EDITORIALS
Anecdotes
and
empiricism
IN
the
modern,
progressive
world
of
general
practice
there
seems
to
be
a
trend
towards
scientific
justification.
The
stand-
ard
of
empiricism
is
being
raised
high
and
cries
are
heard
that
much
that
general
practitioners
do
has
not
been
properly
evalu-
ated
by
scientific
trial.'
At
a
time
when
clinical
audit
is
begin-
ning
to dictate
practice
it
is
important
to
stress
that
much
of
what
general
practitioners
do
is
inherently
not
amenable
to
testing
by
trial
but
is
based
on
knowledge
obtained
in
a
different,
but
no
less
valid,
way.
The
evidence
on
which
a
general
practitioner
works
might
be
described
as
anecdotal
rather
than
empirical
in
the
sense
that
seeing
patients
in
the
context
of
their
own
lives
(and
life
stories)
is
of
the
utmost
importance
in
diagnosis
and
explanation
and
in
planning
treatment.
The
description
'anecdotal'
will
immediately
damn
this
approach
in
the
minds
of
those
who
hold
up
the
ran-
domized
controlled
trial
as
the
gold
standard
in
medicine.2
But
should
it?
There
is
a
need
to
balance
these
disparate
approaches
and
to
this
end
it
is
important
to
examine
more
closely
the
use
of
anecdotes
in
medicine,
both
in
learning
and
in
practice.
Anecdotes
are
generally
regarded
as
short,
pleasant
and
humorous
stories
told
in
sociable
situations.
They
are
seen
as
light
and
trivial,
carrying
little
weight
in
serious
discussion.
The
context
in
which
the
term
is
used
by
doctors
bears
this
out:
'there
is
only
anecdotal
evidence
for
that'
is
a
put-down
frequently
heard
at
medical
meetings.
However,
at
the
same
meetings,
anec-
dotes
(although
not
recognized
as
such)
may
take
on
a
different
significance.
A
speaker
presenting
a
scientific
paper
will
tend
to
illustrate
the
talk
with
a
story
about
a
patient
he
or
she
has
treated.
It
is
often
only
at this
point
that
the
audience
sits
up
and
takes
notice.
The
essential
features
of
an
anecdote
here
are:
first,
that
it
is
being
told
about
a
patient
personally
known
to
the
speaker;
secondly,
that
it
is
being
told
by
a
doctor
personally
known
to
the
audience
(as
the
speaker
is,
at
the
very
least,
stand-
ing
there
in
front
of
them);
and
thirdly,
that
it
refers
to
a
unique
individual
in
a
unique
situation
rather
than
to
a
group
experience
(as
in
a
randomized
controlled
trial).
Because
of
these
features
the
anecdote
may
have
a
greater
impact
on
the
audience
than
the
scientific
paper
in
that
it
is
both
memorable
and
believable;
its
effect
on
their
practice
may
even
outweigh
the
effect
of
the
paper.
General
practitioners
tend
not
to
change
their
practice
simply
on
the
basis
of
results
of
trials;
they
are
more
impressed
with
wisdom
passed
on
through
someone's
clinical
experience.3
The
'I
remember
a
patient
once'
scenario
is
also
an
important
aspect
of
medical
education.
Clinical
medical
teaching
is
done
on
an
apprentice
basis
where
the
experience
of
the
teacher
is
handed
down
largely
by
anecdotes:
the
case
of
one
patient
will
be
con-
trasted
with
that
of
another
patient
whose
presentation
was
similar
but
memorably
different.
Undergraduate
students
are
therefore
confronted
with
the
uniqueness
of
each
individual's
illness.
From
seeing
people
as
homogeneous
(in
the
scientific
preclinical
years
of
the
course)
students
learn
the
reality
of
medical
practice
through
the
experiences
relayed
in
narrative
by
teachers
and
patients
alike.
In
fact,
they
already
knew
that
people
were
all
different,
it
was
just
that
medical
education
was
trying
to
teach
them
otherwise:
'The
first
staggering
fact
about
medical
education
is
that
after
two
and
a
half
years
of being
taught
on
the
assumption
that
everyone
is
the
same,
the
student
has
to
find
out
for
himself
that
everyone
is
different,
which
is
really
what
his
experience
has
taught
him
since
infancy.'4
Learning
clinical
medicine
traditionally
starts
with
taking
case
histories.
Students
learn
to
allow
patients
to
unfold
the
story
of
their
illnesses
in their
own
way
without
interruption
before
homing
in
on
specific
symptoms
for
clarification.
Students
are
often
asked
to
record
the
presenting
complaint
in
the
patient's
own
words
without
first
putting
a
clinical
gloss
on
it.
'I'm
that
breathless
I
can't
even
climb
the
stairs
with
the
shopping'
says
much
more
about
the
meaning
of
the
illness
to
that
individual
patient
than
'exertional
dyspnoea
NYHA
[New
York
Heart
Association]
grade
2'.
The
way
in
which
a
patient
orders
events
in
his
or
her
story
can
be
highly
meaningful.
Compare
two
presentations
of
breast
cancer:
'About
a
month
ago
I
fell
against
the
banisters
and
it
was
just
after
that that
I
felt
the
lump.'
'I
don't
usually
examine
myself
but
about
a
month
ago
I
fell
and
hurt
my
chest
and
when
I
was
rubbing
on
a
pain
reliever
I
felt
the
lump.'
The
first
patient
clearly
feels
that
there
is
some
connection
between
her
injury
and
the
development
of
cancer
whereas
the
other
patient
views
her
injury
as
fortuitous
as
it
allowed
her
the
opportunity
of
discovering
the
lump
earlier.
If
the
doctor
ignores
these
narrative
distinctions
then
the
patient
can
be
left
confused
and
disoriented,
with
many
questions
left
unanswered.
Alertness
to
the
patient's
story
allows
the
doctor
access
to
a
deeper
under-
standing
of
the
patient,
beyond
the
purely
scientific
and
patho-
logical.5
Allowing
a
patient
to
tell
his
or
her
story
completely
can
be
an
important
part
of
the
therapeutic
process.
This
gives
the
patient
the
opportunity
to
order
and
clarify
in
his
or
her
own
mind
the
experience
of
the
illness
and
helps
the
patient
towards
under-
standing
it.
It
is
surprising
how
difficult
it
is
to
listen
properly
to
a
patient's
story
to
its
conclusion.
But
it
is
important
to
do
so
because
if
the
doctor
interrupts
with
comments
these
are
often
completely
ignored
by
the
patient
who
wishes
to
finish
the
story.
As
Peter
Hoeg's
heroine
comments
in
his
book
Miss
Smilla's
feeling
for
snow:
'Very
few
people
know
how
to
listen.
Their
haste
pulls
them
out
of
the
conversation,
or
they
try
internally
to
improve
the
situation,
or
they're
preparing
what
their
next
speech
will
be
when
you
shut
up
and
it's
their
tum
to
take
the
stage.'6
Patients'
medical
knowledge
and
attitudes
towards
disease
are
often
built
up
from
a
series
of
anecdotes
about
what
has
hap-
pened
to
family
or
friends.
Most
doctors
will
be
familiar,
when
trying
to
persuade
a
patient
to
give
up
smoking,
with
the
story
of
uncle
Jimmy
who
smoked
30
cigarettes
each
day
and
was
still
playing
bowls
at
the
age
of
80
years.
It
should
be
remembered
that
such
anecdotes
are
usually
true
and
that
the
patient
has
a
point.
Uncle
Jimmy
is
proof
to
the
patient
that
the
doctor's
warn-
ings
could
be
wrong
and
that
the
much
publicized
scientific
evid-
ence
of
the
risks
of
smoking
is
not
absolute
for
the
patient
as
an
individual.
So
the
doctor's
approach
to
the
patient's
illness
(or
to
the
patient's
potential
to
be
ill)
should
be
tempered
by
the inher-
ent
uncertainty
of
much
medical
knowledge
and
by
the
unpre-
dictability
of a
disease
process
in
a
unique
person.
British
Journal
of
General
Practice,
November
1955
571
