us out of the laboratory and into the sickroom, away from computer print-outs and lab reports and face to face with a patient who is performing as a person. One way to combine the complements of narration and performance in the case report would be to borrow and adapt Charon's suggestion that the particular illness, rather than the patient, be the focus of the case report. If, as Hillman explains, the illness is construed as a narrative, then the patient can become the joint author of the story, sharing that more powerful and privileged role with the physician. Of course, the physician has, by virtue of medical training, a special techné, a special knowledge of diseases; but, as Charles M. Anderson observes, the patient, through experience, has a special knowledge of his or her particular illness that is different from the physician's knowledge, which Richard Selzer calls "this knowledge that is ours [as doctors] and no one else's."48 Thus, the patient and physician can help each other replace the current case report with a more comprehensive, more useful, narrative re-presentation of a particular illness. Both physician and patient 58 "IS THERE A PERSON IN THIS CASE?" are, after all, engaged in the process of healing, and that process is not merely a biomedical, intellectual, or cognitive exercise. Emotions, beliefs, values, and desires, as well as bodies, are elements of the healing process , and physicians, patients, and others work together to perform a narrative of healing. This recursive, reciprocal process could be made more self-conscious. The crucial step is imaginative rather than biomedical : the patient and the physician conceive of themselves as enacting a mutual performance, the purpose of which is to discover or construct a story of wellness. But the problem is not solved by merely substituting a more concrete or reliable or thorough terminology—text, narrative, performance— for terms and patterns that are abstract or unreliable or inadequate. Whatever our method of rendering patients, it will be incomplete. Burke is especially helpful when he observes that our methods for examining and interpreting reveal "only such reality as is capable of being revealed by this particular kind of terminology."49 The style and structure of the form that we use is therefore crucial, literally of vital importance, for our terminology makes us act one way rather than another in a given circumstance. In fact, Burke contends that "much that we take as observations about 'reality' may be but the spinning out of possibilities implicit in our particular choice of terms."50 Burke suggests that we perceive reality, and thus persons and illnesses, only by means of "terministic screens." Some screens are better than others for some purposes, but any method of rendering or interpreting yields a limited perspective. We believe, then, that physicians should be critically aware of the limitations of our habitual, biomedical, abstract way of rendering patients— that is, to recognize it as one way of seeing. But the more concrete stories and the collaborative methods endorsed above also constitute just one way of seeing, and physicians should remain aware of their limitations as well. We do not, then, want to propose the narrative-performance paradigm as a new system, a template that can be used to fix all the world's ills—or even solve the problems associated with rendering patients. The underlying problem remains: whatever our method of representing each other, it will distort and violate. But part of the value of the notion of performance is that it captures the complexity and artful madeness of enacted literary, professional, and cultural narratives. Using the term helps us avoid dubious claims to exclusively authoritative stances, codes, interpretations, or standards—in a medical diagnosis, for example. In the words of Barbara Hernstein Smith, we need values that include the admission of contingency, values that do not make an exclusive claim Monroe, Holleman, and Holleman 59 to truth.51 Any particular way that a physician sees a patient and talks about his or her professional practice will necessarily preclude other terministic screens, other ways of seeing, acting, and interacting. Participating in concrete stories and collaborative performances cannot eliminate distortions, violations, or misapprehensions. IV. Conclusion More thought should be given to the way that the case report, in its current form, shapes and limits the practice of medicine. There are unlikely to be major changes in the case report in the near future, given the biomedical, political, and legal prestige of the current form. Moreover , despite the limitations of the case report, a precipitous change would not be wise: the current form has developed over time and therefore provides manifest benefits, many of which would soon be quickly missed if it were scrapped. Such forms or genres, embedded in the practice of professions, evolve slowly, as they should. What does seem advisable and possible is for physicians to become more aware of what the case-report form does to them, their patients, and the quality of medical care in general. In this essay, we have identified a number of these limitations. Physicians aware of these biases and exclusions can try to compensate for them; those unaware that the case report has limitations will remain, of necessity, subject to them. And, as more physicians become aware and perhaps critical, there is a greater likelihood that the case report will evolve into something more congenial to the full health and humanity of patients and physicians. We would like to see the case report evolve into a more inclusive, collaborative narrative performance with multiple authorship. Both physician and patient are, after all, engaged in the process of healing, and that process is not merely a biomedical, intellectual, or cognitive exercise. Emotions, beliefs, values, and desires, as well as bodies, are elements of the healing process, and physicians, patients, and others must work together to create such an outcome. Only a model of the case report that includes narrative can do justice to the complex and crucial activity of re-presenting a sick person in a form that is not pejorative or otherwise deleterious. And only a model that includes performance can empower the patient to function as a collaborator in the narrativizing of his or her illness. The case report should not be viewed as an assembling and presentation of medical data, but as the construction of a story—a story that incorporates the patient's own metaphorical language. A narrative- 60 "IS THERE A PERSON IN THIS CASE?" performance model of the case report calls for just such a mutual, reciprocal , collaborative storytelling by the physician and patient. Hence the paradigm of storytelling or narrative performance offers a way of revisioning and "personifying" the case report, a way to put the person back into the case. NOTES 1. Stanley Fish, "is There a Text in This Class?": The Authority of Interpretive Communities (Cambridge, Mass.: Harvard University Press, 1980). 2. According to Eric J. Cassell, illness stories, as told by patients, "are different from other stories because they almost always have at least two characters to whom things happen. They always have at least a person and that person's body." Eric J. Cassell, Talking with Patients, vol. 2, Clinical Technique (Cambridge, Mass.: MIT Press, 1985), 15. Our suggestions are aimed at making the case report similarly comprehensive . 3. Interpretation theory has been used by James S. Terry and Edward L. Gogel, for instance, to elucidate aspects of the professional work of physicians. See "Medicine as Interpretation: The Uses of Literary Metaphors and Methods," Journal of Medicine and Philosophy 12 (August 1987): 205-17. Interpretation, as Terry and Gogel say, "stresses intellectual acuity, inventiveness, [and] imagination as cognitive processes" (pp. 206-7). An emphasis on cognition prevents the connection between narrative and the professions from seeming vague, or fanciful, or merely suggestive and evocative —cognition, as they observe, "preserves expertise" (p. 206). 4. Kenneth Burke, Language as Symbolic Action: Essays on Life, Literature, and Method (1966; reprint, Berkeley and Los Angeles: University of California Press, 1968), 49. 5. See, for example, Samuel Shem, The House of God (New York: Dell, 1978), 424, and Cato 6, "Dirtball," A Piece of My Mind, Journal of the American Medical Association 247 (11 June 1982): 3059-60. Like dirtball, gomer refers to an unwanted patient and is an acronym for "Get out my emergency room!" 6. See William J. Donnelly, "Medical Language as Symptom: Doctor Talk in Teaching Hospitals," Perspectives in Biology and Medicine 30 (Autumn 1986): 81-94. 7. Jiminy, "Gomers," A Piece of My Mind, Journal of the American Medical Association 243 (13 June 1980): 2333. 8. See Howard Brody, Stories of Sickness (New Haven, Conn.: Yale University Press, 1987), 3, and John L. Coulehan, "Who Is the Poor Historian?" Journal of the American Medical Association 252 (13 July 1984): 221. 9. To be sure, skilled and sensitive physicians do rely on the patient's perception of what is wrong with his or her health, especially in the early stages of the diagnostic process. But even the best clinicians often limit themselves to eliciting narratives that can soon be confirmed by tests. Those characteristics that are not measurable—for example, the patient's social and psychic environment, what and who the patient enjoys, fears, or values, the patient's moral concerns and imaginative life—are usually ignored, even by those physicians who value the patient history for what it can reveal about biomedical conditions. In other words, the patient's experiences are selected and filtered by the physician, who looks only for information that is appropriate to the formal case report. Specialties such as family medicine, however, are attempting to consider a broader range of data and to train residents to discuss and interpret patients as contextualized beings who have emotional, social, and spiritual dimensions Monroe, Holleman, and Holleman 61 to their lives. See Donald S. Williamson and Michael L. Noel, "Systemic Family Medicine: An Evolving Concept," in Textbook of Family Practice, 4th ed., ed. Robert E. Rakel (Philadelphia: Saunders, 1990), 61-79. 10. This case was brought to the attention of one of the authors in spring 1991. 11. Ursula K. LeGuin, "Feeling the Hot Breath of Civilization," New York Times Book Review, 29 October 1989, 1, 49-50. 12. Burke, Language as Symbolic Action, 51-52, 66. One student of Burke summarizes his theory of terministic screens as follows: "language in general, not only in its idiosyncratic private uses but in every single one of its specialized technical variants—physicist, sociological, psychological, poetic, and others [including biomedical ]—serves as so many 'terministic screens' which select and deflect reality as they reflect it." See Armin Paul Frank, Kenneth Burke (New York: Twayne, 1969), 159-60. 13. Laurence B. McCullough, "The Abstract Character and Transforming Power of Medical Language," Soundings 72 (Spring 1989): 111-25. 14. William J. Donnelly, "Righting the Medical Record: Transforming Chronicle into Story," Journal of the American Medical Association 260 (12 August 1988): 823-25. 15. Suzanne Poirier and Daniel J. Brauner, "Ethics and the Daily Language of Medical Discourse," Hastings Center Report 18 (August/September 1988): 6. 16. Donnelly, "Righting the Medical Record," 823. 17. H. Tristram Engelhardt, The Foundations of Bioethics (New York: Oxford University Press, 1986), 164-76. 18. McCullough, 113. 19. Donnelly, "Righting the Medical Record," 823. 20. Ibid., 824-25. 21. Larry R. Churchill and Sandra W. Churchill, "Storytelling in Medical Arenas: The Art of Self-Determination," Literature and Medicine 1 (1982), 73-79. 22. Brody, especially pages 5-13; Joanne Trautmann, ed., Healing Arts in Dialogue : Medicine and Literature (Carbondale: Southern Illinois University Press, 1981). 23. Richard Selzer, Mortal Lessons: Notes on the Art of Surgery (New York: Simon and Schuster, 1975), 23. 24. Rita Charon, "Doctor-Patient/Reader-Writer: Learning to Find the Text," Soundings 72 (Spring 1989): 137-52. 25. See, for example, Jacques Derrida, Of Grammatology, trans. Gayatri Chakravorty Spivak (Baltimore: Johns Hopkins University Press, 1976). 26. In addition to Fish, see David Bleich, Subjective Criticism (Baltimore: Johns Hopkins University Press, 1978). 27. For a relatively early explanation of the deconstructive method, see J. Hillis Miller, "Stevens' Rock and Criticism as Cure, II," Georgia Review 30 (1976): 330-48. 28. See, for example, Michel Foucault, Discipline and Punish: The Birth of the Prison, trans. Alan Sheridan (New York: Pantheon, 1977); Stephen Greenblatt, Shakespearean Negotiations: The Circulation of Social Energy in Renaissance England (Berkeley and Los Angeles: University of California Press, 1988); and Jonathan Dollimore and Allan Sinfield, eds., Political Shakespeare: New Essays in Cultural Materialism (Manchester, England: Manchester University Press, 1985). 29. Eric J. Cassell, The Healer's Art: A New Approach to the Doctor-Patient Relationship (New York: Lippincott, 1976), 95. 30. See James Hillman, "The Fiction of Case History: A Round" in Religion as Story, ed. James B. Wiggins (New York: Harper and Row, 1975), 123-73, reprinted in James Hillman, Healing Fiction (Barrytown, N. Y.: Station Hill Press, 1983), 1^9; David Barnard, "A Case of Amyotrophic Lateral Sclerosis," Literature and Medicine 5 (1986): 27-42. 31. Eric Rabkin, "A Case of Self Defense," Literature and Medicine 5 (1986): 4353 . 32. Willard Gaylin, "Modern Medicine and the Price of Success," Bulletin of the American College of Surgeons 68 (June 1983): 6. 62 "IS THERE A PERSON IN THIS CASE?" 33. Michael J. Hyde, "Human Values and the Culture of Technology" in Communication and the Culture of Technology, ed. Martin J. Medhurst, Alberto Gonzalez, and Tarla Rai Peterson (Pullman: Washington State University Press, 1990), 124. Hyde borrows the phrase "the body in the bed" from Jay Katz, The Silent World of Doctor and Patient (New York: Free Press, 1984), xix. 34. Poirier and Brauner, 6-8. 35. Clifford Geertz, The Interpretation of Cultures (New York: Harper and Row, 1973). 36. Hillman, 124. 37. Arthur S. Elstein, Lee S. Shulman, and Sarah A. Sprafka, Medical Problem Solving: The Analysis of Clinical Reasoning (Cambridge, Mass.: Harvard University Press, 1978). 38. Kathryn Montgomery Hunter, "Making a Case," Literature and Medicine 7 (1988): 73. 39. Rabkin, 43, 50-53. 40. Janet Malcolm, The Journalist and the Murderer (New York: Knopf, 1990). 41. Ethical appeal is exerted on an audience by a speaker who exhibits sound sense (phronesis), high moral character (arete), and benevolence (eunoia). See Aristotle's Rhetoric and Edward P. J. Corbett, Classical Rhetoric for the Modern Student, 2d. ed. (New York: Oxford University Press, 1971), 93. A short history of classical and modern rhetoric is available in Corbett, 594-630. 42. Erving Goffman, The Presentation of Self in Everyday Life (Garden City, N.Y.: Doubleday/Anchor Books, 1959); Victor Turner, The Anthropology of Performance (New York: PAJ Publications, 1986). Marie Maclean and, especially, Warwick Wadlington have applied the concept of performance to literature with fascinating results. Whereas Wadlington relies primarily on Burke, Geertz, and Bakhtin, Maclean has been more influenced by J. L. Austin, speech-act theory, and Continental theories of narratology. See Marie Maclean, Narrative as Performance: The Baudelairean Experiment (New York: Routledge, 1988). Wadlington describes literature as a "hazarded cooperation" between writer and reader. It is not uncommon for writing to be thought of as performative , but Wadlington argues that reading stories is itself a performative act that involves the process of trying on, selecting, and habituating oneself to roles. See Warwick Wadlington, Reading Faulknerian Tragedy (Ithaca, N.Y.: Cornell University Press, 1987), 31-32, 47. Wayne Booth also utilizes the haberdashery metaphor when he speaks of "trying on" certain stories to see how they suit us. "I should be able to embrace the unquestioned ethical power of narratives," Booth says, "in order to try on for size the character roles offered me. I can hold a fitting of various 'habits,' to see if they enhance or diminish how I/we appear to myself/ourselves." See Wayne C. Booth, The Company We Keep: An Ethics of Fiction (Berkeley and Los Angeles: University of California Press, 1988), 268. Performance also recalls the oral tradition in which professionals actually bring a tale to life for flesh-and-blood audiences by performing it. 43. Dwight Conquergood, "Rethinking Ethnography: Cultural Politics and Rhetorical Strategies" (paper presented to the Temple Conference on Discourse Analysis, Philadelphia, April 1990), 16. 44. Clifford Geertz, Local Knowledge (New York: Basic Books, 1983), 48. 45. Wayne C. Booth, " 'The Way I Loved George Eliot': Friendship with Books as a Neglected Critical Metaphor," Kenyon Review, n.s., 2 (Spring 1980): 4-27. A revised version is published as chapter 6 in The Company We Keep. 46. The familiar academic habit of interpreting texts is arguably distinct from the common habit of reading books and the universal habit of enacting stories. 47. Wadlington, 48. 48. Charles M. Anderson, Richard Selzer and the Rhetoric of Surgery (Carbondale: Southern Illinois University Press, 1989), 9-10, 18-19. Anderson quotes from Selzer's notes for speeches, which Selzer gave him "in April 1984" (p. 112, n. 25). Monroe, Holleman, and Holleman 63 49. Kenneth Burke, A Grammar of Motives (1945; rev. ed., Berkeley and Los Angeles: University of California Press, 1969), 313. 50. Burke, Language as Symbolic Action, 46. 51. Barbara Hemstein Smith, Contingencies of Value: Alternative Perspectives for Critical Theory (Cambridge, Mass.: Harvard University Press, 1988), 15-16, 94-102. ^rC