The Chief Concern of Medicine: The Integration of the Medical Humanities and Narrative Knowledge into Medical Practices

Preface

Preface The Chief Concern of Medicine aims at enlarging our sense of the profession of medicine and, more important, enlarging its effectiveness and service, by including a self-conscious awareness of the nature of narrative within a working definition of the way medicine understands itself as a profession and its very activities. Medicine seeks to heal, to care, and to comfort, and we believe that each of these goals is improved with the understanding of how narrative functions, both in general and within medical practices. To this end, we offer, first of all, a pragmatic understanding of the science on which medicine is based, particularly in relation to the larger theme of Part 1 of the book, the definition and the practical and ethical strategies of what aristotle calls phronesis (translated often as “practical reasoning” and sometimes even as “practical wisdom”). aristotle believed that phronesis was the means to a “good life” (eudaimonia), and one of his chief models for the accomplishment of phronesis was successful doctoring. We argue here that phronesis is closely related to narrative—to its structures and, most notably, its purposes, particularly the “end” or “concern” of any particular narrative. We also argue that the logic of hypothesis formation that informs medical diagnosis closely aligns itself with narrative and what we are calling “narrative knowledge.” Thus Part 1 of The Chief Concern of Medicine aims at enlarging our sense of science and scientific understanding and procedures in order to complement evidence-based medicine. evidence-based medicine aims, ideally , at what atul gawande has called “the idea that nothing ought to be introduced into practice unless it has been properly tested and proved effective by research centers, preferably through a double blind, randomized controlled trial” (2007: 188). We hope to complement—not replace— evidenced-based medicine with what we are calling “schema-based medicine .” The schemas we set forth—on the model of schemas as they appear in viii / preface cognitive psychology and artificial intelligence—are schemas of narrative, ethical actions, and procedures for the medical interview. in appendix 1, we even suggest that schemas might allow us to understand what might be called “humanistic understanding” more generally, in terms of a model of discipline building in the humanities. The simplest, but perhaps most profound, of these schemas is the suggestion, as we note in both the introduction and chapter 3, that doctors elicit a patient’s chief concern as well as a chief complaint in the formal procedure of conducting the history and Physical exam and eliciting the history of Present illness. We believe that the understanding of the schemas and procedures we describe in this book that grow out of humanistic understanding can find their place alongside scientific understanding in governing how physicians and health care workers conceive of and go about their everyday encounter with people who are suffering, in distress, and in need of help. for this reason, it is our contention that the nomological sciences—lawgoverned understandings, based on thoroughly repeatable experiments or large-scale statistical measurements—can be complemented by the human sciences, which depend on schematic understanding of forms and structures that govern cognition, experience, and judgment more generally. a model for such complementarity is the science of evolutionary biology, whose results are widely accepted by physicians, medical-school faculty, and students aspiring for a career in medicine, even though the kind of randomized control trials that epitomize evidence-based medicine is rarely possible in the study of evolution. evolution, Stephen Jay gould has persuasively argued (see especially 1986, 1989), is not a nomological science—rather, he says, it is a historical science—yet it still bases itself, at times, on retrospective evidence (see Weiner 1995 for remarkable empirical evidence of generations of finches on the galapagos islands). a third category of science—what we suggest , early in the book, seeks functional knowledge—bases itself on the pragmatic achievement of goals in the systematic pursuit of understanding. insofar as it does so, we suggest, it is a species of narrative science (or at least systematic analyses of narrative), which is based neither on the deductive laws and quantifiable evidence of nomological science nor on the inductive retrospective understanding of evolutionary-biological science but on the schemas of the humanities in general and of abductive logic more specifically . (in chapter 4, we closely examine Charles Sanders Peirce’s “logic of abduction,” which is a systematic understanding of hypothesis formation.) in Part 1 of The Chief Concern of Medicine, we trace the...