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What Lies Beneath

2021; Lippincott Williams & Wilkins; Volume: 43; Issue: 4 Linguagem: Inglês

10.1097/01.eem.0000743196.48103.71

1552-3624

Michelle Johnston,

Empathy and Medical Education

Figure: fact, evidence-based, anecdoteFigureEdvard Munch is the artist for our times, isn't he? If 2020 were a painting, it would have to be “The Scream.” We are hoping 2021 will be more serene, but who knows what horrors may be lying in wait. You are all intimately familiar with the fearful, crazed iconography of Munch's masterpiece: the sexless twisted skull, the wide sightless eyes, the ovoid mouth caught mid-scream, the writhing psychotic colors, the disconnect from everybody else on the bridge, perhaps even on the planet. This is an image wracked with anxiety and uncertainty, swirled in oil, and staring straight into our own disquiet and unease. Munch was a curious character. Hardly unique for an artist of genius, you say, but even still, he pushed through many boundaries of normality. When describing the inspiration for “The Scream,” Munch told the story of walking across a bridge at sunset with two friends. Out of nowhere, a vision simply seized him. The “air turned to blood,” and “the faces of my comrades became a garish yellow-white.” He described hearing a huge endless scream coursing through nature. This representation of the abstract would carry Munch through the rest of his career. He succinctly encapsulated his ethos in the sentence, “I do not paint what I see but what I saw,” which leads us into the emergency medicine part of this column. What we experience as individuals has enormous influence on our interpretation of matters. Anecdotes have power. Story and narrative, however, make uneasy bedfellows with medicine. For much of history, story was all medicine had, as elegantly put in the New York Times, “Once upon a time, until the last century or so, doctors ... had little in their tool bags except their humanity with which to channel that mysterious thing we call a healing encounter: that charged interaction—personal and impersonal, physical and spiritual—upon which so much depends. Now that blood tests have replaced bloodletting, how can we make that interaction be more rewarding?” (April 18, 2004; http://nyti.ms/3b9gCzZ.) Be Wary of the Anecdote Story was, of course, superseded by evidence-based medicine. Research. Data. Numbers derived from populations that did not bend to the whim and whimsy of once upon a time. Narrative medicine has returned to the party over the past few decades, however, flouncing its way back in past the doormen and proclaiming its importance. It complements our knowledge; it brags, allowing a holistic and intuitive approach to patient care. We are now positively encouraged to tell stories while educating, to incorporate individual patient's experiences into our understanding of population science. Prudence tells us, though, to be wary of the anecdote and its seductive power. It is likely humans are hardwired for story. It makes good evolutionary sense that as we developed into communities, reliant on each other for safety, food, and sharing of tasks, we needed stories about the behavior of others to understand social cues and relationships for survival. We know that learning facts when there is an emotional association, such as the tension of a story or a striking visual metaphor, means a manifestly stronger memory is linked to that fact, with much easier recall and integration. Herein lies the problem with story: the case of n=1. It becomes enfolded into our knowledge, wrapped in memory, indistinguishable from hard facts. It becomes what we saw, as opposed to what we see. It feeds into our biases, as much as we believe we are above them. Stories are a haven and a playground for our own biases, a place where our prejudices can run wild and build associations in our brain, friendships and bonds that can be difficult to break. Take the example of your own recently departed president and his conversation with Anthony Fauci, MD. Forty-Five “knew” that certain treatments worked. “Boy, this convalescent plasma is really phenomenal. ... [T]his stuff really works.” (New York Times. Jan. 24. 2021; http://nyti.ms/3jV2u1o.) Or the example of people becoming converts to tPA in stroke because they have “watched people get better on the end of a needle.” These individual stories, associated with emotion and tense narrative, can become branded into our cortices, hard to uncouple when tedious datasets disagree with them. Far be it from me, a hapless lover of story and fiction, to suggest that story is not vitally important. Somewhere, however, lies a delightful medium, where truth and beauty play equal roles with its opposite number—unimpeachable fact. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website, www.EM-News.com. Comments? Write to us at [email protected]. Dr. Johnstonis a board-certified emergency physician, thus the same as you but with a weird accent. She works in a trauma center situated down the unfashionable end of Perth, Western Australia. She is the author of the novel Dustfall, available on her website, http://michellejohnston.com.au/. She also contributes regularly to the blog, Life in the Fast Lane, https://lifeinthefastlane.com. Follow her on Twitter@Eleytherius, and read her past columns athttp://bit.ly/EMN-WhatLiesBeneath.