Medical history as oral tradition

In this article, we progress the original work of Richard Ratzan2 who argues that the traditional presentation of the medical case history is a legitimate form of oral recital (in Ratzan's term ‘winged words’) in the Janus-faced tradition of Homeric poetry—on the one hand strongly coded, rule-bound and formulaic, and on the other, open to creative interpretation according to audience response. Ratzan, however, only looks backwards to Homer to justify his claim, while we suggest also looking around, to modern contemporary aesthetic forms such as Minimalism,3 to find a genre or aesthetic home for the case presentation and its creative possibilities in performance.

Further, we argue that a genre shift, from the purely functional to the aesthetic of Minimalism, challenges a typical objection from within medical humanities and ethics that the case presentation is both depersonalising and dehumanising for patients—where the ‘case history’ acts as an irreversible translation device from the patient's felt ‘illness’ to a medicalised ‘disease’.4 Rather, in acting as a medium for identity construction of the doctor as professional performance artist, we suggest that learning how to recite the case history does not just provide a means for forming a professional identity within the medical culture, but sensitises doctors towards the public, as audience, offering a radical version of ‘patient-centredness’. The history of the development of oral poetry shows that performers must be able to translate readily between select audiences (the court, senior doctors) and public audiences (coffee houses, the ward). In other words, the doctor herself must be Janus-faced, looking inwards to satisfy medical culture's demands for a polished performance, and looking outwards as a sensitivity towards maintaining the interest and understanding of an audience of ‘patients’. The latter is achieved as the patient is (re)enacted as the intra-professional recitation, a unique and aesthetically valuable form of embodiment through expert practice. For example:

Mister Smith is a sixty-year-old man who came to A&E with crushing, central chest pain, which radiated down the arm and up into the neck. The pain came on out of the blue while working in the garden. There has been no previous episode. His ECG showed ST elevation ….

This is a fairly typical medical history that a junior doctor might relate to a senior member of the clinical team. We argue that this and other ways in which healthcare professionals communicate have many central characteristics of Homer's Iliad and Odyssey, showing features typical of oral narrative traditions that are an integral part of oral cultures. We return to Homer because this work is fundamental to the development of the epic genre and the Western psyche, and we wish to offer a fundamental review of the narrative of medical work. We have made the case in previous articles5 6 that a return to Homer can illuminate issues of professionalism and communication in contemporary medicine, going beyond more traditional medical history such as Friedrich's study of Homer's extraordinary, real time and shockingly detailed descriptions of war wounds, which also reveals a particular, historically situated knowledge of human anatomy.7

We argue here for the important part that narrative traditions play in both medical memory and identity construction and compare these traditions with Homer's. We recognise that a return to Homer can be seen as nested in the larger activities of (i) considering the structure of medical speech as performative (enactments or practices), adding to a recent interest in ontology (states of being) in medical practice, rather than epistemology (conditions of knowing)8; (ii) employing Homer's epic poems as touchstones to explore communication both within and between communities of experts, novices and laypersons.

The Iliad and The Odyssey are long poems of some 15 000 and 12 000 lines, respectively. If we started to recite the Iliad at the start of the working week, we would be finished on Wednesday or Thursday, depending on the stamina of the audience (see http://wiredforbooks.org/iliad/ for Lombardo reciting the first book of the Iliad).9 Both epics were written around 750 BC and describe events occurring 300–400 years before. Various aspects of the composition of the texts, both at the level of words and phrases and at the level of major themes, puzzled scholars through the 18th and 19th centuries. They began to address the problem when it was realised that the poems predated writing; they were part of an oral tradition—epic stories handed down from one generation to another.10 Only the ‘spoken’ (or, in fact, sung) word was available, where ‘oral epic song is narrative poetry composed in a manner evolved over many generations by singers of tales who did not know how to write’(p 4).(1)

Critical to this definition is that Greek epic poetry was not simply recited but constructed and created during recital. In ancient Greek, ‘singers’ and ‘poets’ share the same descriptor—aoidoi—the modern equivalent of which would be ‘performing artists’. Such ‘entertainment’ was a performance, known as much for creation as recreation, where a formulaic epic narrative would be re-storied through leaps of the singer's imagination, against a predictable hexameter, six-beats to the line rhythm. So the singer was also called rhapsodos, literally ‘a stitcher together of songs’.11

As Ratzan notes, it soon became recognised by scholars that a major and characteristic feature of oral epic is that a very large part of the language was formulaic, a necessary condition to relieve the immense burden on the memory of the bard, in spite of elements of innovation.2 ‘Formula’ is defined by Parry as ‘a group of words which is regularly employed under the same metrical conditions to express a given essential idea’ (p 272).12 For example, the same words are often combined throughout the poem, to form pairs of noun and epithet, or even longer combinations sometimes running to complete sentences.

Achilles, around whose wrath and appeasement the Iliad revolves, very often has the epithet ‘swift-footed’ attached to his name. When dawn breaks, personified as a goddess, she often has the lovely epithet ‘rosy-fingered’ attached to her. Indeed, the whole line for the breaking dawn is used several times—ημος δ′ηριγενεια ϕανη ροδοδακτυλος ηως (‘When the child of morning, rosy-fingered dawn appeared’).

But the extent to which the poet called on and reused a stock of words, phrases and sentences only became clear on detailed examination, through work carried out by two iconic figures in Homeric scholarship—Milman Parry (1902–1935) and Albert Lord (1912–1991). The first lines have been used to demonstrate this (the following is Lord's version (p 143), itself based on Parry's (p 301)).1 12

‘Wrath; sing, Muse, of Peleus’ son Achilles,

The baleful wrath that brought countless sufferings to the Achaeans,

And many brave souls sent to Hades

Of heroes, and made prey of them for dogs

And carrion birds; so brought the will of Zeus to pass,

When first in strife apart stood

Atreus' son, king of men, and godlike Achilles'.

The unbroken lines represent formulas—that is, collections of words that appear verbatim elsewhere in the epic. The broken lines are formulaic—parts of them or the words in different form appear elsewhere. ‘Aιδιπροιαψεν’(Aidi proiapsen) means ‘sent to Hades’, a common activity around the walls of Troy as men fell in brutal, hand-to-hand combat. When the poet has in mind to kill off one of his fighters in a battle scene, this gives him his line ending. Each time Achilles appears in the tale, the metrics of his name—ti-tum-tum—allow it to be placed almost anywhere in the line. There is then a set of formulas that allows the poet to fill the rest of the line, while he plans how to move the story forward.

Parry and Lord extended their research to then modern oral poetic traditions, in particular in Yugoslavia between the First and Second World Wars.1 They found an equivalent use of formulas. Their work showed that the formulas were not aide-memoires to allow the poet simply to remember the poem and recount the tale verbatim. Rather, they were metrical combinations that allowed the poet to compose on the spot. Again, oral poetry is not simply recited, but constructed and created during recital, while containing a formulaic element. The point is that the formula provides the basis for improvisation, just as a jazz musician will use a well-practised structure of chord changes or harmonic patterns from which to express something novel in an extended solo.

Each telling of the Iliad was then a new and different poem. That is a wonderful concept, difficult for us to understand. Most modern speakers would not give even a short talk without notes or a PowerPoint backup. The singer of the Iliad sang for 6 hours a day for three or 4 days. In the Yugoslavian tradition, the singer-poet tailored the story to the audience. If they were restive, a shorter story would suffice. The issue is probably more subtle and complex than this. It is easy to imagine that a particular poet might become revered and his style imitated more closely than others, so that a greater degree of fixity of the text emerged. Kirk, for example, distinguished between kinds of singers which we noted earlier: the older aoidoi—singers in oral society—and the rhapsodes—literally ‘stitchers-together of songs’—members of the literate world.13

Songs in hospital

‘Songs’ appear in hospital as routine medical work. Seen from a Homeric perspective, this may turn ordinary labour into the extraordinary stitching-together-of-songs as recitals. There is a parallel with different medical scenarios. We started with a fairly typical account of a patient's illness that a junior doctor might relate on a ward round. This is not a new parallel. Again, Ratzan2 saw this two decades ago. Drawing on the Iliad, he compares the oral tradition with the medical Grand Round in terms of ‘professional, social, and pedagogical significance’, where ‘a singer of medical tales recites a medical case history that is judged by its skill in transmitting the story and, in some venues, by its performative excellence.’ (In the UK, the Grand Round is a meeting of all grades of medical staff at which one or more patients of particular interest or complexity are discussed. Typically, a junior member of the team describes the patient's illness, and senior members and the audience discuss points of interest and educational importance.) The parallel is therefore attractive because these are ritualised occasions and the experience of both Parry and Lord was that the Yugoslavian epics were typically sung on ceremonial occasions such as weddings and religious festivals.

There are better parallels. The Grand Round presentation is too serious to risk all on memory and the medical history will usually be summarised in writing for the presenter. Not so the ‘business ward round’ (‘specialty’ or ‘unit’ round in North America), when the presentation is often truly oral and from memory. (These are regular meetings when some or all of the team discuss and visit their patients).

Are there other examples? ‘Sing, Muse’ is not confined to medical work, but embraces healthcare more generally, involving, for example, multidisciplinary team meetings, such as briefing and debriefing in operating theatre teams and patient care reviews in community mental health teams. We would argue that the handover between nursing shifts falls into this category, as do telephone conversations between healthcare staff, some aspects of clinicopathological conferences and handover and triage on Accident and Emergency units. Also, in Nendaz and Bordage's model of clinical reasoning, students are asked to represent the problem in a brief and medicalised language which is itself very formulaic and which is intended to help them arrive at differential diagnoses.14 At our medical school, each student is assessed weekly on a case presentation that he or she is encouraged to deliver in formulaic style.

The medical history and genre

We started with a typical case presentation. Let us look at it with the eyes of a Parry or a Lord:

We could argue about the details of whether a phrase is a formula or formulaic. The point is that these are also aide-memoires that allow the junior doctor rapidly to present each of the 15 patients whose story she heard the previous night. The formulas will pertain particularly to medicine; surgical or psychiatric patients will need their own set of formulas, just as the different stories of the Iliad and the Odyssey do. The power of the case presentation rests with its brevity and pointedness and the—often striking—link of word and image (given extra power where it is pathologised, such as ‘crushing pain’).

While Homeric poetry is composed in hexameter verse—‘regular, rhythmical lines that always have six beats and thirteen to seventeen syllables’ (p 1),11 the case above could readily be transposed, ‘sung’ as Shakespearean iambic pentameter—five beats (doubled) to the line:

Our point is that rhythmic form is the standard weave of the song or recitation, upon which the details are embroidered. The case presentation is a mantra whose repetition does not lead to spiritual transformation but creation of professional identity as an expert practitioner. The case presentation is a convention and is systematic, based on brevity, clarity and concision:

A 62-year-old man came to the emergency department complaining of midsternal pain, shortness of breath and nausea.

Mr K is a 23-year old who had an episode of bleeding two weeks ago. He was sitting on a bar stool when he noticed bleeding from the tip of the penis.

There is apparent objectivity, or singular lack of affect, that irons out an initially disturbing account (‘bleeding from the tip of the penis’). But this is sense-based, ontological, where description prevails over analysis. If there is a characteristic style, then it is the ‘smoothness’ of the presentation. Aesthetically, this can be compared with the presentation of smooth, industrially precise surfaces that characterises Minimalism in its sculptural forms since its heyday in the 1960s.3 However, smoothness of surfaces does not signify lack of deep affect. Ratzan2 notes that the heart rates of junior doctors increase as they enact the performance of the case presentation in a ‘highly charged atmosphere’.

Lorelei Lingard argues that there are identifiable genres of case presentation—in particular the difference between the medical ‘school genre’, where students seek to present without interruption and the ‘workplace genre’ where seasoned practitioners seek to use case presentations as a way of constructing shared professional knowledge.15 Again, the way the story is recounted, or ‘sung’, declares and defines an identity construction. The expert sews-the-song-together (rhapsodos), often bringing together several stories in a grand story. Novices must learn this poetic technique and ritual and those who do impress expert teachers and also shift identity, from ‘medical student’ to ‘trainee doctor’. Those who sew-the-song-together in clinical settings under clinical supervision enacting the ‘school genre’, rather than the ‘workplace genre’, will be seen as less capable by those supervising experts.15

Narrativists who have turned their attention to the ways that stories are told in medical encounters consistently note the bias in the medical narrative towards objectivity, to include objectification of the patient.16 17 This serves, they suggest, to encapsulate and stabilise the objects of interest, placing symptom before person and medicalisation before existential ‘lifeworld’ accounts of the patient. The process of the medical case history is seen as boiling the rich soup of the patient's narrative to the hard tack that medics can stomach.4 18

We suggest another reading—that the typical case recitation fits (and adds to) the genre of Minimalism, a form of objectivism whose aesthetic is the pared-down and the polished surface. Here is a radiologist reading x-ray images:

This is a double contrast barium enema. There is an area of narrowing in the sigmoid. The under cut edges give an apple core appearance. This is colonic carcinoma.

This is a chest x-ray of an adult patient. Calcification is rounded and peripheral. With this degree of symmetry and also eggshell calcification in the right para-aortic region, the most likely diagnosis is sarcoid.

In both cases, pattern recognition is at work, through use of metaphor or resemblance (‘apple core lesion’ and ‘eggshell calcification’). The language is stripped back, precise, polished through the generations of cultural (medical specialty and sub-specialty) oral narrative practice. Indeed, we could push the boat out and suggest that, in terms of the power of embodied metaphors, these descriptions offer a kind of minimalist poetry. Here is the archetypal minimalist poem by the father of this genre, William Carlos Williams, himself a doctor19:

The red wheelbarrow

so much depends

upon

a red wheel

barrow

glazed with rain

water

beside the white

chickens.

An even more radical poem by Ian Hamilton Finlay, from The Blue Sail, claims that surface—or what is ‘given off’—is all20:

Sea-lane with hay barge

What a

scent

of hot

sweet hay

and salt

As the Minimalist sculptor Robert Morris suggested, ‘simplicity of form is not necessarily simplicity of experience’21 and Susan Sontag22 echoes this sentiment in Against Interpretation, her infamous challenge to hermeneutics:

Ours is a culture based on excess, on overproduction; the result is a steady loss of sharpness in our sensory experience …. What is important now is to recover our senses. We must learn to see more, to hear more, to feel more …. Our task is to cut back content so that we can see the thing at all.

What better advice for diagnosticians, whose business is close noticing? And does the oral poet not sing to his audience for precisely the same reason—to educate both the senses and sensibility, to bring a new level of awareness?

The powerful link between word and image engineered by the precise form of the medical case account satisfies the demands to educate what Rudolf Arnheim calls our ‘visual thinking’, where ‘The discipline of intelligent vision cannot be confined to the art studio; (but) it can succeed (in other disciplines) only if the visual sense is not blunted and confused in other areas of the curriculum’.23 Here is a precise lesson for medical education as it learns from the arts and humanities.

Readers at this point may feel that we are offering an apology for a method that fails the patient as person, as narrativists such as Montgomery have claimed.16 17 However, we argue that such method is not cold-hearted (especially as it is aligned with a minimalist aesthetic) but rather highly perceptive as it offers appreciation prior to explanation. The symptom is not the person and must be contextualised, but the symptom must also be addressed in its self-display. There is a danger in such appreciation turning into morbid fascination, a charge often brought against medicine, but our point is nevertheless made, that medical aesthetics is prior to medical ethics in its need to describe symptom prior to diagnosis. A burning down to dry essences as method (the word ‘clinical’ is used in everyday speech to describe this) disguises perceptual riches of close noticing and attention that constitute the deep structure of medicine's minimalist poetics of practice.

To return to Homer, when a character has spoken in the Iliad, Homer's next line creates itself, with a formula to fit every circumstance:

Answering him (her, them) spoke forth swift footed Achilles (white armed Hera, Odysseus of many counsels).

So the doctor can call on formulas to move through familiar territory as s/he also makes sense of an unknown bodily event:

The start of each sentence can reach any of the three endings given a suitable bridge. Equally important is that, in addition to the formula theory that affects word combinations and sentences, whole themes recur throughout both the Iliad and the Odyssey.24 Arranging a truce, preparing a meal, offering a sacrifice and sticking a spear in a member of the opposing camp occur several, often many times. Such iterations, as protocols, are expected to progress in a certain way and a certain order whether in Homer or in healthcare. Just as the pilot and co-pilot must run through the safety checklist prior to take-off to avoid potential disaster, no matter how many times each of them has flown this particular plane, so the litany of the WHO's surgical safety checklist must be repeated for each patient at each operation to avoid error such as ‘wrong patient operated on’, ‘wrong side operated on’, ‘equipment not available’, ‘we didn't know she had a latex allergy’, ‘the blood was not ordered’, ‘the x-rays are not here’ and so forth.25

Whatever formulas—that occur frequently in these set pieces—offer to poet and audience, these stock themes offer on a larger scale. Looking again at the medical story, that too has its stock themes. Our running example is in the process of moving from the ‘presenting complaint’ theme to the ‘clinical findings’ theme (here represented by ECG findings).

The effect of oral traditions

Before considering where this comparison of oral traditions might lead, we should consider the limits to the argument. We make the point later that ours is a literate world. Oral traditions now are very different and we have moved, with the advent first of writing and then electronic information, to what was already described three decades ago as a secondary orality, a product of the era of word-processing and the world wide web.26 Yet many characteristics remain the same. There is a risk of regarding primary orality as primitive and ‘folksy’. Ong draws a parallel, for the literate world considering the oral, of describing a horse to those who know cars but have never seen a horse (p 12–13).26 A horse is then a wheel less car, running on hay rather than petrol, and so on, where ‘In the end, horses are only what they are not’.

The format in which doctors narrate in the special circumstances described is formulaic. Why does it have this fixity, this tradition? First, it aids memory. It is hard enough to remember the patient's story without also having to think about the format and language with which to recount it. George Bordage introduced the term ‘semantic qualifiers’ to describe the transformation of the patient's story into simpler abstracts or structures, employed as cultural code and capital within medical circles and translated back into varieties of medical tales.14 This aligns with current models of expert clinical reasoning, drawing on findings from cognitive psychology research, as a mix of the intuitive and the rational.27 ‘Intuitive’ refers to enactment of tacit knowledge—‘clinical scripts’ as memorised series of patient presentations linked to scientific knowledge or ‘concept maps’—elaborated through recall and stimulated by pattern recognition.

So the pain that came on suddenly in my knee and that I have had a couple of times before becomes ‘acute, recurrent, large joint pain’. Students armed with this language remember the patient's story more easily, realise similarities with other stories and so move to the diagnosis. In (al) chemical terms, there is first reductio (from the complex story to the abstract signifiers) and then iteratio (repetition). Note that the abstraction is still an embodied metaphor, a series of potent images stalking the student's mind or imagination (‘acute’, ‘recurrent’ linked to ‘pain’). Where chemistry is literally formulaic: A+B+C=X; alchemy is the power of the image to provoke and be remembered. Francis Yates in The Art of Memory reminds us that memory is stimulated through powerful sense-based associations, such as those between words and images and is laid down through iteration or repetition.28 ‘Rote’ is not a good word to describe what is deliberate and focused practice. For medical education in diagnostic acumen, students do not simply need repeated exposure to patient ‘cases’, but deliberate structuring of such exposure. Structuring takes the local context into account and then resonates with the bard's movement between convention and invention according to the nature of the audience.

There is a risk of exaggerating the importance of memory for our modern singer, given the ready availability of a written record. It cannot be exaggerated for the ancients. So critical was memory in a pre-literate society that the ancient Greeks' Mnemosyne, Memory personified, was seen as one of 11 children from the union of Gaia (Earth) and Uranus (Heaven), and a titaness.29 30 In a society that could not record, the poet was one of the few preservers of collective memories, of recording the law, of disseminating ideas. Others might be priests, wise men and wise women. He was the living record of society and its mores. In ancient Greek society, his performance created his identity—an enactment of identity (although not necessarily giving great status, if the one contemporary account we have of a bard in the Odyssey is accurate). This is an irony, as the bard sings largely of the honour of the hero—where honour is achieved as status of those who will be talked of in admiration after their death, achieving a kind of immortality.

Mnemosyne becomes a very minor figure in later literate society, but her symbolic importance lived on in her daughters, the nine Muses, who are invoked at the beginning of both the Iliad and the Odyssey. Our own capacity for memorisation is dismal by contrast. The Greeks put the blame for this squarely on the advent of writing. Plato, in the Phaedrus, tells the story of an Egyptian sage introducing writing to his king.31 It will, he says, make the Egyptians wiser and will improve their memories. The king disagrees. Writing will ‘produce forgetfulness … because they will not practise their memory … . You have produced an elixir not of memory but of reminding’. Yet the immensely elaborate mental mechanisms to aid memory put in place in the ancient world owed everything to later-developed visual memory and nothing to pre-literate culture.32

Earlier, we noted (and answered) the objections of narrativists to the reduction of the patient's story to a formulaic medical ‘case’. Similarly, classical scholars argued whether Homer's formulas produced a dulling effect. Some thought he was protected from a similar process by the richness of the epithets available to him—‘grey-eyed Athena’, ‘ox-eyed Hera’, ‘Agamemnon king of men’. These are all evocative, but do they remain so when Athena is grey-eyed for the 14th time in the Iliad? ‘Crushing, central chest pain’ is hugely dramatic; it is just that doctors have read it in textbooks, heard it as students and used it often early in their careers. Parry takes an objective view (pp 426–7).12 He accepts that the epithet formulas can be disappointing but in general, ‘They flow unceasingly through the changing moods of the poetry, inobtrusively blending with it, and yet, by their indifference to the story, giving a permanent, unchanging sense of strength and beauty’. Perhaps too, Lord's view of his singer of tales applies even more to the medic: ‘expression is his business, not originality, which, indeed, is a concept quite foreign to him and one he would avoid, if he understood it’ (pp 44–45).1

If we accept an element of performance in the recounting of the patient's story, we must not forget the importance of the audience.33 Lord stresses how great an effect they might have on the performance—how their restlessness may shorten the delivery, or their enthusiasm may lead to a richer embroidering of themes (pp 14–15).1 So the medical singer's audience may affect the details and elaboration of the account and ultimately the care of the patient. This offers a radically new version of ‘patient-centredness’, where the junior doctor or medical student presenting the ‘case’ has already talked with the patient (as audience), and now, in front of her seniors, is re-presenting the patient in minimalist style. Paradoxically, the rehearsal may occur after the public performance, where ‘backstage’ for patients is now ‘front stage’ for physicians, but the play's concern is the (re)embodiment of the patient.

The creation of identity

As we have said, each telling of an epic poem was in part a new poem, an act of creation. The bard was not just remembering 15 000 lines using the techniques described, repeating them verbatim, but quite the reverse. Each recital created the story anew. As he sang, so he made the poem—he was the singer and the song.

The poems of ancient Greece were performed in Panathenaic Games, in symposia and in public places, and were also sung to select audiences—the king and his court. Similarly, traditional song-poems of Yugoslavia were sung in coffee houses to an inclusive public audience, but also exclusively to male guests at a Moslem wedding. While medical tales are told to a select and critical audience, often in the case of junior doctors an audience ready to pounce on mistakes, the public audience (patients) is enacted and embodied in the process (and not just kept ‘in mind’). This re-creation of the patient is slyly criticised by Ratzen2 as disembodying the patient through the case history conventions, to be presented as a ‘skeleton’. The pun is good as the case history must be in skeleton form, but we argue that considered Minimalist form and style must not be mistaken for a disembodiment. Stripping back to dry essences, as William Carlos Williams and Ian Hamilton Finlay do in their poetry, is not the same as disembodying, depersonalising or dehumanising. It is perhaps more likely that this depersonalisation will occur in Lingard and colleagues's15 ‘school genre’ form of presentation than in the ‘workplace genre’, where the former presentation is dislocated rather than disembodied.

The outcome of the clinical presentation, again, is an identity construction as an ‘aesthetic forming’,34 where ‘physician’ is formed in difference from ‘patient’, but in respect for, and tolerance of, that difference. Paradoxically, this has often involved ritual humiliation in medicine, where respect and tolerance are not enjoyed in the enactment of professional hierarchy, but times are changing. This also describes a classic apprenticeship. In an oral society, everything is so learnt; study, as we understand it, is not possible. The embryonic Slavic poet first listens and absorbs the rhythms, metre, themes and formulas. Then he starts to piece together parts of the poems; finally, he sings the full song before a critical audience—an audience capable of greasing his bow and instrument strings when he left the room if his performance was dull.

What of our young, trainee doctor? Her (the average intake in medical schools is now over 60% women) identity is in part formed by the performance of the ward round and in other public arenas. The performance takes place within strict limits learnt by first listening as a student, then, just like the Slavic bards, performing before a critical audience. This absorption of words, phrases and expressions is not just a question of learning and memorisation, but more an active ‘soaking up’ grounded in performance that Nagler long ago described as a ‘gestalt’, a holistic grasp of the occasion.35 This, again, is the ground for identity construction, the means by which a medical self, an identity of ‘diagnostician’ in particular, is formed, both aesthetically and ethically.34 There is undeniably heroism in this self-forming and it will be interesting to see if this is tempered in an age in which the gender balance has shifted to more women entering medicine.

The doctor is currently trained (rather than educated) to recast the patient's story into a medical mould; she is a critical intermediary between the illness that patients bring into hospital and the disease they take home.4 We have described elements of this speech act—a set of linguistic transformations, or compressions, from lay talk to stylised medical talk—as ontological practices that serve to construct identities. This compression limits the doctor to a greater extent than the bard. The form in which the tale is couched is highly traditional and both styles very conservative. There are specifics of the patient's illness, the physical findings and laboratory tests that have to be included and to be accurate. Other material—such as illness in the family or whether anyone is looking after the cat—are embellishments whose inclusion will depend on local attitudes. They will depend too on the character of the doctor. Expression of the social aspects of medicine depends on education, temperament, beliefs and audience. The cat may be written in the record but it takes on a different life when it is spoken out loud. From a previous generation, Parry suggests this is ‘Just so, writing may influence the text of a poem … but will not have any (influence) upon the style, nor upon the form, nor upon its life in the group of poets and the social group of which its author was a part (p 270)’.12 The singer in the Odyssey reduces Odysseus to tears when he unwittingly sings of the quarrel between Achilles and Odysseus.36

The spoken word moves us in a way that writing cannot, although followers of Jacques Derrida would disagree, where Derrida famously sets out how speech has gained dominance over writing in the West, so that we are a ‘logocentric’ or word-centred and writing-impoverished culture.37 Poetry and philosophy for Derrida are acts of mark-making rather than sound, practices that literally make an impression (in the soft clay). This, says Derrida, is because writing gives you time to think. Speech is too hasty and unprepared. But this returns us to the interesting dilemma in the pre-literate Homeric tradition. Speech for the singer is well rehearsed, built on a template that includes repetition and iteration. But there is also continuous reinvention, room for improvisation and spontaneity.

Speech, suggests Derrida, aims more at the control of others than collaborative exchange. Those in authority, such as surgeons, may think that they talk with their teams, but they are more likely to talk at them, giving instructions and advice rather than asking open-ended questions or soliciting the views of others. Hospital songs too, by the nature of their forms, can be authoritative, rather than facilitative of collaboration—telling, rather than conversing to share differences.

Another feature of orality is that its thinking is concrete rather than abstract. Ong discusses the work of the Russian developmental psychologist and linguist Luria with illiterate subjects and concludes that ‘oral cultures tend to use concepts in situational, operational frames of reference that are minimally abstract in the sense that they remain close to the living human lifeworld’ (p 49).26 We cannot say that orality produces the same effect among doctors because they exist in a literate culture, but there are interesting parallels with the medical mindset.

Telling the same story

The junior doctor will tell the patient history more than once to different audiences. A different doctor on the same team might also repeat the same history. Is it the same? Is it the patient's story? Does it matter? Is the distinction between the medical song and the patient's song that we made above valid? Parry and Lord had the opportunity to ask their Yugoslavian singers to repeat the same tale twice, sometimes with an interval of years between; or to listen to a tale sung by another and then sing it themselves. They asked the bard whether they were the same tale.

Q: Was it the same song, word for word and line for line?

A: The same song, word for word and line for line.

All versions were recorded. To the literate recorder, they were quite different: to the singer, they were the same (pp 26–27).1 With or without the help of the written record (the patient's ‘notes’), the telling of the history differs with each teller and telling. To the Slavic singer, tradition and the stability of the story are everything, but this does not mean that the words are fixed. He probably has a quite different notion of what a ‘word’ and ‘line’ are.13 In professional settings, we regard writing as dominant and the written record as the definitive version of events. In a court of law, the medical record will be the gold standard, though it will probably not be the memory of either party. Imagine a society where laws reside in the memory of a few bards; where lawyers do not exist and cannot be imagined.

There are two issues here: first the recasting by the doctor of the patient's tale. As Kleinman suggests, ‘The physician and family care giver are situated in the gap between the copy and the original (p 207).4 There is a great danger when they recognise only the original’. This is an issue of translation, of which we can learn much from Homer and his translations, but which is too large a topic for this paper. The other is a concern with truth and accuracy—the primacy that the professional world gives to writing over speech, the opposite of the patient's world, where everyday speech genres are privileged over writing.

It is a cliché now to recognise the doctor's story as radically different from the patient's. The issues rest on what is happening about the story's reformulations (in both directions) and how far it does and should go. How far should the patient's account be believed in the first place? (How often is ‘admits to two glasses of wine per day’ written rather than ‘drinks two glasses of wine’ or ‘denies alcohol’ rather than ‘does not drink’?).17 18

The next crisis

One of the great pleasures of studying Homer is to try to conceive what it is like not to be illiterate but to have no letters—to have only (why only?) the spoken word. What, for example, does it do to individual and collective memory? We literally have no concept of how it feels to remember, think, make laws and come to agreements in an oral society. What happened after the alphabet arrived, during the difficult childhood and adolescence of writing? Because we write, we may think we have some idea of what was gained but do we have any notion of what was lost? What would happen if our doctor could not record the patient's story but had to process it all internally? And to look forward to the next great event in medical recording, what will happen when we have the electronic patient record? How much patient narrative should be a part of this? The information technology ideal is, of course, none. While we have argued for the value of Minimalism as a style and form for re-presenting patients, we do not equate this with a collapse of the patient into the virtual.

If we lose now from transforming Mr Smith's agonising chest pain—with all that it means to him and his loved ones—into a myocardial infarct, what is lost when he becomes a T2800 M58000 (the code for an infarct in SNOMED, the Systematised Nomenclature of Medicine)? Havelock refers presciently to the move from orality to literacy as a crisis.32 We are about to turn patients into avatars. Is that our crisis in medicine? On the other side of the coin, doctors too are patients, but perhaps as a body are in denial of this.