"Is There a Person in This Case?"

Abstract

r<* j*¡* "Is There a Person in This Case?" William Frank Monroe, Warren Lee Holleman, and Marsha Cline Holleman The clinical case report serves a fundamental role in patient care and medical education by organizing knowledge about a patient into a standardized form. Whether written or oral, the form is fixed and consists of the following elements: the chief complaint, followed by a history of present illness, past medical history, social history, family history, review of systems, physical exam, results of tests, assessment, and plan. To question or suggest altering the case report would be regarded by most physicians as trying to fix what's not broken. Yet some critics are challenging the worth of this sacrosanct form. We agree with those who argue that the case report uses and legitimates deleterious, even degrading , terminology, that it encourages hasty categorizations and excludes the voice of the patient. The form also emphasizes description (often numerical data) at the expense of storytelling and biomedical objectivity at the expense of empathy. In short, the case report has become the story of a mechanistic entity, a biomedical body. It seems fair, then, to modify a locution of Stanley Fish and ask, "Is there a person in this case?"1 There are ways to render the story of a person in addition to the story of a body.2 Promising suggestions for improvement have come from writers who apply insights from literary criticism and interpretation theory to the case report.3 The primary benefit of such critical theory is its revisioning of the patient as a cultural text rather than a biomedical body. Yet the cognitive, analytical mode delimits the value of critical theory for physicians, nurses, and other health-care professionals. By casting the patient as a text, the interpretive paradigm does not render the patient as a person. Thus, in the hope of building on the insights developed through literary criticism and interpretation theory, we want to suggest a performance paradigm, a way of thinking about patients and cases that would enrich and enliven the notion of textuality and narrative Literature and Medicine 11, no. 1 (Spring 1992) 45-63 © 1992 by The Johns Hopkins University Press 46 "IS THERE A PERSON IN THIS CASE?" re-presentation. Minds may know and be known by cognitions. But persons are enacted rather than known, enacted by performances with a story in mind. Before turning to recommendations, however, we should review the recent criticisms of the case report. I. Review of Recent Criticisms Deleterious Terminology Kenneth Burke says that "a way of seeing is also a way of not seeing."4 The way physicians see their patients and talk about their professional practice will necessarily preclude other ways of seeing, acting , and interacting. Thus an attentive concern for the language of the case report is crucial. Much has been said about the use of overtly hostile terms such as gomer and dirtball.5 Though these and other derogations are scrupulously edited from formal case reports, there are a number of less overtly offensive expressions that similarly undermine the physicianpatient relation and yet appear routinely. Even locutions such as "the patient complained of . . .," "the patient denied . . .," "the patient admitted . . .," "the patient is noncompliant," and "the patient failed therapy" can have deleterious consequences.6 Such language is a more tactful and accepted manifestation of the physician's desire to distance the patient and may bespeak the very antagonism communicated by overtly hostile terms such as gomer. Without intending to do so, the physician implies that the patient is a complainer, a malingerer, even a hypochondriac. Admittedly, to say "the patient denied having frequent headaches" is quite different from saying "the patient denied having anal intercourse" or "the patient denied heavy alcohol use." The latter statements suggest that the physician doubts the veracity of the patient and may imply that the physician suspects the patient of behavior that is medically or morally objectionable. To eliminate such connotations, the physician ought to substitute neutral expressions for the offending ones: "the patient reported," rather than "complained of"; "the patient stated that he [or she] did not [or does not]," rather than "denied"; the patient's "chief concern" or "worry," rather than "complaint." The term noncompliant, again, suggests an antagonistic relationship between physician and patient and casts the patient as a child or ward and the physician as a domineering parent or sovereign.7 Physicians should find ways to describe patients in the case report that Monroe, Holleman, and Holleman 47 enhance rather than erode the patients' responsibility and competence: "the patient disagreed with . . ."; "the patient did not understand [why] . . ."; or "the patient placed a higher value on χ than on y." "The patient failed therapy" suggests that the patient is at fault for not getting well. It also suggests an attempt by the physician to avoid or transfer blame, a reluctance to accept the role of comforter as well as healer, and a hubristic refusal to admit that the physician is a catalyst to the healing process rather than the causa sui. To call the patient "a poor historian" also assigns blame. This label provides a handy excuse for not uncovering relevant information and may also signal an irritation with patients whose stories are not easily translatable into the standard case-report form.8 Physicians may also seek to assign responsibility to the patient because they lack the requisite patience, diligence, or interpretive skills to be good historians themselves. When patients cannot or will not respond, as a result of, say, dementia or intoxication, physicians can avoid placing blame by stating their perceptions as directly as possible in the case report. For example: "The patient appeared to be intoxicated. I could not decipher his words, which were incoherent and barely audible ." If patients become, in the minds of their doctors, complainers, liars, or failures, then therapeutic care will surely imitate language. If patients are depicted as distractions or as intractable opponents in a conflict of wills, then we should not be surprised that lab reports are preferred to personalized patient histories, that paperwork, charts, and tests take precedence over bedside care. With such language the patient —rather than the illness—is designated the problem. We do well to remember that the language we use to render patients has the power to "commodity" physicians and medical care as well as patients, transforming physicians into ombudsmen and gatekeepers and making the practice of medicine a business or a technology rather than a healing profession. Objective Description at the Expense of Narrative The preference for the objective (the test) to the exclusion of the subjective (the history) has become solidly embedded in the culture of modern hospital practice. Also entrenched is the scientistic bias that history and narrative are inadequate or unreliable modes of communication about the biomedical conditions of patients. Description, especially when buttressed by quantifiable data, is more scientific, somehow more 48 "IS THERE A PERSON IN THIS CASE?" medical, than narrative: description (data) is "hard"; narrative is "soft." This bias is supported by the unexamined assumption that objective data are not only essential but also sufficient for the optimal diagnosis and treatment of an illness.9 The quest for objectivity should not be abandoned , but physicians should seek ways to acknowledge the full humanity of both their patients and themselves. Certainly individual feelings , beliefs, values, and desires are important in patient care, and these elements cannot be adequately rendered by the mode of description. There are human costs exacted by medicine's de facto marginalization of narration, and an actual case can be used to underscore them: The physician of a young man bedridden with AIDS ordered an MRI brain scan after the patient reported a constant headache. The scan showed no abnormality. The pain continued. More tests were ordered while the young man remained in the hospital. Two weeks later the physician happened by and discovered that the patient lay in bed with his neck completely flexed. He suggested that the patient adjust his posture. In 24 hours the patient's headache resolved.10 A thorough history, taken before the tests were ordered, could have saved the patient considerable time, anxiety, and money. Certainly, collecting clinical data is part of the culture of modern medical practice, but the physician is probably also motivated by the fear of missing something and the sense that there is no time to waste before running some tests. Perhaps the impulse to test and even to hospitalize are motivated by desire for the absent narrative. Tests, then, and their charted results, can be seen as substitutions made necessary by medicine 's narrative silence. The testing itself, however, far from a benign aspect of professional work, wastes a great deal of time —time that is the terminally ill patient's most precious resource. The case illustrates the deleterious nature of our overreliance on objective and quantifiable descriptions, especially as it manifests itself in a penchant for "running a few tests." We have cultivated a scientistic bias that presumes that history and narrative are inadequate modes of communication about the conditions of patients. Put more philosophically , we could say that medical professionals, by ignoring the case report's potential to function as a collaborative performance, repeat and reinforce the subject-object dichotomy that has vexed Western culture at least since Descartes. In an effort to be scientific rather than performative , physicians often reduce persons to objects and enhance the illusion that they can understand and care for their patients, to borrow Monroe, Holleman, and Holleman 49 the words of Ursula K. LeGuin, "without bias, without participation, without imagination and without moral concern."11 The result of an exclusive reliance on scientistic, abstract language is to render or "screen" a sick person, in Burke's sense, as merely a specimen or exemplum of a type of disease.12 A particularly candid junior medical student, when asked "What is a patient?" replied, "Some lab values on a chart." Distortions, Biases, Exclusions A third criticism, recently articulated by Laurence B. McCullough, is that the case report consists of abstract language masking as concrete.13 Physicians like to think of themselves as just-the-facts empiricists who are careful not to jump to conclusions. Instead, they often reduce persons to patients or even to instances of diseases and ignore many of the particularities that make each person's illness unique. We hear a person pigeonholed as an "obese black female, diabetic with hypertension" and immediately assume that she has poor health habits, is uneducated, passive, and not motivated to lose weight. Abstract language, used exclusively, abstracts the person out of the case. Physicians, then, ought to pay closer attention to that which is unique and resist the temptation to define patients as instances of general disease categories. The particular history, individual situation, and even the personality, or character, of a sick person should be acknowledged as important and rendered responsibly in the case report. Including observational and narrative material that is particular (and thus unlikely to be quantifiable) does not undermine the objective validity of the case report: a patient's demeanor, attitudes, affiliations, commitments, beliefs, values, desires, and expectations can all be considered without dismissive , pejorative, or demeaning language. Concrete descriptive details and specific, emplotted narratives should be included, not only out of respect for the patient as a person, but also because they may improve the patient's outcome. Consider the case of a man with groin pain who believes that his illness is a punishment from God for committing adultery . His version of the etiology, however unscientific, will almost certainly play a role in his recovery. Therefore, his beliefs and his narrative ought to be included, without condescension, in the case report. Many physicians exclude beliefs they regard as superstitions when rendering an illness; instead of describing the illness of a particular person, they use pseudoscientific, abstract-as-concrete language to shape and define the patient. 50 "IS THERE A PERSON IN THIS CASE?" Biomedical Brevity A related and final criticism makes use of literary theory to point out that case reports invariably involve interpretation, though we often presume that only facts are reported. In "Righting the Medical Record," William J. Donnelly observes that case reports are usually terse, empirical "chronicles" rather than fuller, fleshed-out "stories."14 These brief chronicles are presented without affect or interpretation, and in a "Mr. Spock mode" typically associated with the communication of hard facts and scientific data. Suzanne Poirier and Daniel J. Brauner note that during the delivery of the case report, the face and voice of the physician become expressionless. His speech is frequently rapid and businesslike. He uses passive verbs, avoids first-person references, and seldom names the patient.15 Donnelly argues that even such a bare-boned case report requires selection, interpretation, and ordering of information.16 H. Tristram Engelhardt shows that medical language is not merely descriptive and explanatory but also evaluative, that it shapes the social reality of the patient.17 McCullough goes further in claiming that not only the social reality, but also the individual reality, even the individual identity of the patient, is shaped by the physician's language.18 Because case histories are, in Donnelly's view, "made," not "taken," he asks physicians to view their task, not as the collection of medical data, but as the making, the construction, of a story.19 Furthermore, to make patients' stories good stories, physicians ought to incorporate the patient's own language into them. Physicians should encourage patients to express themselves in metaphorical as well as flat, literal language—to say, for example, "It feels like someone is pinching the inside of my shoulder joint with a pair of tweezers," rather than simply, "My shoulder hurts." Physicians ought also to elicit and describe the patient's feelings regarding his or her sickness.20 Larry and Sandra Churchill, as well as Donnelly, lament the fact that the contemporary style of case reporting systematically distorts or even excludes the patient's own account of his or her condition .21 Donnelly, however, does not consider the potentially problematic legal status of storified patient accounts. Without a large body of familiar precedents, vivid patient accounts may be interpreted in unpredictable ways by third parties. This concern does not justify ignoring the patient's story, but it does suggest the need for caution, for a thorough integration of the patient's characterization of his or her illness with the physician's, and for an analysis of the legal precedents, if any, regarding the status of self-diagnostic pronouncements by patients. Monroe, Holleman, and Holleman 51 Finally, Donnelly does not offer a full theoretical justification for the use of stories in a situation in which problem solving, not narration, is the primary objective. Howard Brody, concurring with Joanne Trautmann , argues that storytelling itself is a healing art.22 In other words, the stories exchanged between patients and physicians can actually exacerbate or relieve suffering. Richard Selzer has also made the point that the poet, not the surgeon, is "God's darling" because his words have the capacity to heal.23 If we agree that stories can help not only in diagnosis but also in the process of healing itself, then a rehabilitated case report would serve this healing process better. II. Rehabilitating the Case Report The Patient as Text The metaphor of interpretation or hermeneutics is useful for bringing to the case report new vocabularies and new modes of analysis: once the patient is seen as a text, he or she can be interpreted by using any number of methods familiar to literary critics but novel to physicians. Rita Charon, for example, wants doctors to learn better how to understand , interpret, and write patients' stories, and she suggests that physicians study literary criticism and contemporary narratology. Charon argues that such study would help physicians by teaching them to become better, more capable and confident interpreters of patients' accounts of illness.24 We need to move carefully, however, as we consider alternatives to or enhancements of the traditional case report. The underlying problem is not solved merely by substituting literary or philosophical vocabularies for familiar biomedical terms. A physician who wants to become a better storyteller can spend time more by stories than by literary theory or in the literary or biomedical will not help physicians their role as and the of often by of physicians that a medical is an for or Such the need for , and for the and the medicine as an between and does "IS THERE A PERSON IN THIS CASE?" not the relationship between the physician and the passive patient. a or the to be and for by the The notion that a text has a has into critics and rather than and from literary interpretation suggest that a text is that the and the There would to be for physicians who would such which typically a text itself, and apply them to of critics that both the and the text are merely the of of power and These of "the of the the and see as or power a particular is If a theory that the of were to the status of patients as human as ill would certainly be . these of and interpretation do not to offer help to the In of the patient as a text may reinforce rather than the very subject-object dichotomy that and makes and healing more With the we once transforming the person who is sick into a thus an for and theory can be a and and physicians would serve themselves and their patients well by it with The as Text metaphor the illness, not the patient, as a The patient then the joint of the text, that more and role with the the knowledge that a physician from a patient about illness the physician's and his both physician and patient are in the process of This metaphor of illness as text should be to the case report There in been recent to incorporate the and Monroe, Holleman, and Holleman of narrative into the case report, by and however, or subjective cannot be in the case report without criticism and even We need to and that acknowledge the essential role of storytelling and in medical practice. treatment as values and as well as medical If physicians are to move a in "the disease in the body in the they to J. their of the patients' narratives to these narratives are saying about To this the case report could be as a text that has been by the report, of the narrative between physician and patient, and the and by from to the report is presented . of the case report, as essential to the process of and could and if Admittedly, such take time, that most precious medical and are not for The health-care may to move and when We may without to be the with using collaborative case reports in clinical practice from the fact that narratives , even after in are more and metaphorical than the case report. These the of insights and from social and medical should be more frequently to help the physician and patient better understand the illness, the which they face To this we the medical in this the in We a great deal of the case report as a narrative that it interpret, and the healing a of the case report, its joint or can do to the and of adequately sick person in language that is "IS THERE A PERSON IN THIS CASE?" the Case Report of cases to and only become collaborative collaborative case have been in care by Poirier and report that after a usually case-report by a by other of the elicit family and the physician's and the patient's attitudes, and and the patient's This usually would call a description of the patient, embedded with If the by Poirier and Brauner were the case report could be as a collaborative that it could the and immediately relevant beliefs, values, desires, , and of the patient and the physician more the patient a with which to his or her own recovery. the fact that stories and subjective can the to criticism and even to there have been other to cases and to more attention on the subjective of physicians. for example, argues that the case report is other than a story, a narrative that can be as a of a good case report, he requires those skills associated with Lee and that physicians usually on analysis to do their problem but as we does attempt to the of storytelling for the of effort as to the of the medical case by the patient's subjective and by the medical with a made frequent to the of an man from The medical attention the but his who for at by her great in the of their effort to be more subjective and a fuller, more narrative with criticism and by argues that attempt to a written the Monroe, Holleman, and Holleman reality that did in fact and that and his physician could have to the of the suggests that more about getting the story than in the patients. In other words, by a story about the and and of and who become merely in a medical , in view, an of In it should be out that he and his rendered most physicians would consider to be care and that are by the benefit of . that literary benefit from the and in our view, to for his to the and his of using narrative to physicians. Furthermore, this of literary which on the of by especially professional for example, the way the of by the has suggested that the relationship between and human is and It is such that we hope to yet a in the sense, will be present in any that does may physicians from a sense of and in their about patients. point is that the traditional case report is form of rendering and that physicians should consider its and with the critical attention that has been on more narrative We also that physicians should with such modes of especially in be as to the criticism from It would not to take such a to on the methods of rendering patients. The or we call the of narrative no has its and in the biomedical of clinical practice. The of and biomedical technology have been and have physicians and patients to following These the power of the the and of the medical It is this that most the from the patient, and it is to that it is this that patients "IS THERE A PERSON IN THIS CASE?" with their and to Physicians have to on the objective , descriptive the and the exclusion of the narrative history, which in some sense the of the patient. But the of narrative and that can be in our with the running of tests and our in the technology that makes such testing and and Donnelly, then, a to a fuller, more and more narrative than we find in the of the case report. the of narrative to and while Donnelly suggests from to story to make physicians better interpreters more and want to the voice of the