5 Case history-taking
Hearing the patient’s story
Case history-taking, as we discussed in the previous chapter, is the key means of getting to know the patient. The majority of diagnoses in phytotherapy, conventional medicine and many other modalities are based principally on the case history. For example, Peterson et al. (1992), studying medical doctors, found that in 76% of cases: ‘the leading diagnosis after taking the history agreed with the diagnosis accepted at the time the record was reviewed two months after the initial visit’. Yet, despite its central importance, in conventional medical practice, it has been suggested that ‘skilled history-taking is in danger of becoming a lost art’ (Schechter et al. 1996). We can propose that this is likely to be primarily due to biomedicine’s emphasis on acute medicine (where history-taking tends to be pointed and abbreviated) and over-emphasis (leading to over-reliance) on investigative technology. Herbal practice remains a place where the case history is accorded central importance and where adequate space is made available for its exploration. This is in part because herbal practice has been less occupied with acute medicine and more focussed on chronicity (especially since around the mid-twentieth century) and the attendant need of the chronically ill patient for more profound personal exploration of their predicament; and since herbal practice has been excluded from mainstream medicine it has not had direct access to, and therefore has not become excessively entangled with, technological methods of patient exploration.
Regardless of the orientation of one’s therapeutic discipline towards it, however, history-taking remains a tricky art. Students are generally exhorted to ‘maintain objectivity’ and ‘keep a clinical distance’, while engaging with the patient’s story but such directions represent forlorn hopes raised to protect against the fact that case taking is a subjective phenomena and therefore a suspect area of activity viewed from the perspective of positivistic medical science (and this is another reason why history-taking is a threatened species in biomedicine). So we need to ask whether a history can ever be ‘taken’ as if it existed as a solid object that can be ‘extracted’ (Note: it is common for clinical texts to purport to instruct students on how to ‘extract the history’) from the patient and then held up to the light for analysis. To ‘take’ or ‘extract’ a history is to de-contextualize it and risks rendering it an insipid and flimsy simulacrum – great care needs to be taken when basing clinical decisions on such an untrue-to-life creature. Rather the practitioner needs to be aware of the fact that she cannot help but be actively involved in building, constructing and creating the ‘case history’. The case history, as written, is an artefact, and one that usually requires interpretation when being exhibited to others – even colleagues trained in the same style of questioning and documenting. One practitioner’s precise clinical record is another’s incomprehensible screed.
The practitioner is involved in the construction and presentation of the patient’s history of necessity and this fact should be negotiated rather than resisted. The practitioner cannot help but set the patient’s story within her own frame of reference, which is based on her theoretical and clinical training, personal history (early education, parental influence, etc.), political bias, social status, cultural milieu and so forth. In other words, since the practitioner cannot be other than who she is, then the limits to her capacity to comprehend patient’s stories are set by the expansiveness and subtlety of her worldview. The greater the practitioner’s own fund of experiences and stories, and the greater her degree of subtlety of thought, the broader will be her capacity to appreciate the experiences and stories of her patients. The practitioner’s formative influences and inner and outer journeys determine her ability to leave the history in the context of the whole patient as opposed to taking it from them. This is analogous to the herbal practitioner’s insistence on leaving active phytochemicals within the context of the whole plant (amidst a mass of material that is indeterminate or only partially appreciated) rather than extracting isolated active constituents (in order to only deal with factors that are precisely and concretely known).
As the practitioner is ‘taking the history’, she is selecting, editing, omitting, mishearing, ‘overhearing’, interpreting and developing the patient’s picture – by all these means, she constructs a version of events and builds a thesis regarding their significance and meaning. While direction of the patient in this process can be minimized (e.g. by posing ‘open’ questions and avoiding ‘leading’ ones; see below), it cannot be eradicated. Even with the greatest awareness of the various issues involved the practitioner cannot be aware of every factor in the clinical encounter that adapts the way that the patient tells her story, nor, even with identification of the issues, can she change (or predict the impact of) some of these, e.g. the practitioner’s gender, skin colour, accent, age, etc.
Histories are not consistent entities, they change in the telling and retelling and depending on the audience. Patients may discover new insights as they tell their story (a desirable and often therapeutic outcome that should be one of the key goals of history-taking) but alternatively, they may mechanically repeat an oft-told and negatively reinforced self-tale (a scenario to be detected and challenged), or creatively ‘play’ with adding new elements to the storyline to see if they fit or to ‘play tricks’ on the practitioner (strategies that may confuse or mislead the practitioner if they are not picked up on).
Epstein et al. (1997) maintain that: ‘For generations, there has been little change in the method of recording information from the history’, but is such an argument sustainable? Certainly the ‘method of recording’ has changed dramatically, at least in biomedicine, in that patient records are now computerized, although we will save discussing the intrusion of the computer as the ‘third person in the consulting room’ for later. I take Epstein to mean, however, that the process of taking the history is little changed, but again this is hard to credit. As doctors have moved from the bedside to being desk-bound, there has also been a shift of location of emphasis from the context of patient (represented by ‘bed’: resting, sleeping, dreaming, copulating) to that of doctor (’desk’: acting, writing, filing, working). Factors such as the means by which information is recorded and the setting in which information is obtained affect the conduct and content of the consultation itself, including history-taking.
We should not assume, despite the emphasis placed on the importance of the history at the beginning of this chapter, that the ‘case history’ – meaning a verbal dialogue between patient and practitioner – has always been the dominant means of knowing the patient or that ‘case history’ has always equated to ‘verbal dialogue’. Kuriyama (1999) provides an alternative perspective:
In the second century B.C.E., in the earliest case histories of China, the sick summon Chunyu Yi not with vague pleas for succor, but with the specific wish that he come and feel their pulse. And that is just what the great doctor does. In each case, he arrives, straightaway grasps the pulse, then prescribes a remedy, explaining, ‘The way I knew the ailment is that when I felt the pulse …’ As if it were all a ritual, and his role was that of pulse interpreter.
Primary focus on the pulse was not limited to China but, based on the pronouncements of Galen, dominated diagnosis in the west until recent centuries. Kuriyama names the four ways of assessing patients used in ancient Chinese medicine as: ‘gazing (wang); listening and smelling (wen); questioning (wen); and touching (qie)’, but asserts that ‘in practice … attentions concentrated mainly on qiemo, palpating the mo’. Mo can be translated as (but without being limited to) blood vessels or pulse. This focus on the pulse contrasts with the diagnostic hierarchy outlined in various classic Chinese medicine texts described by Kuriyama. For example in the Nanjing:
Whereas the Shanghanlun ‘was blunt: the physician who knew by gazing belonged to the top class (shanggong); the physician who questioned and knew was average (zhonggong); the physician who touched and knew was inferior (xiagong)’.
Kuriyama concludes that: ‘Mastery of medicine was defined first by an exceptional eye’, and proceeds to discuss the subtleties of what was represented by the concept of the diagnostic ‘eye’ and the ‘gaze’. We might consider the progression of this emphasis on visual knowing to extend through X-ray machines to MRI scanners though the notion of the doctor’s ability to ‘see inside’ the patient is an ancient one.
Commenting on the case reports collected in the Hippocratic Epidemics, Nutton (2004) observes that the authors ‘are already selective in their presentation of signs and symptoms, focussing in particular on things that would, in future, enable the writer (and later his audience) to estimate the severity of a similar condition, forecast its outcome and, where possible, intervene successfully’. Nutton lists the relationships and features associated with disease described in the case histories in Epidemics 1:
… the common nature of all things and the particular nature of the individual; the disease and the patient; the regimen prescribed and the prescriber; the constitution of the heavens and the region, in general and in particular; the custom, way of life, practices and age; talk, manner, silence, thoughts, sleeping or not; dreams, plucking, scratching, tearing; exacerbations, stools, urines, sputa, vomit; the stages of a disease, and its potential for crisis and death; sweat, rigor, chill, cough, sneezes, hiccoughs, flatulence, haemorrhoids and haemorrhages. Behind all this lies shrewd, careful and accurate observation, using all the senses.
Yet these are reports dealing with acute cases and we hear fewer stories regarding chronicity from ancient medical texts, partly because, as Nutton explains: ‘given the age structure of the population, the degenerative diseases characteristic of the twentieth century will have been fewer in number’, and partly due to a different conceptualization of disease, in that ‘ancient doctors saw the gradual physical and mental deterioration of old age as part of an inevitable process’ so that consequently, ‘it is not the infirm we hear of, but the exceptions, the hale and hearty, like the Elder Pliny’s centenarian friend Antonius Castor, still pottering around his herb garden’. Nutton points out the importance of prognostic ability in early Greek doctors, as a means of establishing trust in their capacities. Prognostic skill was a means by which the doctor ‘could establish his credentials and, at the same time, protect himself against accusations of malpractice. By being able to predict the likely outcome of a disease … he could gain obvious credit for a cure … [but] should the patient die, he had a strong defence if he had already announced that this was a likely outcome’. An emphasis on prognosis then served as a ‘tactical’ strategy regarding ‘both advertising and insurance’ but was not limited to these goals since it was also ‘essential to the understanding and treatment of the individual patient, ensuring that whatever is prescribed will be appropriate for that patient’. Furthermore, ‘the doctor who professes the art of prognosis declares that his particular technique deals with the past, present and future of his patient, a bold claim incorporating what today would be termed obtaining the case history, diagnosis and prognosis’. This attempt to stand in the present and yet be able to look backwards and forwards in time continues to be one of the hallmarks of the clinician but also constitutes one of the key characteristics of the shaman. ‘Shaman’ can be translated as ‘one who knows’ (or ‘clever fella’ as McKenna reports) and figures occupying the shamanic role typically act simultaneously as repositories of the history of the tribal group; authorities on the present; and seers who are able to predict future events. Healthcare practitioners, then, partake in a shamanic tradition at least in being accorded the status of possessing an uncommon temporal facility. The origin of case history-taking in the consultation then might be extended back to shamanism in archaic cultures.
The case history represents a gathering together of information about the past and the present in order to be able to see into, and to make predictions about, the future. The current emphasis in conventional medicine on diagnosis, prognosis and acute cases therefore does not represent a particularly recent trend. However, the reliance on technology and the extent to which the individual personal characteristics of the patient are excluded from consideration do signify breaks with a long medical tradition and are major current influences preventing mainstream medicine from adapting to meet the requirements necessitated by the shift in burden from acute to chronic disease. Current mainstream medical methods of assessing past impacts, present influences and future likelihoods, including imaging technology and genetic testing could be considered as a concretization of archaic visionary capacities or as phenomena emerging within an ancient project. The major concern surrounding the point now reached has to do with the extent to which this continuum has shot beyond the human dimension to a place where the patient is viewed differently – de-personalized and disembodied.
The relationship between herbal medicine and shamanism is profound but complex. In ancient indigenous cultures, the possession of substantial personal knowledge of the healing properties of a wide range of plants is commonplace and tends to be seen as ordinary or basic knowledge that is therefore considered unremarkable, although some people have greater knowledge than others and are accorded ‘practitioner’ status. Lenaerts (2006) studied the Asheninka people who live on the Peru–Brazil border and found a distinction in that: ‘Shamans are deemed to have a superior knowledge, since they are able to heal illnesses that ordinary people or herbalists cannot’ although herbalism and shamanism do not represent ‘two specialized, separate fields of healing, (rather) they form two distinct expressions of the same issues’ [original emphasis]. The shaman’s advantage does not rest in his superior knowledge of plants (in fact Lenaerts suggests that, in some cultures at least, the shaman may know less about healing plants than other types of healers) but rather in his status as a ‘specialist in relationships with other beings’. The Asheninka shaman is able, with the assistance of ingested ‘entheogenic’ plants (entheogen means ‘God generated within’, and is an alternative way of viewing and describing so-called ‘hallucinogenic’ plants) to meet other beings such as plants, animals and stones as people. Discourse with these beings can lead (among other things) to diagnostic insights and the subsequent implementation of therapeutic strategies.
Such encounters also give rise to creation stories, human–environment relationship schemas and rationales for the interpretation of experiences. They are the source of philosophies, religions and medical systems and they unify and hold together the distinct cultures that the agglomeration of these elements give rise to. We are engaged here with the construction and interpretation of worlds, plunged into the matrix of myth, story, saga, fairy-story, morality-play and ‘case history’ that spin out of this generative centre. Although it may seem at this point that we have travelled a long way in this chapter, and very quickly, the suggestion remains that if we follow the thread of what the case history actually is (i.e. an attempt to temporally comprehend one person, to understand their predicament and to discern ways of assisting them), back far enough it will lead us to the root of art, science, philosophy and medicine that resides in the person of the shaman and in the presence of the entheogen.
It is difficult to perceive the sacred worldview from the perspective attending that of the profane but the shaman and the physician share a common origin. Both are ‘ones who know’ and what they know has to do with nature – they know the nature of nature. In origin and essence both encompass the roles of artist, scientist, philosopher and healer. Although the scope of the physician (whether phytotherapist, doctor or other) has diminished to the generic mediocrity of ‘healthcare practitioner’, the territory and the possibility of the shaman remain available and are accessible through means of ‘taking the history’, since the case history is the place where all our stories come together and where time travel is the mandatory mode of transport.
Referring to the ‘case history’ may seem somewhat inadequate to the task of describing a way of looking that includes assessment of the present and speculation about the future, since ‘history’ is commonly perceived as referring to the study of what is past. Collins English Dictionary (2000) describes ‘history’ as deriving from ‘Latin historia, from Greek: enquiry, from historein to narrate, from histor judge’ and gives one definition of history as a: ‘Narrative relating the events of a character’s life’. Enquiry, narrative, events, judgement – these are all features of the consultation that can easily be identified with the case history. Churchill’s Medical Dictionary (1989) defines the case history blandly as: ‘A recording of information relating to a particular case …’. This view, emphasizing the production of a historical record by a neutral observer, lacks any sense of the assessment and dynamic interplay that occurs during the process of history-taking – of what the practitioner gives to the encounter alongside what she takes away from it. So perhaps there is a better term to describe the question and answer session that transpires during the consultation, and which, in contemporary phytotherapy at least, forms its most significant part?
It was the convention in medical textbooks on clinical examination until recent times to describe it as ‘the interrogation’ (e.g. Hunter & Bomford 1956; Macleod 1967). This term refers to formal and detailed questioning but it also suggests aggression and its use in medicine is now hard to countenance since the word ‘interrogation’ is inextricably linked with a visual image of a bright light being shone into one’s face. The negative associations we have with the concept of interrogation are disturbing, since we now connect the word with torture. Many authors have described and considered the history of, and continuing involvement between, medicine and torture (e.g. Maio 2001; Lifton 2004; Klein 2007). A recent questionnaire-based study (Bean et al. 2008) exploring the attitudes of one population of American medical students (336 students at the University of Illinois College of Medicine) to the ‘permissibility and ethics of the use of torture’ found that ‘35 percent of students agreed that torture could be “condoned” under some circumstances. Moreover, 24 percent … disagreed that torture should “be prohibited” as a matter of state policy and a similar 24 percent disagreed that torture was “intrinsically wrong”’. This is a hugely complex as well as troubling area but we may suggest that an excessive, indeed a pathological, emphasis on objectivity and clinical distance is one amongst a number of underlying factors that enable medical torture. If objectivity extends to the objectification of bodies, and if clinical distance ranges to the point where human connection and feeling is lost, then some of the conditions in which unforced torture can be conducted are set. Clinicians are still encouraged to ‘put the spotlight on the patient’ and ‘keep yourself out of the picture’ but we should remain aware of the double reading that is possible when this type of language is used.
More recent textbooks on clinical examination have tended to refer to history-taking as ‘the interview’. This can be read as an attempt to retain the formality and the objectivity/neutrality of the practitioner implicit in the use of ‘interrogation’ while losing the negative correlations that word now gives rise to. The move from ‘interrogation’ to ‘interview’ also represents a shift from the practitioner as ‘policeman’ to the practitioner as ‘manager’. To be interviewed is to be cast in the role of applicant or news item. The practitioner-as-interviewer has a power role where she can:
• Act as a journalist in taking the patient’s information and spinning it into a (more or less reliable) story. In this role we can see the short conventional medicine consultation as a form of rushed TV interviewing where only pre-formulated sound-bites can register and a nuanced discussion of the complexity and multidimensionality of a given issue is impossible.
Some clinicians have suggested the use of ‘conversation’ (e.g. Kaplan 2001), which is certainly informal and devoid of unpleasant connotations but seems a little, well, aimless and insipid. We know that a lot of conversations ‘don’t go anywhere’, that people tend to make ‘polite conversation’ and do things ‘just for the sake of’ conversation. Perhaps it would help if we medicalized it by calling it the ‘clinical conversation’? Or therapized it by calling it the ‘therapeutic conversation’? Or how about we try something else – the ‘discussion’ anybody?
Perhaps, after all, ‘the history’ still works best since it suggests a comprehensive view and implies an attempt to take in and make sense of the big picture. In which case, it may be helpful to explore the notion of ‘history’ as applied to the consultation in a little more detail.
The way that history is practised varies but the archetypal model reflects the dominant scientific values of contemporary western culture. This type of history is based on objectivity, chronology and classification. Complex, sinuous themes and elliptical notions are forced into ill-fitting (and sometimes delusional) categories such as that of ‘the baroque period’ or ‘the scientific revolution’. Other forms of historical method focus more on contextualization and interpretation but even here the preference is to begin deconstructive work on what purport to be finished objects. The patient represents history-in-process and only becomes a finished project when the heart stops beating – a study option that is not consistent with the aims of the clinician!
Gadamer (1989) addresses the issue of historical analysis and its temporal separation from its topic of study, commenting with reference to works of art. He recognizes that in historical studies, it is generally believed that: ‘objective knowledge can be achieved only if there has been a certain historical distance’ from the creation of the object, and maintains that ‘it is true that what a thing has to say, its intrinsic content, first appears only after it is divorced from the fleeting circumstances that first gave rise to it’. A person is not a ‘thing’ and does not materially endure for long, although the same could be said of ‘the baroque period’ or ‘the enlightenment’ and yet, these continue to be topics of historical study. We can consider previous events in the patient’s life (or their ‘previous medical history’) to represent ‘things’, however – at the time of the consultation the patient may have achieved enough distance from the event for it to be open to analysis and be capable of yielding its ‘intrinsic content’. Yet the practitioner is frequently trying to make sense of events as they happen, to make sense of ‘fleeting circumstances’ especially in acute medicine. At these times it is necessary to make the best judgement one can and then to keep that assessment continually open to revision.
Gadamer (1989) further describes the dominant historical perspective:
The positive conditions of historical understanding include the relative closure of a historical event, which allows us to view it as a whole, and its distance from contemporary opinions concerning its import. The implicit presumption of historical method, then, is that the permanent significance of something can first be known objectively only when it belongs to a closed context – in other words, when it is dead enough to have only historical interest.
In terms of living patients, ‘relative closure’ is the only type of closure available and it will rarely be possible to gain much distance from ‘contemporary opinions’; such an achievement is only attainable when we view events-as-things in older patients where sufficient sociocultural and medical change may have occurred within one lifetime for that event to be viewed differently (as has happened with, e.g. HIV/AIDS). Even then we can never be certain that this ‘different view’ represents the definitive, ultimate, true or truest view – it can only appear to be relatively such. Let us return once more to Gadamer as he criticizes the historical method previously outlined, saying that it represents a paradox since:
… the discovery of the true meaning of a text or a work of art is never finished; it is in fact an infinite process. Not only are fresh sources of error constantly excluded, so that all kinds of things are filtered out that obscure the true meaning; but new sources of understanding are continually emerging that reveal unsuspected elements of meaning. The temporal distance that performs the filtering process is not fixed, but is itself undergoing constant movement and extension.
The same argument holds for people and it well describes the potentiality of practice – to increasingly discover the self and discern enhanced meaning. It also holds for texts about those no longer living. Consider the ways that successive biographies written about people (e.g. Joan of Arc, Napoleon, Bernard Shaw, Sylvia Pankhurst, Orson Welles) follow the process described by Gadamer. Each successive work (if it is any good/worth reading) filters what was previously known, finds new information and arrives at new meanings and each new biography reflects the time it was written in. There is no closure, then, on a remembered life long after it has been lived just as the same is true of life as it is being lived. There is no closure, only a state of natural chaos fluxing with the eternal emergence of new phenomena. The search for absolute objectivity in the human case history constitutes the pursuit of an unrealizable goal that should therefore be abandoned. Rather the practitioner ought to relish the challenges and breakthroughs that result from engaging dynamically with the contingent, latent and emergent worlds of patients, learning to work with relative wholes and testing theories and refining approaches in the light of feedback.
In the introduction to their exceptional book looking at emotions and their connections with the ‘histories of art, music and medicine’ Gouk and Hills (2005) describe an approach to the practice of history that fits with, and contains insights for, that pertaining to the taking of the case history:
The essays collected here do not, and of course could not, constitute a chronological or geographical survey of the representation of emotions in Western Europe since the Greeks. More significantly, we have not privileged those historical conjunctions conventionally identified as crucial for changing patterns in emotional articulation (for instance, the Ancient World, the medieval era and the eighteenth century), nor singled out those thinkers most usually credited with formulating new approaches (e.g. Plato, Aristotle, Augustine, Descartes, Le Brun, Spinoza, Rousseau, Voltaire). Instead, our principal aim has been to focus the investigative spotlight on specific moments when one formulation of emotions conflicts or converges with another, or when gaps or ellipses in one discourse on emotion are illuminated by another. In adopting this dual approach, we draw attention both to the necessarily non-disciplinary ways in which emotions have been conceived and to the complex processes by which some ideas eventually achieve authoritative status while others wither, neglected.
With a little work, the above could be adapted to form a manifesto for the holistic case history, one especially suited to chronic pictures, bearing in mind the points made in the previous chapter and given that:
• Chronological and geographical considerations are similarly difficult in the consultation – recall the non-chronological chaos narrative and the difficulty of anatomically locating conditions such as chronic fatigue syndrome.
• We could use identical language to describe one of the primary aims of the case history as being to: ‘focus the investigative spotlight on specific moments when one formulation of emotions conflicts or converges with another, or when gaps or ellipses in one discourse on emotion are illuminated by another’. This statement of intent has even wider utility if, in place of ‘emotions’ we broaden the remit to ‘emotions/symptoms/stories’.
Foucault (1963) has distinguished between the ‘historical’ and ‘philosophical’ perception of disease. Here, ‘history’ has to do with such matters as the symptoms and course of the disease whereas the philosophical approach calls ‘into question the origin, the principle, the causes of disease’. In practice these are not separate but rather interweaving lines of thought – as soon as we have some sense of the historical features of the patient’s condition we philosophize as to their meaning. The ebb and flow of this process is strongest in the early part of the consultation where multiple philosophical analyses may be made rapidly and, indeed, intuitively, in response to historical information until the field of options becomes clearer (note that this does not necessarily mean narrower). The practitioner cast as historian, then, needs to be a historian–philosopher; but what use would a historian lacking in philosophy be in any case?
Leder (1990) argues that: ‘clinical medicine can best be understood not as a purified science but as a hermeneutical enterprise: that is, as involved with the interpretation of texts’ and he identifies four textual forms that relate to the consultation:
Of these, the central two constitute the texts available in the consultation, the last is a subtext that may inform the consultation and the first refers to the patient’s life outside of the consultation. This latter text is the most important to the personal experience of the patient but the least accessible in the consultation – although all three of the other texts can combine to attempt some degree of approximation of it. The narrative text of the case history most particularly represents the practitioner’s effort to appreciate the experiential text of the patient’s lived experience. The history represents the practitioner’s best chance of understanding the patient’s life and its attendant phenomena.
How far can/should we take the concept of textual analysis? Leder suggests we should follow the hermeneutical thread a long way down because, at root: ‘certain flaws in modern medicine arise from its refusal of a hermeneutical self-understanding (such that) in seeking to escape all interpretive subjectivity, medicine has threatened to expunge its primary subject – the living, experiencing patient’. The case seems an urgent and crucial one then, except this analysis fails to factor in the substantive rebellion that takes place daily at grassroots level on the part of both patients and practitioners who reject being treated/treating people like automata rather than persons. Churchill (1990), however, argues that Leder does not go far enough and that it is insufficient to limit the hermeneutical argument to medicine, it should be extended to recognize that science itself is, at its core, a hermeneutic enterprise. Baron (1990) meanwhile queries the notion of the textual metaphor since it ‘runs the risk of conceptualizing patients as more static than they are’ and because it does not fit the characteristics of the consultation in that ‘the qualities of mutuality and determinacy are not those one usually associates with texts’. Baron ends by calling for a different metaphor that captures the uncertainty resident in practitioner’s comprehensions of patients. OK, Baron says, you’ve told us to look at the patient’s texts – but it just doesn’t work like that; that doesn’t fit the reality of the clinical encounter – even if one is well disposed to the hermeneutical way.
Churchill (1990) argues that it is necessary to question the foundations of medicine and science and discover that they rest on a base that has to do with hermeneutics. Upshur (2002) questions the notion of a ‘base’ for the practice of medicine with regard to a discussion of evidence-based medicine (EBM) and suggests that, if we are to talk of bases and foundations, they must be pluralistic in nature. Upshur sees no reason why there should be any ‘sharp conflict between facts and values’ and references medical and scientific theorists who are attempting to overcome this duality. He perceives a growing appreciation of the ‘complex values, perceptions and beliefs that frame how medicine is practised’ and notes that the ‘focus on interpretation, subjectivity, natural language and qualitative methods highlights dimensions of practice that escape the methods of EBM’. Such a focus on combining interpretive approaches ‘is likely to lead a move from the metaphor of a uniform base for medicine as the consideration of the qualitative domain acknowledges multiplicity of perspectives and meanings’. Furthermore, Upshur asserts: ‘medicine and health care are not in need of a single solid foundation, but can operate well in a dynamic emergent framework’ that is woven from these multiple ways of perceiving. This brings us back to the fund of stories that represent the roots of knowing and how we might make sense of these ‘texts’ as they form within and around the individual patient and returns us to Baron’s query about how we can work with patient’s texts in a way that reflects the inter-relational plasticity of the clinical encounter and which takes account of the underlying uncertainties in this dynamic. We can best deal with this by moving on to the next section considering one key interpretive method that can be applied to case history-taking.
Much has been written about which techniques and behaviours constitute ‘communication skills’ and how they can be developed and we will draw on some of this work later in this chapter. We will also discuss the structure of the consultation format and the steps in its enactment in the ‘History formats’ section of this chapter. However, regardless of our knowledge and ability in applying such skills, and despite our structural awareness, what we hear in the case history and what we learn from it will be shaped by what we are listening out for (what we are tuned to hear). This tuning is adjusted by what we think are the aims of the consultation and what we think is going on in the case taking. The narrative approach considers that what is essentially occurring in the consultation is a process of storytelling, although this, in itself, tells us little – no more than the blank assertion that patients can be perceived as a collection of texts. What is key to unlocking both of these concepts (history-as-story and history-as-text) lies in the interpretation of these phenomena. Narrative-based medicine represents a contrasting approach to positivistic, deterministic, reductionist medicine in that it is interpretivistic, relativistic, holistic. But stating the case in this way is to suggest a polarity of thought and action that, while it is easy to set on the page (in the ‘text’) does not accurately reflect the reality of practice. Practitioners may, when they think about it (or more commonly when they are asked to think about it) come down on one side or other of an ideological divide between positivism and interpretivism but in the act of practising we tend to be pragmatic. I have already suggested, for instance, that different approaches come into play in dealing with acute and chronic cases. Practitioners in action do not pause to think ‘hmm, shall I take a positivistic or an interpretivistic approach here?’, rather, having an awareness of differing approaches and knowledge of a variety of models and techniques provides options and informs practice.
Narrative-based medicine (NBM) is not an alternative to evidence-based medicine (EBM). Patient narratives are a form of evidence just as research represents a type of narrative. If we recall Sackett et al.’s (2000) definition of EBM as ‘the integration of best research evidence with clinical expertise and patient values’, then we can easily see NBM as providing us with an appreciation of the patient’s part in this triad but we can also view each element of EBM as a narrative type since each is a text and each is a story: ‘research evidence’, ‘clinical expertise’, ‘patient values’ – all stories. Research evidence is a collection of texts, accounts of (or ‘stories about’) studies conducted with an attempt at objectivity (quantitative research) or subjectivity (qualitative research) with each type being open to (and standing in need of) interpretation. Clinical expertise represents accumulated knowledge and skills in action but which can be assessed and described in the form of texts (supervision and peer-review reports; patient feedback forms; practitioner self-reflection documents and so forth) which tell stories that can be interpreted. Patient values (which I take to mean patient opinions, expectations, preferences, morals, etc.) can be assessed in the case history, written down as text and interpreted. Seen from this perspective, any notion of setting up NBM/EBM as opposing models breaks down and becomes unsustainable – they are in actuality merely different takes on the same stuff.
NBM has the potential to be used to scrutinize scientific research evidence and practitioner activity in addition to its usual area of application – the patient’s story. We will shortly move on to focus on this latter domain but need first to point to the practitioner’s involvement with the generation of the patient’s narrative. The way in which stories are told (or performed) in the consultation space, and their content, to varying degrees, is potentially influenced by a number of factors, difficult to exhaustively enumerate and even more difficult to estimate in terms of the extent to which they may have shaped the story. Such factors, on the part of the patient, include:
• Time: whether the patient feels there is enough time available to express themselves (and whether they have enough time to give to the consultation, e.g. they may be in a rush to get home or to another engagement)
The practitioner has some influence over some of these factors and, through active awareness of them, may be able to modulate them. A simple preamble to the consultation will go a long way, for example:
Of course, one can only convey such signals if they are true (i.e. you really do have enough time) and if you mean them – you really do want to know the patient’s story and are not secretly afraid of ‘opening Pandora’s box’ (or at least not so afraid that it stops you trying). A simple strategy like this will only wield its power if the patient believes you and this will only happen if the statement is genuine. Patient’s know when they are being sold a line and trust is diminished when they feel that this is occurring.
These simple sentences act as catalysts for the construction of a narrative but they also set an orientation for the way the narrative should begin. This capacity can be utilized by the practitioner to direct the patient specifically or minimally. Consider, for example, an opening line in a follow-up visit where the patient had previously consulted regarding headaches:
These are virtually identical but radically different, since the first directs the patient straight to a targeted narrative and the second leaves an open space for the patient to bring in whatever is most significant for them. Line 1 invites the patient into a restitution narrative, whereas line 2 opens the possibility of a quest narrative. The patient may respond similarly to either question but there is a risk of missing valuable new information in scenario 1 since this line may be read by the patient as meaning that you only want to know about the headache and are not interested in any additional symptoms that may have arisen between this visit and the last. In scenario 2, you will get on to asking specifically about the headache if the patient has not already mentioned it but you give an opportunity for additional stories to be told first. It can easily be seen from this example that the practitioner partakes in the construction of the patient’s narrative – somewhere along a spectrum from extensively so to minimally so. The practitioner is not, therefore, merely a witness to an improvised performance on the theme of the patient’s autobiography (practitioner-as-audience) rather, she is an active participant in the creation of the story (practitioner-as-ghost-writer).
The practitioner must be aware of her role, power and opportunities in influencing the formation of the patient’s narrative on the one hand but equally aware of her interpretation of it on the other. These two strands: narrative formation and narrative interpretation are the key strands of narrative-based medicine.
So how and when should the interpretive exercise around the patient’s narrative be done? Elwyn and Gwyn (1999) commend the use of discourse analysis which they describe as: ‘the study of language in context … [which] has its roots in linguistics, sociology and psychology but … is really no more than the examination of the processes of naturally occurring talk’. This is a method of textual analysis which works with detailed transcripts of ‘talk’ that are written using notation to indicate pauses, breaths taken, intonations, coughs, etc. Some study is required in order to be able to write and read such transcripts, particularly with regard to learning the language of the symbols used for notation. Discourse analysis can reveal the signals that patient and practitioner give to each other, not only in the words spoken but by pausing, coughing, etc. Practitioner and patient can send signals that indicate their:
We tend to think that we notice these things automatically but discourse analysis reveals how much we miss – especially at the subtler end of the spectrum. Working with discourse analysis then can be hugely valuable in enhancing appreciation of what is actually being said in the consultation, what is wanting to be said and what is not being said. This method takes place in connection with written texts and therefore happens after the fact of the consultation. Nevertheless, it can help develop skills that can then be applied during the consultation. This is vital since practitioners do not deal with written texts, they work with living people and the discourse analysis cannot wait until after the consultation if it is to be helpful to specific patients – it must occur while the consultation is happening. We therefore need to practise a form of discourse analysis in action so that, as the concept of reflective practice maintains, the practitioner can conduct reflection in practice (during the consultation) as well as reflection on practice (after the event). The practitioner’s task during the case history, then, is multilevelled and complex since it combines a number of overlapping or simultaneous foci that must be accounted for, comprising considerations given to:
Although it might be suggested that these four steps be taken sequentially, that only tends to happen at the student or novice practitioner level since one of the hallmarks and necessities of highly skilled practice is the ability to continuously access maps, models and options and to generate and test hypotheses. This is what happens during the case history – this is the heart of it. The key to successful practice in narrative-based medicine lies with the ability to retain primary focus on the patient and what is actually being said while (and not instead of) reflecting and hypothesizing. Having said this it should also be appreciated that there are crucial moments where the practitioner should give total attention to the patient, consciously suspending all other considerations (as far as that is ever possible).
We tend to think of narratives as linear entities; after all, is it not so that all ‘good’ stories have a beginning, middle and an end? Patient narratives are not like this, as we observed in the previous chapter – patients generate multiple stories which overlap, intertwine, repeat, dissolve, mutate, conflict with each other, fizzle out, ‘go nowhere’ and are subject to continual revision. The method of construction of patient narratives is more reminiscent of William Burrough’s cut-up technique than that prevailing in the eighteenth century novel. The practitioner working with narrative needs to pick up on cues, make connections, check for meaning and scry for potentials but should be on guard against, and resist the urge, to form the patient’s narrative into a neatly comprehensible linear tale, let alone try to match and locate it within any single grand historical narrative. In reading about NBM, one gets the feeling that some authors see it as a new medical utopia. Let us guard against this impulse too. NBM, again, represents just one model that is there to be integrated with a multiplicity of others enabling an increased synergistic dynamic.
Gray (2007) has warned of the dangers of constructing grand unifying narratives in a searing critique of current utopianism and millenarianism:
The dominant western myths have been historical narratives, and it has become fashionable to view narrative as a basic human need. Humans are tellers of tales, we have come to think, who cannot be happy unless they can see the world as a story …