The Left Atrium · De l'Oreille Gauche

CMAJ 1999;161:297-300

• Back on the hook
• The social documentary of Daumier
• Oh, I was there, too

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

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 clinician­patient 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.

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 recognised" (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.

Send a letter to the editor Envoyez une lettre à la rédaction

1. Hill AB. Heberden oration 1965: reflections on the controlled trial. Ann Rheum Dis 1965;25:107-13.
2. Enkin MW, Jadad AR. Using anecdotal information in evidence-based health care: Heresy or necessity? Ann Oncol 1998;9:963-6.

[Contents]

This summer the National Gallery of Canada presents, after 11 years of planning, the first major retrospective exhibition of the works of Honoré Daumier assembled since the artist's death in 1879. The show comprises more than 300 works selected from Daumier's prodigious output of lithographs, drawings, woodcuts, paintings and sculptures produced over a span of 50 years. Daumier's nearly 5000 satirical prints on the political and social issues of his time exert a presence even today, and physicians who enjoy contemplating their profession in the mirror of history might be disappointed that the exhibition does not include Daumier's critique on the practice of medicine. On the other hand, there is plenty to consider with respect to the social conditions of nineteenth-century urban France. Daumier provides an encyclopedic proto-documentary ranging over topics as varied as educational reform, women's emancipation (which he reviled), the professions, urban planning, public transport, the arts and the aftermath of war.

One of Daumier's first political caricatures earned him six months in jail: this was his Gargantua (1831), which depicts King Louis-Philippe devouring baskets of money offered up by the starving masses while he excretes political favours on the sycophants clustered below. In this lithograph an emaciated women with an infant at her breast is placed in visual and moral apposition in the bottom right-hand corner; it is tempting to read the recurring motif of breastfeeding in Daumier's work as a symbolic counterweight to the political nastiness of his time.

When in 1835 the French government suppressed political caricature Daumier confined his efforts to social satire. The lithograph The Crinoline in Winter (1858) obviously pokes fun at vanity, but it is not for nothing that the fashionable woman is contrasted by another who is elderly, working and poor. Elsewhere Daumier depicts a citizenry beleaguered by "progress." In the 1850s Emperor Louis-Napoléon commissioned Baron George-Eugène Haussmann to remodel Paris. This urban renewal posed problems familiar today: the displacement of the lower classes from the newly gentrified inner city and the eradication of a tangible history. In Behold our Nuptial Chamber (1853) an elderly bourgeois couple regards the ruins of their matrimonial home, now undergoing demolition. In the meantime, housing conditions left much to be desired; a lithograph entitled One of the Disadvantages of Basements (1856) depicts a married couple lying in bed in an apartment so damp that mushrooms have sprouted on the bedstead; all that is visible through their window is the feet of passers-by.

Honoré Daumier, The Crinoline in Winter, 1858. Lithograph, 26.1 cm × 22.1 cm. Museum of Fine Arts, Boston

Running parallel to Daumier's trenchant satire is a sense of the dignity of family life and of work. In The Soup (c. 1862­1865) a working-class couple hastily eat their supper; the woman appears old and careworn but by no means frail, and her ample breast is well able to sustain the next generation. The laundress who climbs with her child from the bank of the Seine is rendered in a manner that makes her appear both monumental and tender: her heavy frame is bent with solicitude toward the child, whose safety in climbing the stairs she ensures. The family group crowded into the Third-Class Carriage (c. 1862­1865) maintains a rather tragic dignity; even in this very secular context Daumier invokes universal themes of youth and experience, loss (where are the men?) and nurture.

Honoré Daumier, The Laundress, c. 1860­1861. Oil on wood, 49 cm × 33.5 cm. Musée D'Orsay, Paris

Honoré Daumier, The Soup, c. 1862-1865. Charcoal, black chalk, pen and ink, wash, watercolour and conté crayon, 30.3 cm × 49.4 cm. Museé du Louvre, Paris		Honoré Daumier, The Third Class Carriage, c. 1862­1864, reworked in late 1860s. Oil on canvas, 67cm × 92 cm. National Gallery of Canada, Ottawa

Knowing Daumier mainly as a caricaturist, I went to the media preview expecting to be taxed by the exercise of appreciating satire for which the topical references are now obscure. But it is impossible to encounter such a superbly gestural drawing style (one much admired by the Impressionists) and feel it as an academic exercise. Standing in the empty gallery after the tour had ended, I was surprised to realize how strongly I had been affected by Daumier's sentimental side. But I still doubted that I could forgive him the joke in one of his Bluestocking lithographs, which shows a woman "in a fever of composition" at her writing desk while her baby drowns in the bath.

Anne Marie Todkill
Editor, The Left Atrium

The Daumier exhibition continues in Ottawa until September 6, 1999. It will then travel to the Musée d'Orsay in Paris from October 5, 1999, to January 3, 2000, and to The Phillips Collection in Washington DC from February 19 to May 14, 2000.

Send a letter to the editor Envoyez une lettre à la rédaction

1. Gregory S. Daumier. Ottawa: National Gallery of Canada; 1999.

[Contents]

for Dr. John Butt

Among the things that startle
are a set of lungs
perfectly removed from a body,
such that their owner
could float along
and aspirate water yet
never taste burning salt,
the brine merely washing in and out
of that terrified O, a hole gushing fear,
in a palsy the signature of death.

Tourists gaped at the rescue effort,
gasping when helicopters would plunge
from inland to offshore
reclaiming bodies.
Their mouths would ape terrified O's,
murmuring while contemplating flowers littered on the rocks,
the scent of ocean stinging their exposed eyes,
breath taken shallowly
and not such a draught
of rarefied air
as must be in a pressurized cabin
the moment before framing the grimace
which would drink deep
and not taste.

I climbed nimbly over
ancient pathos and guilt
while gazing up at the sun
which rendered Icarus-like
a flaming airborne apparatus,
and I too vicariously followed helicopters out to sea,
then back again,
while others watched on,
some with salt-stained eyes
and terrible exhalations
of hot, painful air
rendered humid and filtered,
coming in jagged waves and
slowly I left that place
as if waking tenderly from
a salt-stained bed of Gothic rocks,
licking my lips as
local fishermen were interviewed
as authorities on this sort of thing,
everyone forming their words from a platform of open mouths
and those lungs again
drinking deep now

Shane Neilson
Clinical Clerk
Faculty of Medicine
Dalhousie University

This poem first appeared in Literary Review of Canada 1999;7(6).

© 1999 Canadian Medical Association