In lieu of an abstract, here is a brief excerpt of the content:

¿¡k, Development of the Physician's Narrative Voice in the Medical Case History* David H. Flood and Rhonda L. Soricelli When I heard the learn'd astronomer, When the proofs, the figures, were ranged in columns before me, When I was shown the charts and diagrams, to add, divide, and measure them, When I sitting heard the astronomer where he lectured with much applause in the lecture-room, How soon unaccountable I became tired and sick, Till rising and gliding out I wander'd off by myself, In the mystical moist night-air, and from time to time, Look'd up in perfect silence at the stars. —Walt Whitman, "When I Heard the Learn'd Astronomer" The poem above, about astronomy, could just as well be about medicine. Substitute "doctor" for "astronomer" and "patients" for "stars" and it comes to represent the tension between the scientific and humanistic ways of knowing, between the detached analytic and the empathie , between the reductive and the holistic—a tension that defines one of the more familiar dilemmas of modern clinical medicine. This dilemma becomes sharply focused in the case history. On the one hand, functional necessity dictates that this document be concise and precise, * The authors presented an abridged version of this essay at the 1991 meeting of the Society for Health and Human Values, in a session celebrating the tenth anniversary of Literature and Medicine. For that session, a preview of the present issue of the journal, the essay was titled "If I Only Had a Heart: Tin Man Syndrome in the Medical Case History." Literature and Medicine 11, no. 1 (Spring 1992) 64-83 © 1992 by The Johns Hopkins University Press Flood and Soricelli 65 and medical training requires that it provide a technological perspective on its subject, the human organism. Additionally, pressures of professionalization demand that it incorporate the formulaic, abbreviated linguistic patterns and expressions characteristically used to communicate within the medical establishment and to identify one as a bona fide member of that group. On the other hand, we must ask whether these pressures have succeeded perhaps too well in shaping this document in such a way that all vitality is squeezed out of its authors and subjects alike. As Oliver Sacks complains, "There is no 'subject' in a narrow case history; modern case histories allude to the subject in a cursory phrase ('a trisomie albino female of 21'), which could as well apply to a rat as a human being."1 Sacks, a self-described "clinical ontologist"2 whose collections of humanistically detailed neurological case histories have become best sellers, is not alone in this view. Critics such as Michael Crichton, William J. Donnelly, Suzanne Poirier, and Daniel J. Brauner point to the case history's abstract, reductionist language;3 Rita Charon to its neglect of the patient's perspective;4 and Larry R. Churchill, Sandra W. Churchill, Donnelly, Charles B. Freer, and Kathryn Montgomery Hunter to its insensibility to the holistic, synergistic level of meaning in the patient's story5—criticisms that, despite their differences of emphasis, all underscore the case history's lack of human dimension, especially concerning the patient. We believe, however, that it is equally important to focus on the physician's narrative presence in this document. Indeed, identification and understanding of what would be called the physician's narrative voice in the case history may prove a necessary first step in correcting the patient's diminished status therein. If we accept the premise that it is unreasonable to expect a patient-centered approach from physicians who are ignoring their own humanistic development,6 then attempts to remedy the ills of the case history mentioned above clearly need to begin with the physician's presence in a document that both reflects and shapes the physician's developing relationship to his or her professional role. The problem created for the physician by the conflicting demands of the case history can be seen in the following excerpts from a narrative simply titled "Jenny" (a fictitious name). It was written and read to her colleagues by a senior medical resident who clearly felt the need to supplement her professional documentation of a patient with a more THE...

pdf

Share