Narrative based medicine: dialogue and discourse in clinical practice; Edited by Trisha Greenhalgh and Brian Hurwitz; BMJ Books, London; 1998; (Available through the CMA's Member Service Centre); 286 pp. $60.95 (CMA members: $50.95) ISBN 0-7279-1223-2
Sir Austin Bradford Hill, generally recognized as the father of the modern randomized controlled trial, perhaps wondered what he had wrought. In his 1965 Heberden Oration he noted that "it is not far off twenty years since the Medical Research Council published the results of its trial of the new antibiotic, streptomycin, in the treatment of tuberculosis. This it was that set off the population explosion in controlled trials until now they appear in a continual and widely ranging stream in the weekly and specialist medical journals. . . . [T]he time has come, perhaps, when it would be opportune for us to relax and reflect. . . . Any belief that the controlled trial is the only way would mean not that the pendulum had swung too far but that it had come right off its hook." [1]
Hill lived for another quarter century and saw the exponential growth of the controlled trial continue, although the modern evidence-based medicine movement came after his time. What would he say today? We will never know, of course, but we think that he might have enjoyed this book.
The first thing that strikes one about Narrative Based Medicine is the title, a conscious parody of "evidence-based medicine." Trisha Greenhalgh acknowledges this explicitly with the rhetorical question, "Is this book a spoof, or a sell-out to a new set of values?" Her answer is "an emphatic no. . . . [A]ppreciating the narrative nature of illness experience and the intuitive and subjective aspects of clinical competence does not require the practitioner to reject one iota of the principles of clinical epidemiology. . . . [F]urthermore, . . . genuine evidence based practice actually presupposes an interpretive paradigm within which the patient experiences illness and the clinician-patient encounter is enacted" (p. 247-8). In other words, the apparent conflict can be resolved by denying its very existence - hardly a fair argument. But this appears in the next-to-last chapter of the book, and the editors have laid their groundwork well.
Narrative Based Medicine is not always easy to read. Complex theoretical discourses are interspersed with poignant anecdotes. It is not until one is well into the book that one recognizes this weakness as a strength. Real life does not unfold with a smooth story line, and the message of the book is embodied in its medium. Moreover, reading on, one realizes that the dissonances are an important part of the music. This collection has been carefully and skilfully crafted, and it more than compensates for the difficulties encountered in some chapters by the delightful passages scattered abundantly throughout the text. It abounds with sound bites that are better quoted than paraphrased. Figure 1
The editors, like most of the chapter authors, demonstrate a clear understanding of evidence-based medicine and its powerful strengths. But in their introductory chapter they declare that "the holy grail of 'pure' factual information in the clinical encounter is a spurious quest" and argue forcefully in favour of the "story stuff." Patients' narratives, they write, "provide us with far more than factual information of the kind that might be more efficiently obtained when they . . . carry electronic smart cards encoded with their entire 'medical history'" (p. 6).
As Stuart Hogarth and Lara Marks describe in chapter 15, the decline and fall of narrative-based medicine began in the late eighteenth century with the development of pathologic anatomy and new techniques of physical examination that allowed disease to be classified and labelled in a new way: "A commitment to scientific objectivity, based upon the increasing authority of quantitative over qualitative evidence, was beginning to emerge in medicine. . . . It is not that doctors stopped listening to patients' stories at this time, but in hearing what patients had to say they were no longer trying to understand the unique histories of individuals. They searched instead for what may have been the common characteristics of the same disease in different people" (p. 142).
The attempts to generalize medical knowledge continued. Although the modern proponents of evidence-based medicine view it, as David Sackett and colleagues have written, as "the conscientious, judicious and explicit use of current best evidence in making decisions about the care of individual patients" (cited by Greenhalgh, p. 247), the message that comes through often emphasizes the evidence more than the individual. Greenhalgh writes: "'Evidence' in this context is generally taken to mean evidence about risk and probability derived from research studies on population samples. It relates especially (but not exclusively) to the results of randomised controlled trials and large cohort studies, which are promoted as more valid and reliable than anecdotal reports" (p. 247). The huge gain from this commitment to scientific objectivity and the application of population-based and experimental data has come with a price. As Marshall Marinker comments, "The development of a pathological nosology generated the language which we use to describe what we see and, at the same time, excluded from the discourse those parts of the encounter between the doctor and his patient with which the new language could not deal" (p. 105).
A paradox lies at the root of modern medicine. The science of medicine is to discover generalizable truths that are demonstrable not in individuals but in groups; but the patient and his illness are unique. As Greenhalgh comments, conventional medical education has taught students to view "medicine as a science and the doctor as an impartial investigator who builds differential diagnoses like scientific theories" (p. 248). As Greenhalgh and Hurwitz argue in their introductory chapter, the skills gained in medical school are "eminently measurable but unavoidably reductionist" (p. 13). Once in practice, physicians rediscover what personal experience has already taught them: that everyone is different. Narrative-based medicine recognizes that doctors learn through an accumulation of patients' stories. Although, as Jane Macnaughton cautions, "because of the haphazard nature of personal experience" we need to supplement anecdote with "other, more systematic, sources of evidence . . . the centrality of the anecdote as a means to what physicians know should be recognized" (p. 204).
This recognition has been slow in coming and is difficult to express. Sometimes it seems as if evidence-based medicine is still too fragile to draw attention to its limitations. But voices, including our own, [2] are being raised. Evidence-based medicine is established strongly enough to withstand legitimate criticism.
In the 12th century the Jewish physician and philosopher Maimonides attempted to reconcile the science of Aristotle with the revealed truth of the Torah. In Narrative Based Medicine Greenhalgh and Hurwitz attempt to reconcile the generalizable truths of evidence-based medicine with the power of the complex and individual patient narrative. They have made an excellent start at a difficult task. We think that both Sir Austin and Maimonides would have approved.
Murray W. Enkin, MD
Alejandro R. Jadad, MD, DPhil
McMaster University; Hamilton, Ont.