"There Was This One Guy . . .": The Uses of Anecdotes in Medicine

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"THERE WAS THIS ONE GUY . . .": THE USES OF ANECDOTES IN MEDICINE KATHRYN MONTGOMERY HUNTER* Medicine is filled with stories. Yet "anecdotal" would stand very near the top of a list of pejorative words in medicine—and for good reason. The number and variety of signs and symptoms observed in illness render the single case a deceptive guide to the understanding of disease, even the same disease in two people. Diseases described in textbooks are hypothetical abstractions, "classic cases," and their most common variations . But how are particular instances of illness in individual patients made to fit these abstractions? In this epistemological gap between the general rules of disease and the particular fact of an illness, anecdotes are told. The clinical story [I],1 a neglected but pervasive interstitial medium for the transmission of medical knowledge, deserves to be studied for its role in medical education, in clinical research, and in the daily care of patients. Studies of disease, surgical procedures, and medical therapy all are necessarily based on a large number of cases, and the medical investigator has the obligation, common to scientific research, to report accurately the negative results as well as the positive ones and to specify the variables which might have contributed to the outcome. Practitioners rely on these statistical abstractions—as do medical students and residents in the process oflearning to take care of patients. Physicians form their habits, and throughout their careers alter their customary practice, to take account of the refinements in diagnostic knowledge and advancements in therapy that have been established and reported in this This paper is part of a project supported by a grant from the National Science Foundation : Ethics and Values in Science Technology, RII-8310291. *Assistant professor, Humanities in Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642. 'The Churchills have compared patients' medical history as recorded by physicians and presented at rounds with the patients' own narration of their illness and its meaning.© 1986 by The University of Chicago. AU rights reserved. 003 1 -5982/86/2904-0499$0 1 .00 Perspectives in Biology and Medicine, 29, 4 ¦ Summer 1986 \ 619 way. Such careful description of diagnostic criteria and reliable studies of treatment are the foundation of modern scientific medicine. There is, in this understanding of medicine, no place for the single, untested case. Stories in medicine, however, like stories everywhere, are inevitably concerned with single instances. Thus, insofar as they purport to convey knowledge, they are regarded as antiscientific in themselves, and late twentieth-century physicians are likely to associate them with unenlightened , prescientific practice. The deceptive power of the single case—a kind of imprinting of the isolated bits of one's experience or of hearsay —is the bane of scientific medicine. The physician who leaps to a mistaken diagnostic conclusion on the basis of limited personal experience , like the surgeon who refuses to use a particular instrument because one of them went bad in the middle of an operation or the internist who employs a marginally effective therapy because it once had good results, swims against the tide of a statistical medicine based on scientific principle. Stories, clinical accounts of single cases, were once the primary medium of medical knowledge. Sir Thomas Sydenham's careful observations in the seventeenth century were an important advance over a practice so tied to theory that physical examination was rarely undertaken , and diagnosis by mail was widespread [2]. Yet his classification of disease was fundamentally a series of witnessed accounts of single cases. Modern medicine is indebted to nineteenth- and twentieth-century human biology for supplying the science on which physicians might better rationalize and thus generalize their empirical practice [3]. Physiology and pathological correlations took the place of single accounts and enabled medicine to correct and extend the understanding of disease and its treatment in the human body. The disrepute in which anecdotes are held in medicine is thus historically rooted in the shift to a scientific, specifically pathophysiological, explanation of disease. The vehemence of their condemnation suggests the collective pain of those moments in medical progress when the old ways stood in the path of the new. Today anecdotal evidence is believed to...

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