A few months ago, an unexpected problem arose during morning rounds. We were discussing Mr. Johnson, a patient with throat cancer who had been admitted for pain control. I mentioned, in passing, that he loved to watch westerns.
A short pause followed before everyone asked for more information. Did Mr. Johnson mention this for a specific reason? I answered that I didn’t think so. Did he want to watch movies in the hospital? He had not mentioned that to me. Was a video service available to inpatients? I said that I had no idea if such a service existed.
This detail about Mr. Johnson had stood out to me during my discussion with him on the previous evening. He had said it while I percussed his belly. He elaborated on it while I examined his motor strength. At the time, it had seemed important, and I had felt like I should remember it along with the medication list and review of systems. But now on rounds, where information needed to have a practical purpose, I wondered if this was wrong. A film preference would not change any part of his medical care—not his pain medications, his diet, or his physical therapy.
Then, as we left the conference room, the attending asked me, “Why westerns? Why not romantic comedies?”
The next morning, I asked Mr. Johnson, “Why is it that you like westerns so much?”
“I don’t know,” he answered.
“Did you live out west?”
“No.”
“Ever travel there?”
“Nope,” he said. He twirled his spoon in the butterscotch pudding on the lunch tray. “Have you seen ‘Fistful of Dollars’?”
“No, I haven’t.”
“You should see it. It’s real good.”
I knew he was dying of his cancer; I had learned the history of his disease. It was a hard and mean squamous cell carcinoma that had arisen under his right mandible and tracked up and down and finally emerged through the surface of his neck. Hospital records told me that the cancer had been diagnosed a little over a year ago—Mr. Johnson had felt a bulge in his throat when he swallowed. A surgeon had resected it, leaving a deep cleft underneath his chin. Radiation therapy had followed and, nine months later, when the disease reappeared, chemotherapy.
His pain had skyrocketed within the last three weeks and he had been admitted for pain control. I remembered well the description of the constant ache in his jaw and the unpredictable shocks that shot up and down the right side of his skull. I knew his vital signs on admission, the ragged contours of his throat and, beneath these, the quick, bounding pulse of his carotid artery. I could picture the raw mucosa of his mouth and the gaps from which teeth had been successively pulled, over several decades.
There seemed to be a reason for every piece of information. I remembered which pain tablets had worked and then failed, because I needed to know where to start. I learned which foods were more difficult to swallow, because I had to be sure he received enough nutrition. I asked him if he smoked or drank alcohol, since understanding risk factors for his cancer seemed important. I did not ask Mr. Johnson about films. I only knew that he loved to watch westerns, because he mentioned it in passing.
After all, medicine is driven by the need to explain that which is relevant to patient care. These bits of information gathered from Mr. Johnson’s story carried a certain value. In time, they fell together like pieces of a puzzle whose assembly dictated his initial plan of care. With the vast amount of information available in a patient’s narrative, one great task of the physician must be to distinguish between what is “relevant” and “irrelevant” to patient care. Reflecting on the efficiency of the standardized medical history, the “social history” acts as a good example of this phenomenon. It rarely encompasses more than a short list of topics: job, marriage or relationships, tobacco, alcohol, and illicit drug use. In this case, the fact that Mr. Johnson smoked two packs of cigarettes a day for forty-five years helped to explain the etiology of his cancer.
This standardized medical history can be augmented. In Mr. Johnson's case, the fact that he quit smoking after the diagnosis was made says something about his willingness to change behaviors. But he had quit smoking believing this would prevent recurrence – when the cancer returned, this time with no options for treatment or cure, he was doubly shocked and afraid. “They said cigarettes caused the cancer, so I quit,” he told me. “Now why did it come back?” He avoided medical care for several weeks; I surmised that he had become mistrustful of physicians. Narratives are windows into the minds of patients and anything is game for interpretation.
So, I wondered, if anything is game for interpretation, then what about westerns?
That weekend, I rented “A Fistful of Dollars.” Clint Eastwood wears a dirty poncho and smokes cheap cigarillos. He rides a donkey into a small Mexican town where two factions rival for control of the area. Over the course of several weeks, he is successively hired by each side to fight against the other. He rescues a beautiful girl and her family from their capture and imprisonment. He is severely beaten by one faction and slips out of town to heal his wounds, only to return to shoot the leader of his assaulters. Then, at last, he leaves town for good.
As the credits rolled, I thought about Mr. Johnson. I wanted to know why he had loved this film so much. He had never left the Virginia county of his birth. He had never ridden a horse or a donkey, had never fired a gun. Did he identify with Clint Eastwood's character or predicament? Did he fantasize about a life of gun fighting and danger?
I wondered how I could interpret Mr. Johnson's love of westerns in the setting of his cancer. Perhaps he saw cancer as a battle of good and evil. Perhaps he longed to live freely like cowboys, not to be pinned down by his morbidity. Many interpretations were possible, but none of them was certain. The explanation that I was seeking appeared absent or, at the very least, unverifiable.
Could that truly make such a detail irrelevant?
In an essay entitled, “The Storyteller: Reflections on the Works of Nikolai Leskov,” Walter Benjamin laments the growing societal role of what he calls “information". Information is a certain kind of intelligence. It is very accessible, easy to understand, and already verified to be true. Benjamin notes, “It is no longer intelligence coming from afar, but the information which supplies a handle for what is nearest that gets the readiest hearing." This “information” is the same as our morning paper and evening news for, although it may come from a great geographical distance, it has been sifted, inspected, reworked, and validated by our own news corporations. If an explanation for the news event is not inherently present in the material, it must be searched out.
Benjamin contrasts this “information” with a different form of intelligence, the kind found in myths, ancient epics, and oral traditions—in other words, the intelligence found in storytelling. He writes, “The intelligence that came from afar—whether the spatial kind from foreign countries or the temporal kind of tradition—possessed an authority which gave it validity, even when it was not subject to verification." Storytelling, by nature of its very art, carried its own license-to-practice. There was no need or even desire to check credentials—hence, the reason that myths are a great part of religious traditions and that fairy tales are still used to teach children. The story carries its own value; it need not be explained, or, more importantly, should not be explained by the storyteller.
Physicians use an efficient language to share the “information” we gather. We tend to include only those facts that are verifiable and pertinent to the medical issues at hand. We may extend the scope of what forms of information are valid, but we still aim to interpret or explain.
Nevertheless, as Benjamin underlines, we must not overlook details that may not fall easily into the traditional medical history. These details may be invaluable, often simply because they cannot be interpreted. They become part of the patient’s story that persists beyond the clinic visit or hospitalization. Old westerns were as much a part of this patient as his diagnosis or medication list or review of systems, whether or not this detail fit into our standardized clinical histories.
Mr. Johnson died nearly one month after I met him; I read his obituary in the local newspaper. By that time, I had forgotten his admission vital signs, the list of medications, and the details of his disease course. Yet, I remembered his five favorite westerns—“The Magnificent Seven,” “High Noon,” “Stagecoach,” “Red Sun,” and “A Fistful of Dollars.” I remembered his impression of Clint Eastwood in San Miguel, Mexico, eyes squinting at an imaginary sun, finger and thumb cocked into the shape of a revolver.
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Reprinted from Veritas, Volume 16, Spring 2004, with permission of the
Center for Humanism in Medicine.
© 2004 The Rector and Board of Visitors of the University of Virginia
Author Hunter Groninger, M.D., M.A., completed residency in Internal Medicine at the University of Virginia in 2005. He is now an Assistant Professor of Medical Education in the Center for Humanism in Medicine and is completing a fellowship in Hospice & Palliative Care Medicine with the Capital Hospice in Northern Virginia - District of Columbia.
Dr. Groninger has published articles in The Pharos and Academic Medicine.