Monday, October 20, 2014


Why Doctors Need Stories: In An Era of Systematic Clinical Research, Medicine Still Requires the Vignette

Title of New York Times Sunday Review essay, by Peter Kramer, Clinical Professor of Psychiatry, Brown University, October 19, 2014

Doctors practice in an era of Big Data, where anything and almost everything can be reduced to a data set, as expressed in an algorithm, protocol, arithmetic trend, and meta-analysis.

The last 20 years has been an era, according to Dr. Kramer of Brown University Medical School, in which “clinical vignettes have lost their standing. For a variety of reasons, including a heightened awareness of medical error and a focus on cost cutting, we have entered an era in which a narrow, demanding version of data-based medicine prevails.”

This is unfortunate, says Dr. Kramer, “ The vignette, unlike data, retains the texture of the individual life.” That is why Kramer assigns only case vignettes for psychiatric residents in training. Vignettes, or case studies, have long been the mainstay for teaching in academic medicine, as indicated by the enduring popularity of a Case Study in the New England Journal of Medicine.

According to NEJM, “Data are important, of course, but numbers sometime an order to what is happeing that can be misleading. Stories are better at capturing a different type of ‘big picture.’”

Narratives and anecdotes have a story-telling power that data sets can never duplicate. I became acutely aware of this power two years ago when I visited an ophthalmologist. He was resisting the implementation of an electronic medical record system in his office.

He groused, with words to this effect, “ I get these data summaries from other doctors, and I can’t make heads or tails of why they sent the patient. The EMRs don’t tell a story. They are a mumbo jumbo of numbers and leave me cold. I’ll be damned if I’ll waste my time entering data or investing in staff to enter that data.”

I share with you this personal vignette , even though the story is anecdotal, and therefore suspect in the modern era of Big Data and Data Sets. The vignette illustrates the graphic reasons why in a physician survey, 40% of 20,000 clinicians, 85% of whom had EMRs, thought EMRs decreased efficiency while only 24% felt EMRs enhanced efficiency (“ Physician Foundation Poll of 20,000 Physicians," Medinnovation Blog, September 24, 2014).

Clinical judgment requires narrative, as well as data.

Evidence-based medicine, while essential, is only half a patient’s story.

A clinical data set, after all is said and done, is nothing but a collection of related information composed of separate elements that can be collected by a computer, but must be interpreted by a doctor.

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