Remaking the Case

^ Remaking the Case' Kathryn Montgomery Hunter To cure sometimes, to relieve often, to comfort always. —Traditional saying Narrative persists in medicine, as it does in the human sciences generally, as both a source of information and a means of organizing its interpretation. Unscientific though narrative may seem, the case is not only a record of medical attention provided a patient, but the fundamental unit of medical discourse and the pattern for clinical reasoning. With its hypothetical, testable, diagnostic plot, it enables the physician to apply the nomothetic principles of biomedical science to the patient's idiographic manifestations of illness.1 Like thinkers in other fields that rely on cases—law, moral theology, criminal detection—physicians reason backward from effect to cause by constructing from the signs (or clues, facts, evidence) a probable narrative whose validity can be tested by further interrogation of the phenomena. Neither so satisfyingly coherent as fictional narrative nor so epistemologically secure as the replicable demonstration of scientific fact, the medical case lies somewhere between the two. It is, in short, history. As a working part of the process of diagnosing and treating disease, the case aspires to scientific rigor. But the epistemological shift that in the late twentieth century has called into question the simple, objective, logical-positivist view of knowledge —medicine's working epistemology—has affected the way we think about case history, too. No longer taking the Newtonian physical sciences as the sole pattern of rationality, thinkers have turned in recent years to the contextual, interpretive methods of knowing that are characteristic of the social sciences and the humanities. Narrative is one of the chief of these. Not surprisingly, then, recent changes in the case * This essay extends an account of efforts to reform the case history that I presented at the 1989 meeting of the Modern Language Association and elaborated in the second half of chapter 8 of Doctors' Stories: The Narrative Structure of Medical Knowledge (Princeton, N.J.: Princeton University Press, 1991). Literature and Medicine 11, no. 1 (Spring 1992) 163-179 © 1992 by The Johns Hopkins University Press 164 REMAKING THE CASE history and proposals for its improvement reflect many of the concerns of contemporary historiography and literary theory. The Case A medical case history is the clinical narrative, oral or written, constructed by physicians from a malady evinced by a patient. Its primary written form is the chart, which serves as the record of medical care. In academic medical centers, it takes other forms: it may be told aloud as a case presentation, transcribed from a clinical-pathological conference, or written up as part of a case report or case study. The case has a generic existence in the minds of physicians and medical students, who, at the juncture of their basic-science education and their clinical training, learn its form as a diagnostic method, a way of organizing information and thinking through a patient's malady. In all its manifestations, the case history is inalienably medical and, for the ordinary reader or listener, potentially alienating. The medical case is not the patient's story—nor is it meant to be. Both are historical narratives concerned with many of the same events of illness occurring to the same person, yet the medical case is radically different in focus and style, plot, narrative point of view, and tone. Its narrator is known to the medical audience: in all cases, oral or written, he or she is identified by name and standing in the medical hierarchy; sometimes, as in an oral case presentation, he or she is physically present . Yet the case narrator is almost entirely effaced in the act of narration. The style of the case history is prescribed, and its tone is the very definition of clinical: objective, detached, impersonal, unemotional about death and loss and limitation. The time frame is the span of present medical attention; all else is the history of the present illness or the wonderfully unredundant past medical history—history within the case history. The plot of the case, like the plot of a detective story, is a given: a report of what has gone wrong; the scrutiny of the physical evidence for further telltale clues...