Narrative based medicine: Narrative based medicine in an evidence based world

Abstract

This is the last in a series of five articles on narrative based medicine In a widely quoted riposte to critics who accused them of naive empiricism, Sackett and colleagues claimed that “the practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice.”1 Sackett and colleagues were anxious to acknowledge that there is an art to medicine as well as an objective empirical science but they did not attempt to define or categorise the elusive quality of clinical competence. This article explores the dissonance between the “science” of objective measurement2 and the “art” of clinical proficiency and judgment,3–5 and attempts to integrate these different perspectives on clinical method. ### Summary points Even “evidence based” clinicians uphold the importance of clinical expertise and judgment Clinical method is an interpretive act which draws on narrative skills to integrate the overlapping stories told by patients, clinicians, and test results The art of selecting the most appropriate medical maxim for a particular clinical decision is acquired largely through the accumulation of “case expertise” (the stories or “illness scripts” of patients and clinical anecdotes) The dissonance we experience when trying to apply research findings to the clinical encounter often occurs when we abandon the narrative-interpretive paradigm and try to get by on “evidence” alone Science is concerned with the formulation and attempted falsification of hypotheses using reproducible methods that allow the construction of generalisable statements about how the universe behaves. Conventional medical training teaches students to view medicine as a science and the doctor as an impartial investigator who builds differential diagnoses as if they were scientific theories and who excludes competing possibilities in a manner …