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Anecdote and objectivity
J Clin Epidemiol Vol. 44, No. 7, pp. 725-726, Printed in Great Britain. All rights reserved
1991
0895-4356/91 $3.00 + 0.00 Copyright 0 1991 Pergamon Press plc
Second Thoughts ANECDOTE
AND OBJECTIVITY JOSEPH HERMAN
Department of Family Medicine, Faculty of the Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (Received 9 November 1990)
My dictionary provides two definitions of the word “anecdote” which do not differ greatly from one another. The first gives the original meaning of the term as “ . . . little-known, entertaining facts of history or biography.” The second records its current usage as “ . . . a short, entertaining account of some happening, usually personal or biographical.” The listed synonyms are “story, incident, tale, narrative, narration” [l]. The 24th edition of Stedman’s Medical Dictionary does not define either “anecdote” or “anecdotal” which suggests a rejection of the idea that these words have any particular medical connotation [2]. Why, then, are certain case reports referred to disparagingly as anecdotal by the editors and reviewers of our learned journals? What, indeed, is the meaning of anecdotal in editorial parlance? Does it imply lack of sophistication? My own experience points in that direction. A paper on two young agricultural workers who presented with widespread pigmentation cum dermatitis in unusual weather conditions when ladybugs were exceptionally prevalent was rejected as anecdotal. This despite photographic documentation, an obscure reference in a respected dermatology textbook to the pretty little insects’ hypodermal glands [3] and a description, in a letter from England of how seaside bathers were being pestered by them during a dry summer [4]. On the other hand, a report of a patient ingesting acetazolamide for glaucoma who developed a syndrome suggestive of gastro-intestinal malignancy was accepted, I suspect, because 125
it mentioned the endoscopic finding of erosive gastritis. The camera, which was intended to preserve the superficial ulcers for posterity, broke down in the middle of the procedure, but the editors were not to be deterred despite of the the decidedly anecdotal nature evidence! Does it imply unscientific? Given the biomedical prejudices of most journals and their thirst for hard proof, this could well be so. Within the broader confines of the biopsychosocial paradigm, however, both the clinical tale [5] and the illness narrative [6] are respectable, even scientific, terms. The eliciting of the former is a basic technique of Oliver Sacks’ romantic science [7] which places patient and physician, “co-authors and collaborators,” in a single context that can even have moral overtones. Thus, Sacks speaks of “the plenum of being” where patients may have something wrong with “ . . . their molecules, their motives or their relations with the world” [8]. The illness narrative, on the other hand, is taken down as an expanded history giving us insight into the meaning of his suffering to the patient and how it obtrudes itself in his relationships with significant others. Does it imply that our learned journals fear entertaining their readers? I certainly pay the ones to which I subscribe to keep me in “state of the art” condition, but I would not accuse their editors of levity should some of what is written occasion a smile now and then. There is, in medical science, with its frenetic pretence to objectivity, enough to be amused over even
126
Second Thoughts
when its purveyors seem to be taking themselves with the utmost seriousness. Perhaps we are speaking of a paper that contains too much of its authors, their ways of making inference and, possibly (heaven forbid!), their feelings too, in a word one that is overly subjective. This touches on the personal aspect of the dictionary definition of anecdote and leads us to a consideration of the search for objectivity. Many of the diseases with which we deal have no pathognomonic sign or symptom and absolutely no specific biochemical marker. Regarding them, an objective diagnosis emerges from lists of criteria drawn up by consensus, a highly subjective process of which an eminent rheumatologist has recently said: “In dealing with disorders of unknown cause and variable presentation, it is essential to define what we think we are talking about” [9]. The psychiatric Diagnostic and Statistical Manual (DSM) is chock full of such and, while it may be simple to determine that a suspected schizophrenic is under 45 years and has been behaving in a peculiar manner for over 6 months, the “essential features” are an entirely different matter. Here, the physician relies on what his patient relates since he is not party to the delusions and hallucinations and cannot, as a rule, observe them directly. Some of these, alas, may be bizarre and even entertaining and bring us back to anecdote as a point of departure. Neither the tender points of fibromyalgia nor the measured grip strength or walking speed of a patient with rheumatoid arthritis offer much in the way of objectivity. In the former condition, which some observers regard as no more than an expression of human unhappiness [lo], it is difficult to objectivize the pressure required for eliciting tenderness. In the latter, a question of compliance might arise. A patient who is in a bad mood because of some significant life event might well be less cooperative during objective testing. Thus, we are left largely with his word on which to base our decisions about the usefulness of a given therapeutic modality. A recent paper on non-gonococcal urethritis distinguishes emphatically between subjective (dysuria or reported discharge) and objective (urethral leukocytosis and observed discharge) findings [l 11. The question of whether the disappearance of the latter only would be counted as a treatment success is not addressed. Since patients do not come in off the street to an STD clinic in order to learn if they have pyuria
but rather because they have dysuria and have noticed stains on their underwear, the dichotomy is probably a spurious one. The report of the U.S. Preventive Services Task Force does not recommend screening for pyuria at any age [12]; therefore, the measure of failed treatment should be persistent dysuria, not leukocytes in the urine. I once enraged a group of senior medical students (is there any other stage when certainty is more the breath of life?) by suggesting that a Tibetan, while certainly subject to coronary artery disease, might not “be able” to experience angina pectoris. The distance in time, geography, culture and ethnicity between Lhassa and late 18th-century England where Heberden, with a figurative stiff upper lip, laid down his diagnostic criteria, is mind-boggling. Many of our patients, too, for reasons varying from the cross-cultural [13] to individuality in pain and suffering [14] may be incapable of presenting the essential features we are accustomed to tick off “objectively.” We are doomed to practice on the perilous rim of an anecdotal abyss. I can see no reason why the term should continue to have a pejorative emphasis unless it is to keep us from coming to grips with what is really down there! REFERENCES 1. Webster’s New Twentieth Century Dictionary. U.S.A.: Collins World; 1978: 2nd edn. 2. Stedman’s Medical Dictionary. Baltimore: Williams & Wilkins; 1982: 24th edn. 3. Rook A, Wilkinson DS, Ebling FJG, Eds. Textbook of Dermatology. London: Blackwell; 1979. 4. Lister J. Letter from England. N Engl J Med 1976; 295: 1001. 5. Wasserstein AG. Toward a romantic science: the work of Oliver Sacks. Ann Intern Med 1988; 109: 440-444. 6. Kleinman A. The Illness Narratives. New York: Basic Books; 1988. I. Luria AR. The Man with a Shattered World. Cambridge: Harvard University Press; 1987. 8. Sacks 0. Awakenings. New York: E.P. Dutton; 1983. 9. Rogers DE, Des Prez RM, Cline MJ et al., Eds. 1989 Year Book of Medicine. Chicago: Year Book Med Publishers; 1989: 639. _ 10. Rogers DE, Des Prez RM, Cline MJ et al. Eds. 1988 Year Book of Medicine. Chicago: Year Book Med Publishers; 1988: 761. 11. Hooton TM, Wong ES, Barnes RC ef al. Erythromycin for persistent or recurrent nongonococcal urethritis. AM Intern Med 1990; 113: 21-26. 12. Guide to clinical Preventive Services. Baltimore: Williams & Wilkins; 1989. 13. Kleinman A, Eisenberg L, Good B. Culture, illness and care: clinical lessons from cross-cultural research. Ann Intern Med 1978; 88: 251-258. 14. Petrie A. Individuality in Pain and Suffering. Chicago: University of Chicago Press; 1967.
1991
0895-4356/91 $3.00 + 0.00 Copyright 0 1991 Pergamon Press plc
Second Thoughts ANECDOTE
AND OBJECTIVITY JOSEPH HERMAN
Department of Family Medicine, Faculty of the Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (Received 9 November 1990)
My dictionary provides two definitions of the word “anecdote” which do not differ greatly from one another. The first gives the original meaning of the term as “ . . . little-known, entertaining facts of history or biography.” The second records its current usage as “ . . . a short, entertaining account of some happening, usually personal or biographical.” The listed synonyms are “story, incident, tale, narrative, narration” [l]. The 24th edition of Stedman’s Medical Dictionary does not define either “anecdote” or “anecdotal” which suggests a rejection of the idea that these words have any particular medical connotation [2]. Why, then, are certain case reports referred to disparagingly as anecdotal by the editors and reviewers of our learned journals? What, indeed, is the meaning of anecdotal in editorial parlance? Does it imply lack of sophistication? My own experience points in that direction. A paper on two young agricultural workers who presented with widespread pigmentation cum dermatitis in unusual weather conditions when ladybugs were exceptionally prevalent was rejected as anecdotal. This despite photographic documentation, an obscure reference in a respected dermatology textbook to the pretty little insects’ hypodermal glands [3] and a description, in a letter from England of how seaside bathers were being pestered by them during a dry summer [4]. On the other hand, a report of a patient ingesting acetazolamide for glaucoma who developed a syndrome suggestive of gastro-intestinal malignancy was accepted, I suspect, because 125
it mentioned the endoscopic finding of erosive gastritis. The camera, which was intended to preserve the superficial ulcers for posterity, broke down in the middle of the procedure, but the editors were not to be deterred despite of the the decidedly anecdotal nature evidence! Does it imply unscientific? Given the biomedical prejudices of most journals and their thirst for hard proof, this could well be so. Within the broader confines of the biopsychosocial paradigm, however, both the clinical tale [5] and the illness narrative [6] are respectable, even scientific, terms. The eliciting of the former is a basic technique of Oliver Sacks’ romantic science [7] which places patient and physician, “co-authors and collaborators,” in a single context that can even have moral overtones. Thus, Sacks speaks of “the plenum of being” where patients may have something wrong with “ . . . their molecules, their motives or their relations with the world” [8]. The illness narrative, on the other hand, is taken down as an expanded history giving us insight into the meaning of his suffering to the patient and how it obtrudes itself in his relationships with significant others. Does it imply that our learned journals fear entertaining their readers? I certainly pay the ones to which I subscribe to keep me in “state of the art” condition, but I would not accuse their editors of levity should some of what is written occasion a smile now and then. There is, in medical science, with its frenetic pretence to objectivity, enough to be amused over even
126
Second Thoughts
when its purveyors seem to be taking themselves with the utmost seriousness. Perhaps we are speaking of a paper that contains too much of its authors, their ways of making inference and, possibly (heaven forbid!), their feelings too, in a word one that is overly subjective. This touches on the personal aspect of the dictionary definition of anecdote and leads us to a consideration of the search for objectivity. Many of the diseases with which we deal have no pathognomonic sign or symptom and absolutely no specific biochemical marker. Regarding them, an objective diagnosis emerges from lists of criteria drawn up by consensus, a highly subjective process of which an eminent rheumatologist has recently said: “In dealing with disorders of unknown cause and variable presentation, it is essential to define what we think we are talking about” [9]. The psychiatric Diagnostic and Statistical Manual (DSM) is chock full of such and, while it may be simple to determine that a suspected schizophrenic is under 45 years and has been behaving in a peculiar manner for over 6 months, the “essential features” are an entirely different matter. Here, the physician relies on what his patient relates since he is not party to the delusions and hallucinations and cannot, as a rule, observe them directly. Some of these, alas, may be bizarre and even entertaining and bring us back to anecdote as a point of departure. Neither the tender points of fibromyalgia nor the measured grip strength or walking speed of a patient with rheumatoid arthritis offer much in the way of objectivity. In the former condition, which some observers regard as no more than an expression of human unhappiness [lo], it is difficult to objectivize the pressure required for eliciting tenderness. In the latter, a question of compliance might arise. A patient who is in a bad mood because of some significant life event might well be less cooperative during objective testing. Thus, we are left largely with his word on which to base our decisions about the usefulness of a given therapeutic modality. A recent paper on non-gonococcal urethritis distinguishes emphatically between subjective (dysuria or reported discharge) and objective (urethral leukocytosis and observed discharge) findings [l 11. The question of whether the disappearance of the latter only would be counted as a treatment success is not addressed. Since patients do not come in off the street to an STD clinic in order to learn if they have pyuria
but rather because they have dysuria and have noticed stains on their underwear, the dichotomy is probably a spurious one. The report of the U.S. Preventive Services Task Force does not recommend screening for pyuria at any age [12]; therefore, the measure of failed treatment should be persistent dysuria, not leukocytes in the urine. I once enraged a group of senior medical students (is there any other stage when certainty is more the breath of life?) by suggesting that a Tibetan, while certainly subject to coronary artery disease, might not “be able” to experience angina pectoris. The distance in time, geography, culture and ethnicity between Lhassa and late 18th-century England where Heberden, with a figurative stiff upper lip, laid down his diagnostic criteria, is mind-boggling. Many of our patients, too, for reasons varying from the cross-cultural [13] to individuality in pain and suffering [14] may be incapable of presenting the essential features we are accustomed to tick off “objectively.” We are doomed to practice on the perilous rim of an anecdotal abyss. I can see no reason why the term should continue to have a pejorative emphasis unless it is to keep us from coming to grips with what is really down there! REFERENCES 1. Webster’s New Twentieth Century Dictionary. U.S.A.: Collins World; 1978: 2nd edn. 2. Stedman’s Medical Dictionary. Baltimore: Williams & Wilkins; 1982: 24th edn. 3. Rook A, Wilkinson DS, Ebling FJG, Eds. Textbook of Dermatology. London: Blackwell; 1979. 4. Lister J. Letter from England. N Engl J Med 1976; 295: 1001. 5. Wasserstein AG. Toward a romantic science: the work of Oliver Sacks. Ann Intern Med 1988; 109: 440-444. 6. Kleinman A. The Illness Narratives. New York: Basic Books; 1988. I. Luria AR. The Man with a Shattered World. Cambridge: Harvard University Press; 1987. 8. Sacks 0. Awakenings. New York: E.P. Dutton; 1983. 9. Rogers DE, Des Prez RM, Cline MJ et al., Eds. 1989 Year Book of Medicine. Chicago: Year Book Med Publishers; 1989: 639. _ 10. Rogers DE, Des Prez RM, Cline MJ et al. Eds. 1988 Year Book of Medicine. Chicago: Year Book Med Publishers; 1988: 761. 11. Hooton TM, Wong ES, Barnes RC ef al. Erythromycin for persistent or recurrent nongonococcal urethritis. AM Intern Med 1990; 113: 21-26. 12. Guide to clinical Preventive Services. Baltimore: Williams & Wilkins; 1989. 13. Kleinman A, Eisenberg L, Good B. Culture, illness and care: clinical lessons from cross-cultural research. Ann Intern Med 1978; 88: 251-258. 14. Petrie A. Individuality in Pain and Suffering. Chicago: University of Chicago Press; 1967.