Table Of Contentthe chief concern of medicine
The Chief Concern
of Medicine
The Integration of the Medical
Humanities and Narrative Knowledge
into Medical Practices
Ronald Schleifer and Jerry B. Vannatta
with Sheila Crow and
a contribution by Seth Vannatta
The UniVeRSiTy of MiChigan PReSS
ann aRBoR
Copyright © by the University of Michigan 2013
all rights reserved
This book may not be reproduced, in whole or in part, including illustrations, in any form
(beyond that copying permitted by Sections 107 and 108 of the U.S. Copyright Law and
except by reviewers for the public press), without written permission from the publisher.
Published in the United States of america by
The University of Michigan Press
Manufactured in the United States of america
c Printed on acid- free paper
2016 2015 2014 2013 4 3 2 1
a CiP catalog record for this book is available from the British Library.
Library of Congress Cataloging- in- Publication Data
Schleifer, Ronald.
The chief concern of medicine : the integration of the medical humanities
and narrative knowledge into medical practices / Ronald Schleifer and
Jerry B. Vannatta with Sheila Crow and a contribution by Seth Vannatta.
p. ; cm.
includes bibliographical references and index.
isbn 978- 0- 472- 11859- 5 (cloth : alk. paper)— isbn 978- 0- 472- 02886- 3 (e- book)
i. Vannatta, Jerry. ii. Crow, Sheila. iii. Title.
[dnlm: 1. narration. 2. Physician- Patient Relations. 3. ethics, Medical.
4. Medical history Taking. w 62]
616.07'51— dc23 2012033644
to our students and colleagues
and the years of our working friendship
Preface
The Chief Concern of Medicine aims at enlarging our sense of the profession
of medicine and, more important, enlarging its effectiveness and service, by
including a self- conscious awareness of the nature of narrative within a work-
ing definition of the way medicine understands itself as a profession and its
very activities. Medicine seeks to heal, to care, and to comfort, and we be-
lieve that each of these goals is improved with the understanding of how
narrative functions, both in general and within medical practices. To this
end, we offer, first of all, a pragmatic understanding of the science on which
medicine is based, particularly in relation to the larger theme of Part 1 of the
book, the definition and the practical and ethical strategies of what aristotle
calls phronesis (translated often as “practical reasoning” and sometimes even
as “practical wisdom”). aristotle believed that phronesis was the means to a
“good life” (eudaimonia), and one of his chief models for the accomplish-
ment of phronesis was successful doctoring. We argue here that phronesis is
closely related to narrative— to its structures and, most notably, its purposes,
particularly the “end” or “concern” of any particular narrative. We also argue
that the logic of hypothesis formation that informs medical diagnosis closely
aligns itself with narrative and what we are calling “narrative knowledge.”
Thus Part 1 of The Chief Concern of Medicine aims at enlarging our
sense of science and scientific understanding and procedures in order to
complement evidence- based medicine. evidence- based medicine aims, ide-
ally, at what atul gawande has called “the idea that nothing ought to be in-
troduced into practice unless it has been properly tested and proved effec-
tive by research centers, preferably through a double blind, randomized
controlled trial” (2007: 188). We hope to complement— not replace—
evidenced- based medicine with what we are calling “schema- based medi-
cine.” The schemas we set forth— on the model of schemas as they appear in
cognitive psychology and artificial intelligence— are schemas of narrative,
ethical actions, and procedures for the medical interview. in appendix 1, we
even suggest that schemas might allow us to understand what might be called
“humanistic understanding” more generally, in terms of a model of discipline
building in the humanities. The simplest, but perhaps most profound, of
these schemas is the suggestion, as we note in both the introduction and
chapter 3, that doctors elicit a patient’s chief concern as well as a chief com-
plaint in the formal procedure of conducting the history and Physical exam
and eliciting the history of Present illness. We believe that the understand-
ing of the schemas and procedures we describe in this book that grow out of
humanistic understanding can find their place alongside scientific under-
standing in governing how physicians and health care workers conceive of
and go about their everyday encounter with people who are suffering, in
distress, and in need of help.
for this reason, it is our contention that the nomological sciences— law-
governed understandings, based on thoroughly repeatable experiments or
large- scale statistical measurements—c an be complemented by the human
sciences, which depend on schematic understanding of forms and structures
that govern cognition, experience, and judgment more generally. a model
for such complementarity is the science of evolutionary biology, whose re-
sults are widely accepted by physicians, medical- school faculty, and students
aspiring for a career in medicine, even though the kind of randomized con-
trol trials that epitomize evidence-b ased medicine is rarely possible in the
study of evolution. evolution, Stephen Jay gould has persuasively argued
(see especially 1986, 1989), is not a nomological science—r ather, he says, it
is a historical science—y et it still bases itself, at times, on retrospective evi-
dence (see Weiner 1995 for remarkable empirical evidence of generations of
finches on the galapagos islands). a third category of science—w hat we sug-
gest, early in the book, seeks functional knowledge— bases itself on the prag-
matic achievement of goals in the systematic pursuit of understanding. inso-
far as it does so, we suggest, it is a species of narrative science (or at least
systematic analyses of narrative), which is based neither on the deductive
laws and quantifiable evidence of nomological science nor on the inductive
retrospective understanding of evolutionary- biological science but on the
schemas of the humanities in general and of abductive logic more specifi-
cally. (in chapter 4, we closely examine Charles Sanders Peirce’s “logic of
abduction,” which is a systematic understanding of hypothesis formation.) in
Part 1 of The Chief Concern of Medicine, we trace the functioning of such
schemas in the ethical understanding of aristotle’s phronesis, in the
viii / preface
evolutionary- structural understanding of narrative cognition (or “narrative
knowledge”), in a general accounting of narrative structures, and in Peirce’s
logic of abductive reasoning. This is more or less the theoretical or philo-
sophical basis of The Chief Concern of Medicine.
in Part 2, we examine the particular everyday practices of medicine in
relation to narrative. almost all medicine, we note, begins with the encoun-
ter of patient and physician, and this encounter is organized around the his-
tory of Present illness (hPi). Such a history begins, of necessity, with the
patient’s chief complaint, but as we already mentioned, we argue that in the
physician’s encounter with the patient, the chief complaint should be for-
mally complemented with the inclusion of the patient’s chief concern as well.
That concern is the patient’s awareness of what his illness means in relation
to the ongoing story of his life, and because of this, its inclusion within the
history and Physical exam—s omething that physicians would routinely ask
in the way that family history is a routine part of the history and Physical
exam itself— would make conscious awareness of narrative an important tool
of medical diagnosis and treatment growing out of the patient- physician en-
counter. as we note in chapter 3 and argue throughout Parts 2 and 3, a sig-
nificant feature of narrative and narrative cognition is the deliberation be-
tween its teller and its listener— an important feature of narrative, we note,
is a witness who learns— and such collaborative deliberation, we believe, is
at the heart of good doctoring. Deliberation is also at the heart of aristotle’s
conception of phronesis. Thus the chapters of Part 2 examine the scene of
narrative, which is the patient- physician relationship, the understanding of
narrative, and the engagement with and responses to narrative available and
proper to the practice of medicine.
finally, Part 3 spells out schemas of narrative and ethical behavior that
can help physicians pursue their work most efficiently, compassionately, and
comprehensively in the face of human suffering. These schemas are orga-
nized in relation to the theoretical sense of science and understanding that
Part 1 describes and the empirical sense of what happens— or ought to hap-
pen, given its goals and practical organization—i n practices of medicine.
Throughout all these chapters, we distinguish between everyday or “popu-
lar” narrative and aesthetic or “art” narrative, and we do so with the assump-
tion that while narrative cognition is, indeed, part of our human inheritance
as a species, the development of aesthetic narrative forms allows us to see
more clearly how narrative works and how we can be more consciously atten-
tive and receptive to the stories patients tell and to the narrative knowledge
they present. Moreover, we argue, aesthetic narrative creates vicarious expe-
preface / ix
