Patient Stories, Doctor Stories, and True Stories: A Cautionary Reading Nancy M. P. King, Ann Folwell Stanford Literature and Medicine, Volume 11, Number 2, Fall 1992, pp. 185-199 (Article)
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^Patient Stories, Doctor
Stories, and True Stories:
A Cautionary Reading
Nancy M. P. King and Ann Folwell Stanford
Over the past twenty years, medicine and medical education have increasingly—and commendably—emphasized the importance of treating the whole patient and the importance of listening to stories as ways of understanding patients and their illnesses more fully.1 This emphasis has allowed physicians to rethink what can (and frequently has) become primarily a technical practice and to return to the healer's values once characteristic of general practitioners but newly recognized as effective across specialities. As Arthur Kleinman observes, talking with patients about their particular experience of illness becomes a kind of "witnessing," an encounter that helps patients "to order that experience" and one that "can be of therapeutic value."2
What George L. Engel first termed in 1977 the "biopsychosocial model" of health and illness is slowly replacing the biomedical model as the dominant explanatory model in Western medicine.3 This model permits and encourages physicians to take into account the many critical factors in patients' lives and health that go beyond the purely mechanical or chemical. Howard Brody, Arthur Kleinman, Eric J. Cassel, and many others have argued that factors such as stress and social support, eco-
nomic realities, the psychological impact of illness, and the like can all be addressed in the care-giving relationship through this model, and that attention to such factors can significantly affect health.4 In many
respects, the biopsychosocial model is a medical breakthrough; in other respects, it reflects timeless knowledge of the relationships among mind, body, and the healer's art.5 For patients, the explanatory model adopted by their care-givers
delimits the care-giver's intrusion into private realms. In many cultures, for example, healers have access to patients' dreams, family quarrels, and spiritual lives without necessarily being afforded the full range of Literature and Medicine 11, no. 2 (Fall 1992) 185-199 © 1992 by The Johns Hopkins University Press
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physical intimacy characteristic of Western medicine. In American culture, few, if any, people have as much license with the patient's body as the physician, yet the American notion of privacy—especially psychic privacy—is extremely strong. The biomedical model takes physical intrusion, no matter how great, as a given; the biopsychosocial model seeks to add to that a corresponding mastery of nonphysical information about patients. This extension of the physician's "reading" of the patient, from the patient's body alone to the patient's psychic and personal life as well, can be just as invasive as access to patients' bodies. For some patients, nonphysical intrusions are much more invasive than their physical counterparts. It is therefore necessary to ask whether this kind of reading is compatible with respect for the autonomy of patients. We believe that, although seeking the "whole story" is not inherently paternalistic, unless careful attention is given to the gathering and interpreting of information, the process can simply become paternalism in modern dress.
The attempt to understand patients' stories is similar to the interpretive difficulties readers encounter in literary texts. What (and how) does the story "mean" and how do we know? In this essay, we attempt to map out some of the ethical issues that arise in obtaining information about patients, particularly when using methods predicated on a biopsychosocial model. We are especially interested in the problematic arena of interpreting or reading such data. We adumbrate these issues in our own readings of two literary texts—one that demonstrates possible misreadings, and thus abuses, inherent in what we are calling a monologic encounter, and one in which the encounter begins to move from monologic to dialogic and hints at the rich possibilities of the latter.6 Obtaining Information: Patient Stories and Moral Conflict A well-liked and respected family physician describes to friends one of the ways he learns about some of his patients: he obtains invitations to their homes and, once there, seeks the bathroom, getting "lost" on the way. This enables him to see as much as he can of the house and to examine the contents of the bathroom and medicine cabinet. He
thus gathers information about household composition, income level, personal habits, and over- (and under-) the-counter drug use—all in order to know and understand his patients better. Engaging in what literary critics might term a close reading of the patient, this doctor comes
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away from the encounter feeling better equipped to serve his patients. His patients, however, know neither that he is gathering this additional information about them nor the conclusions he draws. Some might object if they knew. In another instance, first-year medical students are given the assignment of visiting patients in their homes—interviewing them about their lives, illnesses, and views about health and health care. Two stu-
dents have opposite reactions to the task of writing and presenting a report about their patients. One questions the validity of an exercise that, in his view, seems intended to divine "the truth" about a patient. His objection rests on his sense that the assignment requires him to weave all information gathered about the patient into a neat, complete fabric free of inconsistencies, gaps, and contradictions. This student wonders how a physician-auditor of patients' stories can avoid the temptation of labeling the narrator unreliable when the pieces of the story do not "fit." He is concerned that he is being asked to make a judgment that may be morally suspect based on his one-sided interpretation of the information he has gathered. The second student, struggling to understand a patient who presents only the bare surfaces of his life for examination, asks wistfully, "How are we to treat the whole patient if we aren't given access to the whole patient?" He worries that if patients resist sharing information with him, his judgment will necessarily be flawed. Between them, these students express both the physician's greatest hopes for the biopsychosocial model and the patient's greatest fears. Where one worries that lack of information leads to error, the other fears that possession of information does not guarantee correct interpretation. When physicians seek the information they judge necessary to act in their patients' best interests, and when patients, despite wanting the benefit of physicians' services, resist revealing information or wish to control what physicians learn, a basic moral conflict is established. This conflict is not unlike that presented by informed consent, where both parties in the relationship seek to control information and decisions about treatment: the patient for reasons of self-determination and the physician in the patient's best medical interests. The doctrine of informed consent is still groping toward a balance of autonomy and beneficence;7 it exemplifies the tension between the patient's autonomy and the physician's medical judgment in several ways. First, although informed consent encourages rational decisions (because it requires that patients be given complete and accurate scientific information in understandable language), it does not ensure them. In-
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stead, it mandates only that the decision maker be capable of rational choice. Patients, therefore, are free to make choices that are emotional,
religious, or superstitious; they may consult horoscopes or flip coins; they may weigh risks and benefits differently, value short-term consequences disproportionately, or simply have different plans, priorities, and values from those of their doctors. Patients may waive disclosure and, under some circumstances, if their physicians believe it will harm them, disclosure may be curtailed without their knowledge. Patients who make what their doctors deem bad or foolish choices may be reasoned with, persuaded, cajoled, showered with advice, opinion, and information; nonetheless, patients remain free to make their own choices. Taken as a whole, the doctrine of informed consent represents a painstaking, if not entirely successful, attempt to balance medical priorities with patients' values. The moral conflict created by the biopsychosocial model of wholepatient care is similar except that it arises at the level, not of information giving, but of information gathering. Physicians using the biopsychosocial model quite properly want all the information they can get about patients—and those who use it best frequently employ the technique of sharing and listening to their patients' stories.8 However, patients in their turn may just as properly wish to limit and control the information they share. "Invasion of privacy" is both a familiar phrase and a venerable doctrine of tort law that defines, protects, and delimits the individual's right of control of personal information.9 Invasion of privacy can take different forms, including commercial appropriation (for example, using a subject's photograph in published medical research without permission), publication of private facts (for example, announcing in a tabloid article that a celebrity's child is really adopted), and intrusion upon solitude (for example, taking satellite photographs of a celebrity sunbathing on a private, heavily guarded island). One of its components, "false-light" privacy, permits a complainant to argue that true information has been distorted by the circumstances of its publication so as to place the complainant in a "false light." Although the tort applies only to the publication of personal information, false-light privacy is a useful analogy for the patient who objects to the physician's zeal in uncovering and interpreting information. Patients could reasonably claim that the physician's judgment of what is important about them places them in a false light in the physician's mind—especially when the physician makes moral judgments based on that information. For example, imagine a physician learning
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that a patient with heart disease has failed to eliminate southern-style high-fat, high-salt foods from her diet. The physician might conclude that the patient lacks willpower, or isn't "using her head," or has a death wish. If she is fortunate enough to know the physician's interpretation of her choices, the patient may feel, perhaps, that the physician doesn't appreciate the social significance of her traditional diet, or places disproportionate emphasis on postponing death, or fails to recognize that the patient has accepted her lot in life. Thus, to each, the other sees by a false light. In their desire to ascertain the true or deeper story of a patient's life and illness, conscientious physicians may over-read or may impose private interpretations without having a corresponding interpretation from the patient. This monologic method of gathering and interpreting
information about patients relies primarily on one-sided reading. It may include patient input in the way of story, but it does not seek patient corroboration and collaboration in interpreting that story. Looking at a similar dynamic, Michael T. Taussig comments: It is a strange "alliance" in which one party avails itself of the other's private understandings in order to manipulate them all the more successfully. What possibility is there in this sort of alliance for the patient to explore the doctor's private model of both disease and illness, and negotiate that?10 In daily life, people continually draw private conclusions about one another that could be challenged as false; we do not mean to suggest that such judgments are illicit or ought to be suspended. When physicians make these judgments about their patients, however, they are using
more and different information about the patient than people usually offer in day-to-day interactions. Moreover, in a relationship where the balance of power lies so clearly on the side of the physician, this information can acquire an official air and is likely to be used, perhaps even disseminated, in order to treat the patient.11 Extreme care in gathering and interpreting information is therefore in order. It seems clear to us that this information seeking by physicians is a morally justifiable attempt at a deeper, more holistic understanding of patients. It also seems clear, however, that how the information is gathered and interpreted is morally critical. Monologic encounters simply do not sufficiently acknowledge the patient's story or the patient's autonomy.12 If we wanted to trump our way out of the problem, of course, we
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could simply say that when moral disagreement arises, the patient's "light" ought to control. Yet the patient's light does not necessarily illuminate enough of the truth, and the patient may not even be privy to the physician's interpretation. When physicians, in listening to patients' stories, in watching and exploring carefully the context of their daily lives, arrive at meaning without the corroboration of patients, then the "whole-patient" encounter becomes another avenue for mythologizing, academic voyeurism, and paternalistic care—all in the name of a more holistic and healing practice of medicine. In contrast, a dialogic relationship springs from a more shared, even negotiated, understanding of the information given (or story told) and interpreted between physician and patient.13 Most important, the process of moving from monologic to dialogic encounter may shift the balance of power in the doctor-patient relationship. In literary formulations, the dialogic endeavor has powerful implications: A word, discourse, language or culture undergoes "dialogization" when it becomes relativized, de-privileged, aware of competing definitions for the same things. Undialogized language is authoritative or absolute.14
Even when a physician seeks with all good will to listen to and understand the patient, the encounter may still be monologic if it is based solely on the physician's observations, assumptions, and interpretations. Only the move away from the authoritative, privileged stance of the physician-observer allows for the possibility of a genuine encounter and, ultimately, a better mutual understanding of the patient's story. In a more dialogic, shared relationship, patients would be able to object to physicians' interpretations by claiming, "That's not what I meant at all" or "That's not who I am at all." Patients ought to be allowed to mean what they mean, or to mean nothing at all—and physicians ought, ultimately, to respect that. Nevertheless, as long as there is a story to interpret, disputes about meaning will legitimately arise. The physician may, indeed should, answer the patient's objections by saying, "Maybe you didn't mean this, but I see it." Such an assertion invites discussion in which private interpretations can be brought to light and allowance can be made for dialogue and conflict.15 Such discussions are perhaps the most difficult, challenging, and rewarding encounters of the physician-patient relationship. It would not be surprising to discover that they happen more rarely than we might wish.
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The Interpretive Maze: Reading Doctors Reading Patients In order better to illuminate the path from monologic to dialogic methods, we need to examine the collaborative nature of interpretation. Although language serves the needs of communication well, it is by no means perfect; in fact, as contemporary literary theorists have argued, it is a significantly flawed medium. Meaning emerges, not by a reader's correct discovery of the truth inherent in a written or spoken text, but by the process of interaction between reader (or auditor) and text (or speaker). Considering the doctor-patient encounter in terms of the reader-text encounter provides insight into the problems of obtaining and interpreting information. Using as our model what rhetoricians call the communications triangle (with author, subject, and reader occupying the interior of the triangle), we can position patients as authors, the story they tell as the subject, and the physician as reader.16 Meaning, then, occupies the ground between physician, patient, and story and might, in the best of worlds, enrich diagnosis, prognosis, and treatment.
The implications for the physician-as-monologic-reader have to do, then, with epistemology: Without corroboration, how can one know when one has got a reading right? Even with the triangle properly in place, how is meaning constructed, and how does one locate the (or even a) truth? Does the truth inhere in the contents of a patient's medicine cabinet, in her story, in her physical symptoms, in the physician's interpretation? Patients present a multiplicity of sign systems to a physician. Some of these signs are carefully or clearly articulated ("I feel burning pain in the Achilles tendon of my right foot"), some are accidental ("Oh that? It's just a slight shortness of breath I sometimes feel when I lie down"), and some are involuntary (the medicine cabinet peered into by the visiting doctor). In literary terms, we might call the doctor-patient encounter a heteroglot text in itself, resounding with numerous voices—the patient's, the doctor's, and those of others always present in the historical, social, and cultural apparatus from which readers, texts, physicians, and
patients are never completely separate. What a physician brings to the patient encounter, just as what a reader brings to a text, shapes the interpretations of that encounter, or the physician's reading of the patient.17 Just as no reading is unmediated or pure but is always transformed by what the reader brings to it, interpretations of patients' stories are necessarily laden with the physician's culture and values, both pro-
fessional and personal. Only by collaborating in the construction of meaning can physicians and patients encounter each other dialogically.
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Misreadings and Shared Understandings between Doctors and Patients
Two well-known stories frequently taught in medical schools, Richard Selzer's "Brute" and William Carlos Williams's "A Face of Stone,"
provide very different examples of information gathering (or story making) and interpretation.13 In one, the physician-narrator remains locked in a monologic reading of his patient; in the other, the physician-narrator slowly moves from what is at first a monologic encounter to the beginning of a dialogue. In "Brute," the narrator cautions a student never to allow his own
anger and fatigue to overmaster him and tells of an emergency-room incident during which he subdued a resistant patient by sewing his earlobes to a stretcher in order to suture a gash in the patient's forehead. "You must never again set your anger upon a patient" (p. 59), the narrator instructs. He tells of "a huge black man . . . escorted by four policemen into the Emergency Room" (p. 60) at two o'clock in the morning. What is of interest in this story is not so much the battle of wills that ensues, or the doctor's solution (sewing the man's earlobes to the stretcher), or even the doctor's sense that in this action he, too, has
become a "brute." Particularly significant is the doctor's reading of the patient—his interpretation of the signs that his patient presents to him. The physician sees the man "rearing" against the force of the policemen, "roaring" while "the policemen ride him like parasites" (p. 60). He imagines the patient with horns (both animal and diabolic), goring the police. To the physician, the patient is "blind and trussed ... a great mythic beast broken loose in the city, surprised in his night raid . . ." (p. 60). The sizable gash on the man's forehead reminds the doctor of "the white wound of an ax in the trunk of a tree" (p. 60). Indeed, almost immediately upon seeing the patient, the doctor constructs a mythology about him— the patient is animal, tree, and, later, "scarred as a Zulu," "a netted panther" (pp. 60, 61). The patient is a roaring beast, one who ravishes the doctor by his "wildness which suggests less a human than a great and beautiful animal" (p. 61). Creating mythology about people one encounters is not in itself a negative thing—it is perhaps an inevitability whenever two humans meet in such intense circumstances. But here the physician-narrator's mythology, underscored by his language choices, draws upon and upholds historically denigrating and dehumanizing racial stereotypes of which he seems unaware. The narrator's mythologizing imagination makes possible a vast gulf between himself and his "beastlike" patient.
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Not surprisingly, once the patient himself uses language, the gap narrows, and the physician is no longer able to remain detached. Instead, he becomes furious and enters the fray. The patient's use of language breaks through the physician's distancing strategies (however unconscious he may be of those strategies), shattering the illusion of radical difference—of Otherness—between doctor and patient. Once the patient enters the human realm by way of language ("You
fuckin' hold still" [p. 61]), the stakes in the power dynamic rise. But the narrator continues to describe this shift in terms that veil the patient's
humanity: "Somehow he has managed to capture me, to pull me inside his cage. Now we are two brutes hissing and batting at each other" (p. 61). To the physician-narrator, the issue is not that the "brute" is now human by force of language (and that the physician cannot handle the sameness that shared humanity entails), but that the physician has been dragged down to the "brute's" level. The narrator goes on to confess his unfair fighting tactics and to describe the ear-sewing procedure, stating finally that this action was not as reprehensible as his grin at the sewn-down man, "the cruelest grin of my life" (p. 62). After the lengthy procedure—and, significantly, long after the patient's few spoken words—the "brute" becomes a "maharajah": "The bandage on his head is a white turban. A single drop of blood in each earlobe, like a ruby" (p. 62). The erotic energy undergirding this tale notwithstanding, we think that the physician's unconsciously racist reading of this patient represents one of the pitfalls inherent in whole-patient health care. In a powerful act of imagination, the physician has created a story that expands upon the biomedical facts of their encounter and appears to get at a fuller picture of the patient. Yet it is the physician's story about his patient—monologic, completely inaccessible to the patient himself. This makes possible its destructively stereotypical character. When one of us first taught this story to a group of medical students, the purpose was to examine doctor-patient relationships, to look at the power nexus that binds them together. In the teaching, however, the physician-narrator's voice became more and more disturbing to both instructor and class. The reason? His description, although it seems to give great attention to the patient and to the event itself, in actuality eclipses the patient's story entirely in the doctor's fantasies about him. The class began by looking at the power dynamic described by the narrator (tired doctor and unruly patient) and ended up looking at the power dynamic in the doctor's description (a desperate attempt to maintain the nonhuman Otherness of the black, drunken patient). This physician, reading his patient, could not move beyond deeply embedded
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cultural stereotypes to inquire seriously into who or what manner of man this was—precisely because he could not allow his monologic construct to open up enough to consider and include the patient's story. In "A Face of Stone," the narrator's exterior and interior voices
inform us that he has immediately sized up his new patients, a young couple with an infant, and found them to fit an irritating "type": He was one of these fresh Jewish types you want to kill at sight, the presuming poor whose looks change the minute cash is mentioned. . . .
She, on the other hand[,] looked Italian, a goaty slant to her eyes, a face often seen among Italian immigrants. . . . She looked dirty. So did he. . . . . . . Just dumb oxen. (P. 78)
Like the narrator of "Brute," this physician-narrator sees these patients in animal terms, drawing on cultural stereotypes to buttress his interpretations. One difference, however, is that this physician clearly and knowingly relegates the family to subhuman status. Without apology he treats them accordingly—he is brusque and rude and refuses to make an emergency house call. His private predictions about the "emergencies" the family brings to him are continually proved right, only intensifying his rancor. Finally, against his will ("What the hell do you think I am anyhow" [p. 84]), he examines the woman on her husband's request. Because he notices some things that subtly undercut the typology in which he has placed them (human skin under "dirty silk" [p. 85], the man's blush when he talks about his wife), the physician allows himself to ask questions, for the first time, about the woman's story. On learning that she had lived in Poland during the war and had lost her family, the physician experiences a flash of illumination, sympathy, and connection that is quietly blinding: So that's it, I thought to myself looking at her fussing, intensely absorbed with the baby, looking at it, talking to it in an inarticulate sort of way, paying no attention whatever to me. No wonder she's built the way she is, considering what she must have been through in that invaded territory. And this guy here— (Pp. 86-87) In the space of a few questions and answers, the encounter begins the transformation from monologic to dialogic event. The addition of the patient's voice and history provides the windows the physician needs
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to begin to see beyond the confounding and irritating sign systems the family presents to him. Monologic readings allow the physician to maintain a safe, pater-
nalistic distance from the patient—to keep him or her as Other. Williams's physician seeks to tie all his observations into a neat, complete, unambiguous package, but finds that he can't. His repeated encounters with the family lead him to see things that radically reshape his interpretation and almost force him to begin a dialogic relationship with them. Selzer's physician creates an interpretation for his patient but never has the opportunity to let the patient disabuse him of it; he remains in the monologic, distanced (but certainly not objective) position. Neither physician attempts to be an objective observer nor to adhere strictly to the biomedical model, but we venture that neither of these fictional physicians would try to claim that he ought to aspire to a biomechanical or pure reading of his patients. What these stories suggest instead is that the power of "readership" can be, for physicians, a highly seductive aspect of professional power. Care must be taken lest this relationship, this watching and listening and telling, become a spectator sport that allows the physician to maintain distance from the patient, to keep him or her positioned as Other. Toward a Dialogic Encounter Preventing distanced and counterproductive readings of patients is, as we have said, difficult. We suggest two possible ways of enabling a more dialogic encounter. First, as Williams's physician unwittingly discovers, it is necessary to acknowledge the patient's interpretive role, to allow the meaning of the illness to arise within the triangular interaction of the patient, the physician, and the patient's story of illness. Medical interpretation here differs from literary interpretation because the author of a literary text is not directly present at readings to negotiate meaning with readers. Patients, however, are present; they must be consulted. Talking with patients about meaning reduces the paternalistic
distance between physician and patient because it demands mutual selfconsciousness in the building of their relationship. There are many ways to do this, but only two ways to teach it: by example, and by encouraging students to develop personal qualities of self-knowledge, cultural sensitivity, flexibility, and critical skills.19 The second and closely related way of moving beyond monologue lies in acknowledging that the purpose of the doctor-patient relationship
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reaches beyond the scope of the reader-subject-author analogy.20 Reading literature and reading patients are activities with clearly different goals. The gathering, sharing, examining, and explaining of data that take place in the physician-patient relationship nominally aim not just at reading the patient but also at serving the patient's good, and conscientious physicians acknowledge the patient's necessary role in defining that good. The dialogic encounter permits, through a mutually developed reading, exploration of the differences in physicians' and patients' viewpoints about what constitutes that good. Focusing on the goal of attaining the patient's good helps keep in check the physician's tendency to create monologic interpretations. Having said all this, we reiterate our belief that the usefulness of attempting to know and share stories is immense. Despite our cautions about the potential for misreading stories and misusing the biopsychosocial model, we ourselves have used stories about medical students and about real and fictionalized doctors. We have used and told stories
in our classrooms and will continue to do so. We will continue to en-
courage our students to attempt to understand and know as much as possible about their patients. But we will also point out that walking the delicate balance between counterproductive monologic readings and the respectful but attentive listening and watching of a more dialogic encounter requires of listeners and interpreters the utmost care. NOTES
1. See, for example, Rita Charon, "To Listen, to Recognize," Pharos 49 (Fall 1986): 10-13, and Larry R. Churchill and Sandra W. Churchill, "Storytelling in Medical Arenas: The Art of Self-Determination," Literature and Medicine 1 (1982): 73-79.
2. Arthur Kleinman, The Illness Narratives: Suffering, Healing, and the Human Condition (New York: Basic Books, 1988), xii. 3. George L. Engel, "The Need for a New Medical Model: A Challenge for Biomedicine," Science 196 (8 April 1977): 129-36, and George L. Engel, "The Biopsychosocial Model and the Education of Health Professionals," Annals of the New York Academy of Sciences 310 (21 June 1978): 169-81. 4. Howard Brody, Stories of Sickness (New Haven, Conn.: Yale University Press, 1987); Kleinman (see note 2, above); Eric J. Cassell, The Healer's Art: A New Approach
to the Doctor-Patient Relationship (Philadelphia: Lippincott, 1976); and Eric J. Cassell, Talking with Patients, vol. 1, The Theory of Doctor-Patient Communication (Cambridge,
Mass.: MIT Press, 1985).
5. Clearly, narrative as a form has always been present in the practice of medicine. As Kathryn Montgomery Hunter has noted, "narrative construction of the events of illness is one of the principal ways of knowing in medicine." See Kathryn Montgomery Hunter, "A Science of Individuals: Medicine and Casuistry," Journal of Medicine and Philosophy 14 (April 1989): 209. See also Kathryn Montgomery Hunter, Doctors' Stories: The Narrative Structure of Medical Knowledge (Princeton, N.J.: Princeton
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University Press, 1991). Our focus here, however, is not on the place of narrative in
medicine, but on further exploring its usefulness and its potential misuses. 6. Although we are using language that recalls Mikhail Bakhtin's theories of novelistic discourse, we are not using monologic and dialogic in strictly Bakhtinian terms. Instead we employ them to distinguish between unilateral and mutual physician-patient encounters, as elaborated below. Bakhtin's terminology is useful, however, because it links the doctor-patient encounter with the interaction between
a reader and a text. See, for example, M. M. Bakhtin, The Dialogic Imagination: Four
Essays, ed. Michael Holquist, trans. Caryl Emerson and Michael Holquist (Austin: University of Texas Press, 1981). See especially "Discourse in the Novel," in which Bakhtin describes the difference between unitary language and heteroglossia (pp. 259422).
7. For extensive discussion of the meaning of the informed-consent doctrine,
see, for example, Ruth R. Faden, Tom L. Beauchamp, and Nancy M. P. King, A History and Theory of Informed Consent (New York: Oxford University Press, 1986), and Alan Meisel, "The 'Exceptions' to the Informed Consent Doctrine: Striking a Balance between Competing Values in Medical Decisionmaking," Wisconsin Law Review 1979 (1979): 413-88. 8. See Robert Coles, The Call of Stories: Teaching and the Moral Imagination (Boston: Houghton Mifflin, 1989). Coles relates a conversation he had with the physician-writer William Carlos Williams in which Williams talked about his methods of "hearing" patients' stories: Sometimes when I'm with a patient who is having trouble getting across to me
what he wants to say, I tell him to stop describing the pain, and just tell me where he was when the pain came on, and what he was doing. I say to him: When the pain knocked on your door, interrupting your life, what were you doing? I try to get them to talk about that life before the interruption, and then
as they describe the interruption, I can get a better picture of what happened than if they spend their time trying to find the right words for the bellyache or the chest pain. (P. 105)
9. Samuel D. Warren and Louis D. Brandeis, "The Right to Privacy," Harvard Law Review 4 (15 December 1890): 193-220; see also Restatement (Second) of Torts (1965): 652E.
10. Michael T. Taussig, "Reification and the Consciousness of the Patient,"
Social Science and Medicine 143 (1980): 12.
11. See, for example, Perri Klass, "Invasions," in On Doctoring: Stories, Poems, Essays, ed. Richard Reynolds and John Stone (New York: Simon and Schuster, 1991), 399-402.
12. See, for example, Taussig, especially his discussion of "the illusion of reciprocity," which, he argues, can be induced by "niceties of style in the bedside manner and the culture of caring" (p. 5).
In a perceptive essay, "To Render the Lives of Patients," Literature and Medicine 5 (1986): 58-74, Rita Charon offers the perspective of literature as a means of moving from the biomedical to the biopsychosocial model:
. . . the skills required for a close reading of a literary text or for explication of poetry are akin to the task a physician faces in making sense of a patient's presentation. All these tasks rely on the practitioner's ability to connect seemingly disparate items and to use intuition and understanding of language to recognize patterns of meaning and reference. Medicine practiced without these skills can be mechanistic, paternalistic, misguided, and ultimately ineffective. (Pp. 71-72)
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In this passage, Charon cites Elliot G. Mishler's book The Discourse of Medicine: Dialectics of Medical Interviews (Norwood, N.J.: Ablex, 1984), 187-96, which describes the medical encounter as a dialogue between the voice of the lifeworld and the voice of medicine. Both Charon and Mishler thus emphasize the importance and value of the broadened perspective provided by the biopsychosocial model. Our concern is simply that Taussig's "illusion of reciprocity" may be created unwittingly, even by physicians
ascribing to Charon's and Mishler's views, if they fail to engage with their patients about the lifeworld information they have gathered and the way they have read it.
(Charon, "To Render the Lives of Patients," 66-67). 13. We borrow the terms "shared understanding" and "negotiated narrative" from Barbara F. Sharf et al., whose "A Shared Understanding: Bridging Racial and Socioeconomic Differences in Doctor-Patient Communication" (video and instructor's
manual; Chapel Hill, N.C: Health Sciences Consortium, 1990) scrutinizes the difficulties and possibilities inherent in the doctor-patient encounter. See also Barbara F. Sharf, "Physician-Patient Communication as Interpersonal Rhetoric: A Narrative Ap-
proach," Health Communication 2 (1990): 217-31, in which she discusses the shift from "Compliance" and "Adherence" to a model that "advocates mutually persuasive doctor-patient communication in order to generate interdependent, reciprocally respectful decision making" (p. 218). Sharf argues that "if [doctors and patients] leave the encounter with their original stories intact, it is questionable that progress toward resolution of health care problems has occurred. The most useful rhetorical goal is a narrative co-construction that weaves threads of both points of view into its fabric" (P- 229). 14. Michael Holquist, "Glossary," in Bakhtin, 427.
15. Richard M. Zaner sensitively discusses the act of dialogue in "Failed or Ongoing Dialogues? Dax's Case," in Dax's Case: Essays in Medical Ethics and Human Meaning, ed. Lonnie D. Kliever (Dallas: Southern Methodist University Press, 1989),
43-61. He argues that "dialogue [is] a moral adventure" (p. 51) founded on a need to know and a need to tell, and that it relies on both questioning and listening:
Thus, responses are essentially invitations to further questions, which lead to still further responses, to further questions, and so on—in shared talk (com-munication), until and if that point is reached when the dialogical partners are free from ignorance and freed for truth, that truth which resolves the a-poria [the "no exit"] and is thus freeing. (P. 56)
16. For the communications triangle, see Erika Lindemann, A Rhetoric for Writing
Teachers (New York: Oxford University Press, 1982), 11-20, 33-57. G. S. Rousseau's
notion of the physician as semiotician ("contemporary physicians interpret signs, diagnose symptoms, read clues" [p. 159]), points the way for a further understanding of the physician as "reader." See G. S. Rousseau, "Literature and Medicine: Towards a Simultaneity of Theory and Practice," Literature and Medicine 5 (1986): 152-81. See also Hunter, "A Science of Individuals," 208: "[T]he . . . patient provides the text that medicine must read and make sense of and explain." 17. In The Call of Stories, Robert Coles quotes a medical-school professor who recognized the complexity of communication and told him:
"We have to pay the closest attention to what we say. What patients say tells us what to think about what hurts them; and what we say tells us what is happening to us—what we are thinking, and what may be wrong with us. . . . Their story, yours, mine—it's what we all carry with us on this trip we take, and we owe it to each other to respect our stories and learn from them." (P. 30) 18. Richard Selzer, "Brute," in Letters to a Young Doctor (New York: Simon and Schuster, 1982), 59-64, and William Carlos Williams, "A Face of Stone," in The Doctor Stories, comp. Robert Coles (New York: New Directions, 1984), 78-87. All subsequent
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quotations from the two stories are from these editions and are cited parenthetically
in the text by page number. 19.
Students' most influential mentors and memorable role models are often
expert at these collaborative encounters. For a textual example, see Harold J. Bursztajn
et al., Medical Chokes, Medical Chances: How Patients, Families, and Physicians Can Cope with Uncertainty (New York: Delacorte Press, Seymour Lawrence, 1981). For further discussion, see K. Danner Clouser, "Humanities in Medical Education: Some Con-
tributions," Journal of Medicine and Philosophy 15 (June 1990): 289-301. 20. Cf. James S. Terry and Peter C. Williams, "Literature and Bioethics: The Tension in Goals and Styles," Literature and Medicine 7 (1988): 1-21.
Published by Johns Hopkins University Press DOI: https://doi.org/10.1353/lm.2011.0228
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^Patient Stories, Doctor
Stories, and True Stories:
A Cautionary Reading
Nancy M. P. King and Ann Folwell Stanford
Over the past twenty years, medicine and medical education have increasingly—and commendably—emphasized the importance of treating the whole patient and the importance of listening to stories as ways of understanding patients and their illnesses more fully.1 This emphasis has allowed physicians to rethink what can (and frequently has) become primarily a technical practice and to return to the healer's values once characteristic of general practitioners but newly recognized as effective across specialities. As Arthur Kleinman observes, talking with patients about their particular experience of illness becomes a kind of "witnessing," an encounter that helps patients "to order that experience" and one that "can be of therapeutic value."2
What George L. Engel first termed in 1977 the "biopsychosocial model" of health and illness is slowly replacing the biomedical model as the dominant explanatory model in Western medicine.3 This model permits and encourages physicians to take into account the many critical factors in patients' lives and health that go beyond the purely mechanical or chemical. Howard Brody, Arthur Kleinman, Eric J. Cassel, and many others have argued that factors such as stress and social support, eco-
nomic realities, the psychological impact of illness, and the like can all be addressed in the care-giving relationship through this model, and that attention to such factors can significantly affect health.4 In many
respects, the biopsychosocial model is a medical breakthrough; in other respects, it reflects timeless knowledge of the relationships among mind, body, and the healer's art.5 For patients, the explanatory model adopted by their care-givers
delimits the care-giver's intrusion into private realms. In many cultures, for example, healers have access to patients' dreams, family quarrels, and spiritual lives without necessarily being afforded the full range of Literature and Medicine 11, no. 2 (Fall 1992) 185-199 © 1992 by The Johns Hopkins University Press
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physical intimacy characteristic of Western medicine. In American culture, few, if any, people have as much license with the patient's body as the physician, yet the American notion of privacy—especially psychic privacy—is extremely strong. The biomedical model takes physical intrusion, no matter how great, as a given; the biopsychosocial model seeks to add to that a corresponding mastery of nonphysical information about patients. This extension of the physician's "reading" of the patient, from the patient's body alone to the patient's psychic and personal life as well, can be just as invasive as access to patients' bodies. For some patients, nonphysical intrusions are much more invasive than their physical counterparts. It is therefore necessary to ask whether this kind of reading is compatible with respect for the autonomy of patients. We believe that, although seeking the "whole story" is not inherently paternalistic, unless careful attention is given to the gathering and interpreting of information, the process can simply become paternalism in modern dress.
The attempt to understand patients' stories is similar to the interpretive difficulties readers encounter in literary texts. What (and how) does the story "mean" and how do we know? In this essay, we attempt to map out some of the ethical issues that arise in obtaining information about patients, particularly when using methods predicated on a biopsychosocial model. We are especially interested in the problematic arena of interpreting or reading such data. We adumbrate these issues in our own readings of two literary texts—one that demonstrates possible misreadings, and thus abuses, inherent in what we are calling a monologic encounter, and one in which the encounter begins to move from monologic to dialogic and hints at the rich possibilities of the latter.6 Obtaining Information: Patient Stories and Moral Conflict A well-liked and respected family physician describes to friends one of the ways he learns about some of his patients: he obtains invitations to their homes and, once there, seeks the bathroom, getting "lost" on the way. This enables him to see as much as he can of the house and to examine the contents of the bathroom and medicine cabinet. He
thus gathers information about household composition, income level, personal habits, and over- (and under-) the-counter drug use—all in order to know and understand his patients better. Engaging in what literary critics might term a close reading of the patient, this doctor comes
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away from the encounter feeling better equipped to serve his patients. His patients, however, know neither that he is gathering this additional information about them nor the conclusions he draws. Some might object if they knew. In another instance, first-year medical students are given the assignment of visiting patients in their homes—interviewing them about their lives, illnesses, and views about health and health care. Two stu-
dents have opposite reactions to the task of writing and presenting a report about their patients. One questions the validity of an exercise that, in his view, seems intended to divine "the truth" about a patient. His objection rests on his sense that the assignment requires him to weave all information gathered about the patient into a neat, complete fabric free of inconsistencies, gaps, and contradictions. This student wonders how a physician-auditor of patients' stories can avoid the temptation of labeling the narrator unreliable when the pieces of the story do not "fit." He is concerned that he is being asked to make a judgment that may be morally suspect based on his one-sided interpretation of the information he has gathered. The second student, struggling to understand a patient who presents only the bare surfaces of his life for examination, asks wistfully, "How are we to treat the whole patient if we aren't given access to the whole patient?" He worries that if patients resist sharing information with him, his judgment will necessarily be flawed. Between them, these students express both the physician's greatest hopes for the biopsychosocial model and the patient's greatest fears. Where one worries that lack of information leads to error, the other fears that possession of information does not guarantee correct interpretation. When physicians seek the information they judge necessary to act in their patients' best interests, and when patients, despite wanting the benefit of physicians' services, resist revealing information or wish to control what physicians learn, a basic moral conflict is established. This conflict is not unlike that presented by informed consent, where both parties in the relationship seek to control information and decisions about treatment: the patient for reasons of self-determination and the physician in the patient's best medical interests. The doctrine of informed consent is still groping toward a balance of autonomy and beneficence;7 it exemplifies the tension between the patient's autonomy and the physician's medical judgment in several ways. First, although informed consent encourages rational decisions (because it requires that patients be given complete and accurate scientific information in understandable language), it does not ensure them. In-
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stead, it mandates only that the decision maker be capable of rational choice. Patients, therefore, are free to make choices that are emotional,
religious, or superstitious; they may consult horoscopes or flip coins; they may weigh risks and benefits differently, value short-term consequences disproportionately, or simply have different plans, priorities, and values from those of their doctors. Patients may waive disclosure and, under some circumstances, if their physicians believe it will harm them, disclosure may be curtailed without their knowledge. Patients who make what their doctors deem bad or foolish choices may be reasoned with, persuaded, cajoled, showered with advice, opinion, and information; nonetheless, patients remain free to make their own choices. Taken as a whole, the doctrine of informed consent represents a painstaking, if not entirely successful, attempt to balance medical priorities with patients' values. The moral conflict created by the biopsychosocial model of wholepatient care is similar except that it arises at the level, not of information giving, but of information gathering. Physicians using the biopsychosocial model quite properly want all the information they can get about patients—and those who use it best frequently employ the technique of sharing and listening to their patients' stories.8 However, patients in their turn may just as properly wish to limit and control the information they share. "Invasion of privacy" is both a familiar phrase and a venerable doctrine of tort law that defines, protects, and delimits the individual's right of control of personal information.9 Invasion of privacy can take different forms, including commercial appropriation (for example, using a subject's photograph in published medical research without permission), publication of private facts (for example, announcing in a tabloid article that a celebrity's child is really adopted), and intrusion upon solitude (for example, taking satellite photographs of a celebrity sunbathing on a private, heavily guarded island). One of its components, "false-light" privacy, permits a complainant to argue that true information has been distorted by the circumstances of its publication so as to place the complainant in a "false light." Although the tort applies only to the publication of personal information, false-light privacy is a useful analogy for the patient who objects to the physician's zeal in uncovering and interpreting information. Patients could reasonably claim that the physician's judgment of what is important about them places them in a false light in the physician's mind—especially when the physician makes moral judgments based on that information. For example, imagine a physician learning
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that a patient with heart disease has failed to eliminate southern-style high-fat, high-salt foods from her diet. The physician might conclude that the patient lacks willpower, or isn't "using her head," or has a death wish. If she is fortunate enough to know the physician's interpretation of her choices, the patient may feel, perhaps, that the physician doesn't appreciate the social significance of her traditional diet, or places disproportionate emphasis on postponing death, or fails to recognize that the patient has accepted her lot in life. Thus, to each, the other sees by a false light. In their desire to ascertain the true or deeper story of a patient's life and illness, conscientious physicians may over-read or may impose private interpretations without having a corresponding interpretation from the patient. This monologic method of gathering and interpreting
information about patients relies primarily on one-sided reading. It may include patient input in the way of story, but it does not seek patient corroboration and collaboration in interpreting that story. Looking at a similar dynamic, Michael T. Taussig comments: It is a strange "alliance" in which one party avails itself of the other's private understandings in order to manipulate them all the more successfully. What possibility is there in this sort of alliance for the patient to explore the doctor's private model of both disease and illness, and negotiate that?10 In daily life, people continually draw private conclusions about one another that could be challenged as false; we do not mean to suggest that such judgments are illicit or ought to be suspended. When physicians make these judgments about their patients, however, they are using
more and different information about the patient than people usually offer in day-to-day interactions. Moreover, in a relationship where the balance of power lies so clearly on the side of the physician, this information can acquire an official air and is likely to be used, perhaps even disseminated, in order to treat the patient.11 Extreme care in gathering and interpreting information is therefore in order. It seems clear to us that this information seeking by physicians is a morally justifiable attempt at a deeper, more holistic understanding of patients. It also seems clear, however, that how the information is gathered and interpreted is morally critical. Monologic encounters simply do not sufficiently acknowledge the patient's story or the patient's autonomy.12 If we wanted to trump our way out of the problem, of course, we
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could simply say that when moral disagreement arises, the patient's "light" ought to control. Yet the patient's light does not necessarily illuminate enough of the truth, and the patient may not even be privy to the physician's interpretation. When physicians, in listening to patients' stories, in watching and exploring carefully the context of their daily lives, arrive at meaning without the corroboration of patients, then the "whole-patient" encounter becomes another avenue for mythologizing, academic voyeurism, and paternalistic care—all in the name of a more holistic and healing practice of medicine. In contrast, a dialogic relationship springs from a more shared, even negotiated, understanding of the information given (or story told) and interpreted between physician and patient.13 Most important, the process of moving from monologic to dialogic encounter may shift the balance of power in the doctor-patient relationship. In literary formulations, the dialogic endeavor has powerful implications: A word, discourse, language or culture undergoes "dialogization" when it becomes relativized, de-privileged, aware of competing definitions for the same things. Undialogized language is authoritative or absolute.14
Even when a physician seeks with all good will to listen to and understand the patient, the encounter may still be monologic if it is based solely on the physician's observations, assumptions, and interpretations. Only the move away from the authoritative, privileged stance of the physician-observer allows for the possibility of a genuine encounter and, ultimately, a better mutual understanding of the patient's story. In a more dialogic, shared relationship, patients would be able to object to physicians' interpretations by claiming, "That's not what I meant at all" or "That's not who I am at all." Patients ought to be allowed to mean what they mean, or to mean nothing at all—and physicians ought, ultimately, to respect that. Nevertheless, as long as there is a story to interpret, disputes about meaning will legitimately arise. The physician may, indeed should, answer the patient's objections by saying, "Maybe you didn't mean this, but I see it." Such an assertion invites discussion in which private interpretations can be brought to light and allowance can be made for dialogue and conflict.15 Such discussions are perhaps the most difficult, challenging, and rewarding encounters of the physician-patient relationship. It would not be surprising to discover that they happen more rarely than we might wish.
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The Interpretive Maze: Reading Doctors Reading Patients In order better to illuminate the path from monologic to dialogic methods, we need to examine the collaborative nature of interpretation. Although language serves the needs of communication well, it is by no means perfect; in fact, as contemporary literary theorists have argued, it is a significantly flawed medium. Meaning emerges, not by a reader's correct discovery of the truth inherent in a written or spoken text, but by the process of interaction between reader (or auditor) and text (or speaker). Considering the doctor-patient encounter in terms of the reader-text encounter provides insight into the problems of obtaining and interpreting information. Using as our model what rhetoricians call the communications triangle (with author, subject, and reader occupying the interior of the triangle), we can position patients as authors, the story they tell as the subject, and the physician as reader.16 Meaning, then, occupies the ground between physician, patient, and story and might, in the best of worlds, enrich diagnosis, prognosis, and treatment.
The implications for the physician-as-monologic-reader have to do, then, with epistemology: Without corroboration, how can one know when one has got a reading right? Even with the triangle properly in place, how is meaning constructed, and how does one locate the (or even a) truth? Does the truth inhere in the contents of a patient's medicine cabinet, in her story, in her physical symptoms, in the physician's interpretation? Patients present a multiplicity of sign systems to a physician. Some of these signs are carefully or clearly articulated ("I feel burning pain in the Achilles tendon of my right foot"), some are accidental ("Oh that? It's just a slight shortness of breath I sometimes feel when I lie down"), and some are involuntary (the medicine cabinet peered into by the visiting doctor). In literary terms, we might call the doctor-patient encounter a heteroglot text in itself, resounding with numerous voices—the patient's, the doctor's, and those of others always present in the historical, social, and cultural apparatus from which readers, texts, physicians, and
patients are never completely separate. What a physician brings to the patient encounter, just as what a reader brings to a text, shapes the interpretations of that encounter, or the physician's reading of the patient.17 Just as no reading is unmediated or pure but is always transformed by what the reader brings to it, interpretations of patients' stories are necessarily laden with the physician's culture and values, both pro-
fessional and personal. Only by collaborating in the construction of meaning can physicians and patients encounter each other dialogically.
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Misreadings and Shared Understandings between Doctors and Patients
Two well-known stories frequently taught in medical schools, Richard Selzer's "Brute" and William Carlos Williams's "A Face of Stone,"
provide very different examples of information gathering (or story making) and interpretation.13 In one, the physician-narrator remains locked in a monologic reading of his patient; in the other, the physician-narrator slowly moves from what is at first a monologic encounter to the beginning of a dialogue. In "Brute," the narrator cautions a student never to allow his own
anger and fatigue to overmaster him and tells of an emergency-room incident during which he subdued a resistant patient by sewing his earlobes to a stretcher in order to suture a gash in the patient's forehead. "You must never again set your anger upon a patient" (p. 59), the narrator instructs. He tells of "a huge black man . . . escorted by four policemen into the Emergency Room" (p. 60) at two o'clock in the morning. What is of interest in this story is not so much the battle of wills that ensues, or the doctor's solution (sewing the man's earlobes to the stretcher), or even the doctor's sense that in this action he, too, has
become a "brute." Particularly significant is the doctor's reading of the patient—his interpretation of the signs that his patient presents to him. The physician sees the man "rearing" against the force of the policemen, "roaring" while "the policemen ride him like parasites" (p. 60). He imagines the patient with horns (both animal and diabolic), goring the police. To the physician, the patient is "blind and trussed ... a great mythic beast broken loose in the city, surprised in his night raid . . ." (p. 60). The sizable gash on the man's forehead reminds the doctor of "the white wound of an ax in the trunk of a tree" (p. 60). Indeed, almost immediately upon seeing the patient, the doctor constructs a mythology about him— the patient is animal, tree, and, later, "scarred as a Zulu," "a netted panther" (pp. 60, 61). The patient is a roaring beast, one who ravishes the doctor by his "wildness which suggests less a human than a great and beautiful animal" (p. 61). Creating mythology about people one encounters is not in itself a negative thing—it is perhaps an inevitability whenever two humans meet in such intense circumstances. But here the physician-narrator's mythology, underscored by his language choices, draws upon and upholds historically denigrating and dehumanizing racial stereotypes of which he seems unaware. The narrator's mythologizing imagination makes possible a vast gulf between himself and his "beastlike" patient.
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Not surprisingly, once the patient himself uses language, the gap narrows, and the physician is no longer able to remain detached. Instead, he becomes furious and enters the fray. The patient's use of language breaks through the physician's distancing strategies (however unconscious he may be of those strategies), shattering the illusion of radical difference—of Otherness—between doctor and patient. Once the patient enters the human realm by way of language ("You
fuckin' hold still" [p. 61]), the stakes in the power dynamic rise. But the narrator continues to describe this shift in terms that veil the patient's
humanity: "Somehow he has managed to capture me, to pull me inside his cage. Now we are two brutes hissing and batting at each other" (p. 61). To the physician-narrator, the issue is not that the "brute" is now human by force of language (and that the physician cannot handle the sameness that shared humanity entails), but that the physician has been dragged down to the "brute's" level. The narrator goes on to confess his unfair fighting tactics and to describe the ear-sewing procedure, stating finally that this action was not as reprehensible as his grin at the sewn-down man, "the cruelest grin of my life" (p. 62). After the lengthy procedure—and, significantly, long after the patient's few spoken words—the "brute" becomes a "maharajah": "The bandage on his head is a white turban. A single drop of blood in each earlobe, like a ruby" (p. 62). The erotic energy undergirding this tale notwithstanding, we think that the physician's unconsciously racist reading of this patient represents one of the pitfalls inherent in whole-patient health care. In a powerful act of imagination, the physician has created a story that expands upon the biomedical facts of their encounter and appears to get at a fuller picture of the patient. Yet it is the physician's story about his patient—monologic, completely inaccessible to the patient himself. This makes possible its destructively stereotypical character. When one of us first taught this story to a group of medical students, the purpose was to examine doctor-patient relationships, to look at the power nexus that binds them together. In the teaching, however, the physician-narrator's voice became more and more disturbing to both instructor and class. The reason? His description, although it seems to give great attention to the patient and to the event itself, in actuality eclipses the patient's story entirely in the doctor's fantasies about him. The class began by looking at the power dynamic described by the narrator (tired doctor and unruly patient) and ended up looking at the power dynamic in the doctor's description (a desperate attempt to maintain the nonhuman Otherness of the black, drunken patient). This physician, reading his patient, could not move beyond deeply embedded
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cultural stereotypes to inquire seriously into who or what manner of man this was—precisely because he could not allow his monologic construct to open up enough to consider and include the patient's story. In "A Face of Stone," the narrator's exterior and interior voices
inform us that he has immediately sized up his new patients, a young couple with an infant, and found them to fit an irritating "type": He was one of these fresh Jewish types you want to kill at sight, the presuming poor whose looks change the minute cash is mentioned. . . .
She, on the other hand[,] looked Italian, a goaty slant to her eyes, a face often seen among Italian immigrants. . . . She looked dirty. So did he. . . . . . . Just dumb oxen. (P. 78)
Like the narrator of "Brute," this physician-narrator sees these patients in animal terms, drawing on cultural stereotypes to buttress his interpretations. One difference, however, is that this physician clearly and knowingly relegates the family to subhuman status. Without apology he treats them accordingly—he is brusque and rude and refuses to make an emergency house call. His private predictions about the "emergencies" the family brings to him are continually proved right, only intensifying his rancor. Finally, against his will ("What the hell do you think I am anyhow" [p. 84]), he examines the woman on her husband's request. Because he notices some things that subtly undercut the typology in which he has placed them (human skin under "dirty silk" [p. 85], the man's blush when he talks about his wife), the physician allows himself to ask questions, for the first time, about the woman's story. On learning that she had lived in Poland during the war and had lost her family, the physician experiences a flash of illumination, sympathy, and connection that is quietly blinding: So that's it, I thought to myself looking at her fussing, intensely absorbed with the baby, looking at it, talking to it in an inarticulate sort of way, paying no attention whatever to me. No wonder she's built the way she is, considering what she must have been through in that invaded territory. And this guy here— (Pp. 86-87) In the space of a few questions and answers, the encounter begins the transformation from monologic to dialogic event. The addition of the patient's voice and history provides the windows the physician needs
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to begin to see beyond the confounding and irritating sign systems the family presents to him. Monologic readings allow the physician to maintain a safe, pater-
nalistic distance from the patient—to keep him or her as Other. Williams's physician seeks to tie all his observations into a neat, complete, unambiguous package, but finds that he can't. His repeated encounters with the family lead him to see things that radically reshape his interpretation and almost force him to begin a dialogic relationship with them. Selzer's physician creates an interpretation for his patient but never has the opportunity to let the patient disabuse him of it; he remains in the monologic, distanced (but certainly not objective) position. Neither physician attempts to be an objective observer nor to adhere strictly to the biomedical model, but we venture that neither of these fictional physicians would try to claim that he ought to aspire to a biomechanical or pure reading of his patients. What these stories suggest instead is that the power of "readership" can be, for physicians, a highly seductive aspect of professional power. Care must be taken lest this relationship, this watching and listening and telling, become a spectator sport that allows the physician to maintain distance from the patient, to keep him or her positioned as Other. Toward a Dialogic Encounter Preventing distanced and counterproductive readings of patients is, as we have said, difficult. We suggest two possible ways of enabling a more dialogic encounter. First, as Williams's physician unwittingly discovers, it is necessary to acknowledge the patient's interpretive role, to allow the meaning of the illness to arise within the triangular interaction of the patient, the physician, and the patient's story of illness. Medical interpretation here differs from literary interpretation because the author of a literary text is not directly present at readings to negotiate meaning with readers. Patients, however, are present; they must be consulted. Talking with patients about meaning reduces the paternalistic
distance between physician and patient because it demands mutual selfconsciousness in the building of their relationship. There are many ways to do this, but only two ways to teach it: by example, and by encouraging students to develop personal qualities of self-knowledge, cultural sensitivity, flexibility, and critical skills.19 The second and closely related way of moving beyond monologue lies in acknowledging that the purpose of the doctor-patient relationship
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reaches beyond the scope of the reader-subject-author analogy.20 Reading literature and reading patients are activities with clearly different goals. The gathering, sharing, examining, and explaining of data that take place in the physician-patient relationship nominally aim not just at reading the patient but also at serving the patient's good, and conscientious physicians acknowledge the patient's necessary role in defining that good. The dialogic encounter permits, through a mutually developed reading, exploration of the differences in physicians' and patients' viewpoints about what constitutes that good. Focusing on the goal of attaining the patient's good helps keep in check the physician's tendency to create monologic interpretations. Having said all this, we reiterate our belief that the usefulness of attempting to know and share stories is immense. Despite our cautions about the potential for misreading stories and misusing the biopsychosocial model, we ourselves have used stories about medical students and about real and fictionalized doctors. We have used and told stories
in our classrooms and will continue to do so. We will continue to en-
courage our students to attempt to understand and know as much as possible about their patients. But we will also point out that walking the delicate balance between counterproductive monologic readings and the respectful but attentive listening and watching of a more dialogic encounter requires of listeners and interpreters the utmost care. NOTES
1. See, for example, Rita Charon, "To Listen, to Recognize," Pharos 49 (Fall 1986): 10-13, and Larry R. Churchill and Sandra W. Churchill, "Storytelling in Medical Arenas: The Art of Self-Determination," Literature and Medicine 1 (1982): 73-79.
2. Arthur Kleinman, The Illness Narratives: Suffering, Healing, and the Human Condition (New York: Basic Books, 1988), xii. 3. George L. Engel, "The Need for a New Medical Model: A Challenge for Biomedicine," Science 196 (8 April 1977): 129-36, and George L. Engel, "The Biopsychosocial Model and the Education of Health Professionals," Annals of the New York Academy of Sciences 310 (21 June 1978): 169-81. 4. Howard Brody, Stories of Sickness (New Haven, Conn.: Yale University Press, 1987); Kleinman (see note 2, above); Eric J. Cassell, The Healer's Art: A New Approach
to the Doctor-Patient Relationship (Philadelphia: Lippincott, 1976); and Eric J. Cassell, Talking with Patients, vol. 1, The Theory of Doctor-Patient Communication (Cambridge,
Mass.: MIT Press, 1985).
5. Clearly, narrative as a form has always been present in the practice of medicine. As Kathryn Montgomery Hunter has noted, "narrative construction of the events of illness is one of the principal ways of knowing in medicine." See Kathryn Montgomery Hunter, "A Science of Individuals: Medicine and Casuistry," Journal of Medicine and Philosophy 14 (April 1989): 209. See also Kathryn Montgomery Hunter, Doctors' Stories: The Narrative Structure of Medical Knowledge (Princeton, N.J.: Princeton
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University Press, 1991). Our focus here, however, is not on the place of narrative in
medicine, but on further exploring its usefulness and its potential misuses. 6. Although we are using language that recalls Mikhail Bakhtin's theories of novelistic discourse, we are not using monologic and dialogic in strictly Bakhtinian terms. Instead we employ them to distinguish between unilateral and mutual physician-patient encounters, as elaborated below. Bakhtin's terminology is useful, however, because it links the doctor-patient encounter with the interaction between
a reader and a text. See, for example, M. M. Bakhtin, The Dialogic Imagination: Four
Essays, ed. Michael Holquist, trans. Caryl Emerson and Michael Holquist (Austin: University of Texas Press, 1981). See especially "Discourse in the Novel," in which Bakhtin describes the difference between unitary language and heteroglossia (pp. 259422).
7. For extensive discussion of the meaning of the informed-consent doctrine,
see, for example, Ruth R. Faden, Tom L. Beauchamp, and Nancy M. P. King, A History and Theory of Informed Consent (New York: Oxford University Press, 1986), and Alan Meisel, "The 'Exceptions' to the Informed Consent Doctrine: Striking a Balance between Competing Values in Medical Decisionmaking," Wisconsin Law Review 1979 (1979): 413-88. 8. See Robert Coles, The Call of Stories: Teaching and the Moral Imagination (Boston: Houghton Mifflin, 1989). Coles relates a conversation he had with the physician-writer William Carlos Williams in which Williams talked about his methods of "hearing" patients' stories: Sometimes when I'm with a patient who is having trouble getting across to me
what he wants to say, I tell him to stop describing the pain, and just tell me where he was when the pain came on, and what he was doing. I say to him: When the pain knocked on your door, interrupting your life, what were you doing? I try to get them to talk about that life before the interruption, and then
as they describe the interruption, I can get a better picture of what happened than if they spend their time trying to find the right words for the bellyache or the chest pain. (P. 105)
9. Samuel D. Warren and Louis D. Brandeis, "The Right to Privacy," Harvard Law Review 4 (15 December 1890): 193-220; see also Restatement (Second) of Torts (1965): 652E.
10. Michael T. Taussig, "Reification and the Consciousness of the Patient,"
Social Science and Medicine 143 (1980): 12.
11. See, for example, Perri Klass, "Invasions," in On Doctoring: Stories, Poems, Essays, ed. Richard Reynolds and John Stone (New York: Simon and Schuster, 1991), 399-402.
12. See, for example, Taussig, especially his discussion of "the illusion of reciprocity," which, he argues, can be induced by "niceties of style in the bedside manner and the culture of caring" (p. 5).
In a perceptive essay, "To Render the Lives of Patients," Literature and Medicine 5 (1986): 58-74, Rita Charon offers the perspective of literature as a means of moving from the biomedical to the biopsychosocial model:
. . . the skills required for a close reading of a literary text or for explication of poetry are akin to the task a physician faces in making sense of a patient's presentation. All these tasks rely on the practitioner's ability to connect seemingly disparate items and to use intuition and understanding of language to recognize patterns of meaning and reference. Medicine practiced without these skills can be mechanistic, paternalistic, misguided, and ultimately ineffective. (Pp. 71-72)
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STORIES: A CAUTIONARY READING
In this passage, Charon cites Elliot G. Mishler's book The Discourse of Medicine: Dialectics of Medical Interviews (Norwood, N.J.: Ablex, 1984), 187-96, which describes the medical encounter as a dialogue between the voice of the lifeworld and the voice of medicine. Both Charon and Mishler thus emphasize the importance and value of the broadened perspective provided by the biopsychosocial model. Our concern is simply that Taussig's "illusion of reciprocity" may be created unwittingly, even by physicians
ascribing to Charon's and Mishler's views, if they fail to engage with their patients about the lifeworld information they have gathered and the way they have read it.
(Charon, "To Render the Lives of Patients," 66-67). 13. We borrow the terms "shared understanding" and "negotiated narrative" from Barbara F. Sharf et al., whose "A Shared Understanding: Bridging Racial and Socioeconomic Differences in Doctor-Patient Communication" (video and instructor's
manual; Chapel Hill, N.C: Health Sciences Consortium, 1990) scrutinizes the difficulties and possibilities inherent in the doctor-patient encounter. See also Barbara F. Sharf, "Physician-Patient Communication as Interpersonal Rhetoric: A Narrative Ap-
proach," Health Communication 2 (1990): 217-31, in which she discusses the shift from "Compliance" and "Adherence" to a model that "advocates mutually persuasive doctor-patient communication in order to generate interdependent, reciprocally respectful decision making" (p. 218). Sharf argues that "if [doctors and patients] leave the encounter with their original stories intact, it is questionable that progress toward resolution of health care problems has occurred. The most useful rhetorical goal is a narrative co-construction that weaves threads of both points of view into its fabric" (P- 229). 14. Michael Holquist, "Glossary," in Bakhtin, 427.
15. Richard M. Zaner sensitively discusses the act of dialogue in "Failed or Ongoing Dialogues? Dax's Case," in Dax's Case: Essays in Medical Ethics and Human Meaning, ed. Lonnie D. Kliever (Dallas: Southern Methodist University Press, 1989),
43-61. He argues that "dialogue [is] a moral adventure" (p. 51) founded on a need to know and a need to tell, and that it relies on both questioning and listening:
Thus, responses are essentially invitations to further questions, which lead to still further responses, to further questions, and so on—in shared talk (com-munication), until and if that point is reached when the dialogical partners are free from ignorance and freed for truth, that truth which resolves the a-poria [the "no exit"] and is thus freeing. (P. 56)
16. For the communications triangle, see Erika Lindemann, A Rhetoric for Writing
Teachers (New York: Oxford University Press, 1982), 11-20, 33-57. G. S. Rousseau's
notion of the physician as semiotician ("contemporary physicians interpret signs, diagnose symptoms, read clues" [p. 159]), points the way for a further understanding of the physician as "reader." See G. S. Rousseau, "Literature and Medicine: Towards a Simultaneity of Theory and Practice," Literature and Medicine 5 (1986): 152-81. See also Hunter, "A Science of Individuals," 208: "[T]he . . . patient provides the text that medicine must read and make sense of and explain." 17. In The Call of Stories, Robert Coles quotes a medical-school professor who recognized the complexity of communication and told him:
"We have to pay the closest attention to what we say. What patients say tells us what to think about what hurts them; and what we say tells us what is happening to us—what we are thinking, and what may be wrong with us. . . . Their story, yours, mine—it's what we all carry with us on this trip we take, and we owe it to each other to respect our stories and learn from them." (P. 30) 18. Richard Selzer, "Brute," in Letters to a Young Doctor (New York: Simon and Schuster, 1982), 59-64, and William Carlos Williams, "A Face of Stone," in The Doctor Stories, comp. Robert Coles (New York: New Directions, 1984), 78-87. All subsequent
King and Stanford
199
quotations from the two stories are from these editions and are cited parenthetically
in the text by page number. 19.
Students' most influential mentors and memorable role models are often
expert at these collaborative encounters. For a textual example, see Harold J. Bursztajn
et al., Medical Chokes, Medical Chances: How Patients, Families, and Physicians Can Cope with Uncertainty (New York: Delacorte Press, Seymour Lawrence, 1981). For further discussion, see K. Danner Clouser, "Humanities in Medical Education: Some Con-
tributions," Journal of Medicine and Philosophy 15 (June 1990): 289-301. 20. Cf. James S. Terry and Peter C. Williams, "Literature and Bioethics: The Tension in Goals and Styles," Literature and Medicine 7 (1988): 1-21.
