Me: What I say is evidence.
GP: We have to disagree on that.
This is a real exchange between a medic and myself I tweeted yesterday. But these words are too profound to only tweet. They need a fuller account. Here it is.Only a few days ago I wrote about narrative as evidence, trying to show the complexity of taking on board the narrative in medicine. Little did I know how silly such considerations will be rendered by this brief and inconsequential little exchange. What does the doctor say? Well, basically, something like: “Narrative? Don’t be silly.” And that raises quite a fundamental question. If narrative is not evidence for a doctor, what is it?
I suppose, I could start with an account of the narrative offered by a psychologist. In his book On Being Normal and Other Disorders, Paul Verhaege rejects the narrative. In fact, what the patient says is in the way. The ‘vague complaints’ the patient has, are hardly something to focus on. Rather, the brave clinicians must see through all this rubbish and ‘extract’ the real symptoms. The narrative, the experiences need to be strained with a clinical sieve, flushed away till the symptoms, much like gold nuggets, remain. The clinician then looks at them and jumps to action. The patient’s experience (in this case of psychological distress) is reduced to whatever is stipulated by medical/psychiatric classification and testing. Of course, the patient has no say in how they see, assess, experience what makes them suffer. It is the clinician who knows better. End of matter.
The way I see it, and gosh, I am not a medic, what do I know, is: why do I actually start talking? I mean, think about it. If what I say has no evidential status, it doesn’t help, really, why do you ask me to tell you anything? And this question always reminds me of a doctor-patient conversation I witnessed years ago.
As I was talking to a couple of psychiatrists on a hospital ward, a patient, a woman probably in her late 60s, approached us and started talking to one of the consultants. She asked her to post a letter addressed to the minister of health with a request to intercede on her behalf. Basically, she argued, she was unhappy in the hospital and thought that she would be much better off at home with her family (the logic was sharp and inevitable). The consultant, visibly irritated, said she would not post the letter and said that she would talk to the patient the following day (it almost sounded like a threat). The patient, inconsolable, shuffled away. And I started thinking. What makes my story of delusions acceptable and my story of wanting to go home not? How do you decide? Of course, the question is not exactly very new and was raised for example by the famous Rosenhan experiment.
The scene shows well the problem with the narrative in medicine. You actually need it, doctor, otherwise what will you focus on? I need to tell the medic what is wrong with me, why I bother her/him. So, if I tell them, say, that I have muscle pains, they actually buy it, swallow it like a little pelican, because there is precious little they can do. But here comes the crucial moment. After they heard what I had to say, they press two buttons. First is the power button. It allows them to ignore me; it no longer matters what I have to say, they are putting their God hat on and become omniscient.
You just know better, after all, you are a doctor and my doctorates can never ever trump it. Both they (the doctorates) and my entire self are muted by the wonders of your knowledge.
The other one is the objectivity-and-evidence button. The medic soooo doesn’t need me. Medicine, after all, is completely objective (I am laughing as I write it) and it has nothing to do with my stupid story. No, no, it has all to do with the ‘real evidence’. The objective one. As they hover on the cloud of objectivity, saying, “So, the evidence is…“, my story pales into insignificance. They’ve got the proper evidence.
And this is, really, why I think, a medic disagrees that what I say is evidence. The moment s/he accepts it, s/he actually gives up the two fundaments of medicine: power and objectivity. Obviously, both are merely a mirage, an illusion, but sitting on the objectivity cloud must feel really great, even if it doesn’t last very long. Incidentally, the little exchange at the beginning shows how silly the ‘ICE questions’ are. I mean – please!
Interestingly, the post doesn’t end here. There is a coda to the story of narrative as evidence. In a strange twist of events, it turned out that my narrative can be evidence, at least of sorts, which I don’t want to explore. It also turns out that I can regain some power. How? This is, really, when it gets so silly that I was wondering whether to actually write it at all. So, I can regain power by…shouting! Of course, not at the top of my voice, but by raising the voice sufficiently to stop everything. And, bloody hell, it worked wonders. All of a sudden the same story, just said with a few emotionally loaded words and said loudly, became a completely new story. It was not only focused on, explored, queried, but it also became evidence.
Go figure! Objectivity for you.