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

/ 111 / 4 the logic of diagnosis Peirce, Literary narrative, and the history of Present illness in chapters 2 and 3, we examined the practical wisdom of the physician in relation to narrative and, particularly, the chief concern of the narratives patients bring to their physicians. in this chapter, we will continue examining the role of narrative in the practices of medicine, but with particular focus on the ways narrative can contribute to diagnostic skills. Specifically, we will examine the logic of hypothesis formation that Charles Sanders Peirce articulated at the turn of the twentieth century, and we hope to demonstrate that his “logic of abduction,” as he called it, approximates the “practical syllogism ” that aristotle describes in the Nicomachean Ethics and elsewhere. at the heart of this practical syllogism is hypothesis: “as aristotle often tells us,” Martha nussbaum notes, “teleological explanation requires the introduction of a special notion of necessity, the ‘hypothetical’: if a goal is to be reached, certain things must take place or be present” (1978: 177). The systematic achievement of a precise hypothesis is the work of both the physician and Peirce’s logic of abduction. in other words, diagnosis is also a phronetic skill, and Peirce, particularly, described its systematic procedures, its technē. Introduction as we have noted, the most frequent procedure a doctor performs is a patient interview. interviews occur over two hundred thousand times in the professional lifetime of a physician. This verbal and nonverbal interaction forms the backbone of the patient-doctor relationship. Despite this being the 112 / the chief concern of medicine most common procedure, the physician’s performance in this arena results in the most common complaints about doctors: “My doctor does not listen to me” and “My doctor does not seem to care.” interestingly, patient dissatisfaction almost never centers on the idea that the doctor does not seem to know enough medicine. it is also common wisdom in medical education that the most powerful diagnostic information is the patient interview, specifically the history of Present illness (hPi), which, in fact, is a significant focus of this book. The hPi is the portion of the patient’s story of illness in which the patient tells the symptoms, the time frame of the illness, the relationship of the various symptoms, and his or her interpretation of them. The physician’s task in this portion of the interview is to understand the patient’s story in the context of the nonverbal clues for such things as anxiety, anger, or depression that may also be present. Very often, the physician must facilitate a story from a patient experiencing one of these uncomfortable emotions. as we have suggested, the inclusion of the patient’s “chief concern” as well as her “chief complaint” could go a long way toward facilitating the story and, indeed , realizing phronesis on the part of the physician. in any case, the cumulative task of facilitating and engaging in the hPi requires enormous skill, which is not encouraged in much of the curricula of medical school. Many studies in the medical education literature report that medical students become worse at these tasks as medical school progresses. if the doctor can successfully obtain the story (hPi) and put it together appropriately, he or she must then apply a rigorous logic to this information in order to arrive at the correct diagnosis. Without a sense of this logic, problems leading to improper diagnoses can—and often do—attend the hPi. The process just described can be understood—and incorporated into the practices of working physicians—by discerning the logic of diagnosis in relation to literary narrative. The elements and structures of narrative— especially art narratives found in novels and short stories—illuminate, in many ways, the narratives that patients tell their doctors (besides the references in chapters 2 and 3, see also Charon 2004; Charon 2006b; hunter 1999: esp. 305–8). The purpose of this chapter is to examine the basic methods and skills that allow successful physicians to develop and utilize the hPi to the fullest extent for the purposes of diagnosing the patient’s condition, just as the preceding chapter examined narrative for the purposes of developing the negotiation of the goals of medicine and the particular definition of health that governs the treatment of the diagnosed condition. We began with that aspect of the role of narrative both to set forth a systematic understanding of narrative that might appeal to people trained in science and also to [18.119.136.235...

Share