Allopath endorses “Anecdotal Evidence”

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http://medicine.plosjournals.org/perlserv/?request=get-document & doi=10.1371/jour\

nal.pmed.0030423

 

“Anecdotal Evidence”: Why Narratives Matter to Medical

Practice

 

Rafael Campo

 

Rafael Campo teaches and practices general internal

medicine at Harvard Medical School and Beth Israel

Deaconess Medical Center, Boston, Massachusetts,

United States of America. He is the author of seven

award-winning books of poetry and prose, most recently

The Healing Art: A Doctor's Black Bag of Poetry (W. W.

Norton, New York, 2003). E-mail:

rcampo

 

Funding: The author received no specific funding for

this article.

 

Competing Interests: The author has declared that no

competing interests exist.

 

Published: October 24, 2006

 

DOI: 10.1371/journal.pmed.0030423

 

Copyright: © 2006 Rafael Campo. This is an open-access

article distributed under the terms of the Creative

Commons Attribution License, which permits

unrestricted use, distribution, and reproduction in

any medium, provided the original author and source

are credited.

 

Citation: Campo R (2006) “Anecdotal Evidence”: Why

Narratives Matter to Medical Practice. PLoS Med 3(10):

e423

 

I want to tell you a story. After a lecture I gave

recently at a well-known medical school on the

possible utility of narrative to clinical practice,

from the back of the auditorium came the first

question of the traditional question and answer

portion of the program: “Don't you feel, Dr. Campo,

that what you seem to regard as the arrogant

biomedical science model of medicine is already

sufficiently under attack these days?”

 

As the lights came up, I could make out a tall,

bearded man in a long white coat, standing as if at

attention near the end of one of the aisles. “We have

creationists trying to teach ‘intelligent design’ in

our children's science classes, and even closer to

home, nurses and optometrists being given the right to

prescribe medications.” Their applause having ceased,

my audience now grew hushed as he went on, his voice

steadily rising.

 

“Do you really expect physicians to accept the notion

that what any ignorant patient tells us about his

disease should carry a weight equal to what our years

of training and expertise reveals to us about complex

pathophysiology?” Then came what was clearly meant to

be his coup de grace, delivered in an almost derisive

tone. “Really, sir, do you have anything more than the

anecdotal evidence you shared to support your thesis?”

Our Skepticism about Anecdotes

 

Of course, like any physician trained in the past

several decades, I too had learned to view the

anecdote with the greatest amount of skepticism, if

not outright disdain. The anecdote, though beguiling

in its familiar engagement of our human sensibilities,

is, we are all taught, the enemy of objective,

dispassionate observation.

The anecdote is rife with such difficulties as

openness to interpretation, and the biases of faulty

memory and foolish optimism; it is just as likely to

be explained by fickle chance as by anything truly

under the clinician's control. It is colored by the

inflections

Whether we choose to admit it or not, the anecdote

continues to be an important engine of novel ideas in

medicine.

in our voices and shaped by our gestures and facial

expressions. The case report counts not for academic

promotion, while the randomized controlled trial of

thousands of anonymous subjects has become the lingua

franca of our profession, and for good reason, as

rigorous epidemiologic studies have replaced mere

conjecture with sound, evidence-based understanding of

the causes of countless diseases and effective

treatments for them. Yet to offer an anecdote these

days is almost to admit the insufficiency of one's

knowledge, and so we do so, at least to our fellow

physicians, very apologetically.

Why Narratives Matter

 

The inscrutably enduring power of the anecdote itself

is what incites all our most fearsome defenses. So

furious are we in our rejection of the merely

anecdotal one cannot help but begin to wonder at it.

What is it in the ostensibly harmless tale my

great-grandfather told about the secret of his

longevity being the small glass of bitters mixed with

a raw egg he downed before bedtime each night since

the age of ten that rallies us to spend billions of

dollars in grants from the National Institutes of

Health , disbursed every year to scientists seeking

their own more explicitly pharmaceutical recipes for

living longer? Why does our clinging to superstition

and our willingness to be intrigued by mystery provoke

such an angry, unrelenting diligence? An anecdote,

after all, is just a story.

 

The irony in our growing intolerance of the anecdote

is that storytelling is full of lessons in imagination

and invention so beneficial to the creative

investigator. One of my favorite, if somewhat

hackneyed, anecdotes is the one told to me by my wise

organic chemistry professor at Amherst College, who

claimed that the discoverer of the elusive structure

of benzene said his breakthrough idea of the ring of

six carbon atoms linked by slithering electron bonds

came to him in a wild dream he had of six snakes

swallowing each others' tails. Thus we can begin to

see how such dynamic constructs of narrative—the

characterization of carbon atoms as lithe snakes, the

metaphor of slippery bonds formed by swallowing one

another's tails—animate the static concepts that

perhaps frustrated more rigidly linear thinkers in

their attempts to solve what had been an abiding

chemical conundrum.

 

Whether we choose to admit it or not, the anecdote

continues to be an important engine of novel ideas in

medicine. No matter how wide the perceived rift

between science and the humanities, and no matter what

new technologies may deliver unto us in terms of more

precise tests and life-prolonging therapies, the work

of doctors will always necessarily take place at the

intersection of science and language. How many of us

have first felt inspired to dig deeper into a question

that first took shape in the form of “a couple of

interesting cases”—the beginnings of a case series, in

epidemiological parlance—shared by a colleague over a

cup of bad doctors' lounge coffee?

 

When we fail to listen to our patients' stories, we

lose the opportunity to discover what truly ails them

 

(illustration: Anthony Flores)

 

Our patients' stories too, if only we could listen to

them less critically and cynically, might similarly

inspire us to the more practically important

discoveries of what truly ails them. Yes, we must

always be wary of the ways in which the interlocutor

may lead us astray; the possibility of violation of

the narrative contract, that implicit agreement

between us that the story being told is truthful and

offered in the service of best care, is a real one. A

patient in distress may speak to us across a chasm so

vast that what we can hear is terribly distorted—by

our professional distance, by our own most

unprofessional fears and misapprehensions, and by

society's attitudes which inescapably contextualize

our every action.

 

One common clinical scenario has become so familiar as

to be regarded as paradigmatic of our distaste for the

subjective. The patient, we frequently suspect, is

exaggerating her pain to obtain more narcotics, so we

check to see if she is tachycardic, or whether she

perspires or writhes in her sheets, ever on the

lookout for more reliable objective signs of what her

suspiciously anecdotal description fails to convey.

Yet even in the face of language's shortcomings and

betrayals, understanding narrative ultimately helps

us. If we can recognize a breakdown in our

communication with a suffering patient, we can begin

the crucial process of repair—usually by explicitly

re-establishing the ground rules of empathetic mutual

trust upon which any exchange of language must be

based.

 

Perhaps it is our own mistrust of the anecdotal that

has engendered the backlash against science to which

my interrogator at that recent lecture alluded. We

seem to be of two minds when it comes to science as it

relates to our ever defiantly human bodies. While we

look to medicine to offer us the fruits of its inquiry

into our innermost life-giving processes, at the same

time we refuse to be entirely explicated. We want

answers, but not all the answers. We want Tamiflu as

well as talismans to protect us from avian influenza.

“I Want to Tell You a Story”

 

The young daughter of a patient of mine wrote a poem

about a flamingo, “so the birds won't get mad and make

us sick.” At the bottom of the page blazed a hot pink

stick figure of a bird, as if she had drawn fever

itself. Might her fervent belief in the power of her

own words somehow stimulate her immune system to fend

off an unlucky exposure to a bird-borne virus? In all

the millions of epidemiologic studies we have

published in thousands of medical journals, we have

yet to prove the mechanism behind a phenomenon evident

in nearly all of them: the placebo effect. Perhaps

there remain ideas about ourselves and our bodies that

can never be summarily studied?

 

“I want to tell you a story,” another patient of mine

said to me a few weeks later, back home in Boston, in

the quieter theater of daily life. She was dying of

multiple myeloma that afternoon. No more melphalan and

prednisone, which had caused diabetes, nor more

thalidomide, which had given her neuropathy; instead,

she received only morphine now, because all that was

left to treat was her pain. Rain fell relentlessly

outside, streaking the windows in a way that made me

think inanimate objects might somehow feel sadness.

One of her daughters clutched my hand. I looked into

her mother's watery, deep brown eyes, which at that

moment seemed a well of stories so absorbing and so

numerous that they might unspool forever. “I want to

tell you a story,” she said again. Perhaps she was

going to God, a notion that consoled us all; perhaps

nothing was left of her but the fading impulse

generated by the brain's physiology, whose final

expression would be these last words. But before she

could go on, her breathing stopped—leaving it all at

once plainly obvious, and yet utterly

incomprehensible.