A Controversy about Clinical Form

^ A Controversy about Clinical Form The following debate is so rich and complex mat its sections must be orchestrated delicately. I start widi simple chronology as the basis for fairness. In May of 1980, at a regional meeting of the Society for Health and Human Values, I heard David Barnard's "A Case of Amyotrophic Lateral Sclerosis" as part of his presentation called "Chronic Illness: Perceptions and Realities for Physician and Patient." 1 found the case informative, intelligent , moving — and unusual, as far as I knew, in the tradition of case histories. Moreover, its qualities seemed to stem partly from its power as a narrative. When I decided diat this volume of Literature and Medicine would have as one of its concerns die nature of narration in medicine, 1 thought immediately of Professor Barnard's case history and planned, with his consent , to make it die center of some speculation. Originally, I intended to select a drama critic, a narrative critic, and a physician to participate, but ultimately space considerations brought the issue down to narration alone. So I sent die case to narrative dieorist Eric Rabkin and posed several questions to guide him as he read: What elements of fiction are present in this case history? What would it take to turn these elements into a form that sophisticated readers would recognize as fiction? Would all fully written case histories become fiction? If so, why is that valuable information for literary people, for medical people, and for patients7 Does that information have only theoretical implications at dus stage, or are diere some practical implications as well? What role(s) might doctors play in the fiction ? And how might educators better prepare pre-medical and medical students for these roles? I repeat these questions here largely because they have been incompletely answered and because I think they are still worth asking. Professor Rabkin, using some of them as a launching point, responded to the case with sharp criticism. His paper argues, approximately, that the attempt to formulate an extended case history as an objective, disinterested Literature and Medicine 5 (1986) 24-26 © 1986 by The Johns Hopkins University Press Joanne Trautmann Banks 25 account neglects the elements of subjectivity conventionally woven into narration. The result may be a complacent and spurious objectivity diat could be detrimental to the "narrator" as well as the subjects. Professor Rabkin's position surprised Professor Barnard and triggered a controversy . Barnard's informal reaction was that his original purpose in writing the case had been to draw on his deep appreciation of die experience of both doctor and patient in order to provide an instance of a difficult clinical situation that could then be used by educators. He had not included his own evaluations of people or principles in die case — indirectly exposing himself to Rabkin's anger — because he intended die case to be used for spontaneous discussion of die substantive issues. Professor Barnard also said that he missed in Professor Rabkin's response die sense that Rabkin appreciated the humane gift of their own frailties made to us by the patient and the doctor. For his part, Eric Rabkin does not believe diat David Barnard worked any conscious wrong in the structuring of his narrative; or that he or anyone else did wrong consciously in the substance of the case. In calling certain of the behaviors in this case "inferior," Rabkin has stressed in conversation with me, he is not implying culpability. Furthermore, Professor Rabkin sees the Barnard piece as simply an example of the possibilities and limits encountered by many — perhaps all — who attempt objective clinical narration. He has told me that he does not wish to be seen as anything odier than what he is, an interested layman who is nonetheless an expert in another field, narrative dieory. Professor Rabkin believes that lay people have a right to comment on those matters in any profession which concern them directly and about which they may be thought to have some valuable insight. They should not, he says, comment on technical matters per se, and he does not believe he has done so in his essay. Offered the space to reply to Eric...