Q J Med 2004; 97: 313-314
QJM vol. 97 no. 5 (c) Association of Physicians 2004; all rights reserved.
Coda |
Yellow nose sign
A mother was describing to me how her child had been vomiting over the last few days. ‘And I know just before he's going to be sick’ she told me ‘because the sides of his nose turn yellow.’ She looked at me significantly, no doubt assuming that the yellow nose sign would mean something to me as a doctor and hence lead me to the exact diagnosis.Patients’ narratives are full of these kinds of apparently nonsensical descriptions. Mostly we do not even hear them—quite literally. If you want to confirm this, you have only to watch videos of your consultations. You will almost certainly find that there are details in every history, mostly about yellow noses and the like, of which you have no recollection at all. Because they do not fit the medical construction of the world, your brain either used the time to compute something more useful to you as a doctor, or deemed the details meaningless and therefore consigned them to amnesia.
As the sociologist P.M. Strong pointed out a long time ago, most people are caught in a double bind when they see doctors.1 Often, their main reason for seeing us is precisely because they are not sure if they or their children's experiences fit the patterns of illness that we know about. Yet we get riled and suspicious if they trot out textbook accounts, and we react with selective inattention or mild contempt when they talk about things we do not understand, such as yellow noses.
Social scientists are trained to be more tolerant than doctors. They would take it for granted that the mother genuinely did see her son's nose go yellow each time that he was about to throw up. They would be untroubled by the fact that her notion of yellow did not correspond with my relatively inflexible medical concept of jaundice. They would also be vastly more curious about exploring the network of beliefs and explanations that enabled her to notice when noses turn yellow. They would, in other words, put her perceptions on a level playing field with mine.
What would happen if we as doctors did this too? One of the books that most influenced me as a medical undergraduate—as it did many other people at the time—was Thomas Kuhn's ‘The Structure of Scientific Revolutions’.2 Kuhn argued against the positivistic, Popperian idea that advances in scientific theory came about as a result of systematic attempts to show falsifiability. Instead, he proposed a more sociological view. It was one that focused on how people in each generation develop perceptions of the world that do not fit with previous descriptions. Kuhn examined how people generally discount such perceptions at first, assuming that they must be distorted or incorrect because they do not fit with existing theory. Over time, however, more and more people share these perceptions, until they become the nodal points around which a new world view starts to coalesce. Once this happens, the old theory simple crumbles away. At first it becomes outmoded, then obsolete, and in time quite incomprehensible.
The best demonstration I know of this process in action appears in an essay about the history of asthma by another sociologist, J. Gabbay.3 He goes through accounts of asthma from the 17th century to the 20th, noting how the shifts from one paradigm to the next are not small evolutionary ones but gigantic epistemological ones. Not only does the knowledge change with each version of asthma, but so does the fundamental nature of that knowledge.
Gabbay points out that it is tempting to assume that earlier descriptions of asthma will automatically map on to modern descriptions of asthma, or at the very least on to other recognizable conditions like congestive heart failure, pulmonary fibrosis, or even something a bit more remote like hepatic cirrhosis. Nothing, it seems, could be further from the truth. Seventeenth century asthma does not correspond in any way with modern asthma, but unfortunately it does not remotely correspond with anything else either. People with earlier models of asthma not only believed things we do not believe, but (as Gabbay illustrates in great detail) they saw things we cannot see, used treatments we cannot comprehend, noticed improvements we cannot credit, and offered explanations that are now impossible to follow. Each successive historical version of asthma consisted of a self-referential loop of symptoms, signs, diagnosis and treatment. None of its elements now makes sense to us, and none corresponds to anything that can be found in earlier or subsequent versions of asthma. The same, Gabbay strongly implies, will eventually be true of our ‘asthma’ too.
Doctors often find this kind of constructivist thinking hard to stomach. They believe that modern knowledge must be in some way entirely different from all previous types of knowledge. They find it hard to accept that even such fundamental notions as anatomy and evidence may one day be replaced by other constructions that we are incapable of even dreaming about. Many sociologists see this limitation in our thinking as simple defensiveness. They would argue that we are locked into our own mind sets by self-selection and then by professional indoctrination, We inevitably feel threatened by the idea that our whole system of scientific belief will one day dissolve and leave not a wrack behind. Yet if Gabbay is right, that dissolution is inevitable. And if Kuhn is right, the next medical paradigm may well depend on someone taking yellow noses seriously.
References
1. Strong PM. The Ceremonial Order of the Clinic: parents, doctors and medical bureaucracies. London, Routledge and Kegan Paul, 1979.
2. Kuhn T. The Structure of Scientific Revolutions. Chicago, University of Chicago, 1970.
3. Gabbay J. Asthma attacked? Tactics for the reconstruction of a disease concept. In: Wright T, Treacher A, eds. The Problem of Medical Knowledge: examining the social construction of medicine. Edinburgh, Edinburgh University Press, 1982.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||