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  • Stories versus Evidence

    Posted by Barrett<script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,16,6,33,0), dfrm, tfrm, 0, 0, 0, 0)); </script> (Member # 67) on 16-11-2005 13:33<noscript>November 16, 2005 06:33 AM</noscript>:

    So, this guy comes in last week, fifty, fit and trim, a salesman for a large printing firm. He says he came to me specifically because his wife’s friend had been helped here sometime in the past. He never smiles. His manner, to me, indicates a distinct suspicion and some weariness when asked to recount his story once again.

    Three months prior he’d begun to experience some discomfort in the region of his left upper trapezius. It worsened steadily and he claimed that at times he couldn’t lift the arm for the presence of a “grinding” and spreading pain. He received injections in the buttock on two occasions from his primary care physician that did not help significantly. He denied any cooling in the limb and displayed no neurologic signs. While supine, his left hip was held in internal rotation compared to the right.

    He returned for a second visit seven days later claiming that he’d had no further symptoms, that he’d even played basketball without discomfort and was sleeping well. He was actually smiling, sort of. Though he’d been careful to reposition his left hip as I had suggested and had done the recoordinative exercise a few times, he hadn’t spent any time moving correctively on his own. I added a little more active exercise, reviewed ideomotion and let him go. He is to return PRN.

    When I teach, I virtually never tell stories such as this though I could do so easily and honestly. I know people are hungry for this because they ask again and again, “What kind of results do you get?” Yet, right in front of them, and often in their own hands, people demonstrate movement toward recovery and go on to display an understanding of what they need to do on their own to progress. Still, they want me to tell them stories of success.

    But there’s this: I work ten blocks away from The Cathedral of Tomorrow, a vast church where Rex Humbard, the original televangelist, began his career. It is now occupied by Ernest Angley, one of the world’s best known faith healers. Yes, he’s headquartered in Cuyahoga Falls. I’ve had members of his flock as patients. I cannot help but remember that Ernest could tell many more stories-better ones even. Specifically for this reason I tend not to tell stories, and I cringe when I hear other speakers do so.

    Finally, I always keep in mind this passage from Joel Achenbach’s Captured By Aliens, “The UFO movement’s strength is not in its evidence, but in its overall narrative, its theme. It has an elaborate eschatology, a host of apostles, and a recurring theme of salvation versus doom. It is not the evidence of extraterrestrial creatures but, rather, the idea of the Alien that makes ufology such a powerful faith. The skeptics can dismiss the purported tales of aliens and show the logical flaws in the story, but it will never make any difference. If an idea is sufficiently wonderful, if it springs from deep yearnings, it can easily beat back the yappings of logicians and skeptics and disbelievers. It can overcome a persistent absence of facts.”

    In other words, a good story will trump evidence nearly every time. This being the case, what can we do to enhance the appeal of evidence over story?
    <hr> Posted by Jason Silvernail (Member # 4433) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,16,6,59,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 16-11-2005 13:59<noscript>November 16, 2005 06:59 AM</noscript>:

    Thoroughly ingraining in practitioners the concepts of EBP.
    Also, I recommend as a PT community, doing a better job with instilling concepts of critical thinking and argumentation skills.

    I agree in that I think I judge a speaker sometimes based on their propensity to tell stories vs present evidence and a reasoned argument. If the presentation is story-heavy, I'm outta there. My assumption is that if someone tells a story, they must not have anything more compelling or geared toward a scientific rationale to present.
    J
    <hr> Posted by OaksPT (Member # 2776) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,16,8,6,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 16-11-2005 15:06<noscript>November 16, 2005 08:06 AM</noscript>:

    As far as patient's are concerned, I think that treatment is like religion, patient's will tend to gravitate toward someone who tells them what they want to hear, and something that doesn't disrupt their own belief system/preconceived expectations. Our peers can be harder to convince.
    Obviously there can be exceptions, but for the most part, a good yarn will always trump fact.
    Sorry to be so cynical,
    Scott
    "Everyone may be entitled to his own opinion but everyone is not entitled to his own truth. Truth is but one."~Doug Grootheus
    <hr> Posted by nari (Member # 2772) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,16,13,2,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 16-11-2005 20:02<noscript>November 16, 2005 01:02 PM</noscript>:

    A good fantasy story is a social construct, designed to keep peole's attention while talking; the wilder the story the greater the interest. It's entertainment. Why else do people love tabloids and celeb magazines?

    Evidence-based stories of science aren't so appealing, because the fantasising sections aren't there. Lots of people see facts as rather boring, though plenty of writers can make a riproaring factual story.
    I agree with Scott - and might add that people love mystery, and facts dispel mystery. We are not all that far removed from the early homo species who would have shivered in their cave while the angry gods lashed the skies with lightning and exploded volcanoes; and then the people might have decided that their lives must be devoted to appeasing those mysterious gods.

    Nari
    <hr> Posted by Jon Newman (Member # 3148) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,16,19,16,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 17-11-2005 02:16<noscript>November 16, 2005 07:16 PM</noscript>:

    I've struggled with your question Barrett. I might have an easier time stating what doesn't work. One answer is to house the evidence in a good story. This of course runs the real risk that people are much more interested in the story than the evidence it contains.

    Having a public space for the exchange of ideas with respectable critical dialogue is essential. Getting people interested in participating is the struggle as you well know.

    jon
    <hr> Posted by Barrett (Member # 67) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,16,20,6,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 17-11-2005 03:06<noscript>November 16, 2005 08:06 PM</noscript>:

    I agree with all of you, and I guess if I knew the answer to the question I wouldn't have asked it. Of course, I've been known todo this anyway.

    There's another thing. Though I've sent the referring doctor a letter regarding this man's care and his recovery, I'd be flabbergasted if I ever saw another patient from him. Do you suppose he'd prefer some sort of story too? Every day I wonder, "What do these guys want?" In thirty years I've never come up with a good enough story for them.
    <hr> Posted by Jon Newman (Member # 3148) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,16,20,25,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 17-11-2005 03:25<noscript>November 16, 2005 08:25 PM</noscript>:

    Perhaps the answer begins in teaching our children critical thinking skills early and continually through their education rather than emphasizing memorization skills. This is not a new suggestion by any stretch of the imagination but I don't think we've made it that far yet.

    I'd be flabbergasted if the doctor read the letter.

    jon
    <hr> Posted by nari (Member # 2772) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,17,0,38,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 17-11-2005 07:38<noscript>November 17, 2005 12:38 AM</noscript>:

    The trick might lie in the theory that people read letters/articles/essays if they are not too long; about an A4 page worth. The average person (sort of including busy doctors)will read short epistles and take them in.
    The problem I see is capturing the essence of the report succinctly, including the EBM, in a story.
    What does the doctor want to know? What does he need to know? If we can sort that one out, we might be halfway.
    Most letters to doctors had to be on a regulatory form where I worked, and it was very bland. Short of scribbling what I wanted to say in the margins, the form made life difficult. as forms do.

    I have asked patients who returned (at my request) was the letter read. Invariably they replied "Oh yes." It's encouraging.

    Nari
    <hr> Posted by Jon Newman (Member # 3148) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,17,13,5,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 17-11-2005 20:05<noscript>November 17, 2005 01:05 PM</noscript>:

    Here's one person's attempt to reconcile the discrepency.

    Stories as data, data as stories

    jon
    <hr> Posted by nari (Member # 2772) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,17,14,24,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 17-11-2005 21:24<noscript>November 17, 2005 02:24 PM</noscript>:

    I love the term "knowledge spa" - much better than 'think tank' and similar metaphors.

    I would suspect that having a primary degree in humanities and medicine as postgrad will go a long way towards molding hard data and narrative into a useful cohesiveness. Psychologists can do this pretty well, I think.
    Reading Ramachandran's work also gives the feeling that he is telling a good yarn while filling it with humour and lots of good data.

    Nari
    <hr> Posted by OaksPT (Member # 2776) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,17,14,39,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 17-11-2005 21:39<noscript>November 17, 2005 02:39 PM</noscript>:

    I agree with Nari, most people who are not familiar with the subject matter, may not see its applicability, unless told in "story format". How kooky does it sound (regarding Ramachandran's work)when you are telling a patient to sit in front of the mirror and move their good arm, in order to trick the brain. Makes perfect sense to me knowing the science behind it, but for a patient(and his physician) to buy into it, I have to give clinical success stories, I care how it works, they really don't, unfortunately.
    Scott
    <hr> Posted by Jon Newman (Member # 3148) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,17,21,22,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 18-11-2005 04:22<noscript>November 17, 2005 09:22 PM</noscript>:

    I continue to think about this and currently conclude that story is the primary "interesting" way to relay evidence based on a lot of complex reasons, some of which are hard to articulate. If so, the question might then be "how can we enhance the appeal of stories worth telling?"

    jon
    <hr> Posted by nari (Member # 2772) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,17,22,23,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 18-11-2005 05:23<noscript>November 17, 2005 10:23 PM</noscript>:

    I think we might tell stories more than we realise, while we are adding knowledge to the patient's repertoire. For instance, when talking about sensitisation, we might refer to the brain as an animate, living thing (rather than refer only to the visible personbody at the end of it);it tends to get cranky with the status quo and deliver pain to remind you that it is not happy about something...(elaborate)...sometimes it is quite difficult to sort out why it's cranky...and so on. It also tends to sway patients away from the notion that they have pain because of something they've personally done and harmed themselves.
    This is primarily about chronic pain patients, but as they form about 80% of patients we see,it is quite relevant.
    It sounds sort of Cartesian in context, but at least gets across the message that their 'muscle' or 'joint' isn't the prime troublemaker.
    Humour and a bit of satire always helps in a story; apart from those patients (and health professionals) who are convinced that to keep control over the PT/pt thing, conversation must be serious and "professional".

    Nari
    <hr> Posted by Randy Dixon (Member # 3445) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,18,0,54,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 18-11-2005 07:54<noscript>November 18, 2005 12:54 AM</noscript>:

    I find this to be a very interesting question coming from Barrett, a man who seems to almost need to tell stories. His question comes in the form of a story of sort. The difference in the stories being told, it seems to me, is whether the goal of the story is to make you question or to prevent questioning.

    I agree with Jon that the problem lies not in storytelling but in the our formal educational system. Critical thinking is not taught, it is often unwittingly discouraged. I have know many well educated, intelligent people who seem unable to differentiate between facts, opinion and theory.

    I love a good story, the ones I like best both answer questions and raise more and allows everyone to take away something different.
    <hr> Posted by Barrett (Member # 67) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,18,6,37,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 18-11-2005 13:37<noscript>November 18, 2005 06:37 AM</noscript>:

    Randy,

    I write stories. And yes, it fulfills a need I seem to have. I rarely speak them.

    Perhaps my remarkably low tolerance for small talk has something to do with this. Not one of my more charming traits.

    You're right also in that stories have various purposes. Sam Keen speaks of this and points out that they can elicit empathy or demonstrate the heroic character of the teller. I dislike these and seek his third category, what he calls "communion" (I think); a story that illustrates our common experience, often containing humor.

    That first one implying heroic action by the story's teller I find especially irritating, yet many seem to want to hear them from me.
    <hr> Posted by Diane (Member # 1064) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,18,9,34,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 18-11-2005 16:34<noscript>November 18, 2005 09:34 AM</noscript>:

    No information can truly pass from one "domain" (one branch of study, one human mind) to another without stories. I have never considered that they are anything other than a means to make a point, delivered (one hopes) at a level appropriate to the listener, and not misleading or cloaked in deception. (E.g., opinion or pseudoscience disguised as authoritative factual info). Delineating it all is full time housekeeping (..and lots of people have messy brains, as was pointed out earlier..).

    Stories can be embedded successfully into factual information to help "move it", so the recipient doesn't die of boredom. The story teller, or dispenser of the information is seeing it as a complete package, and has likely examined it in far more detail than the recipient, and the recipient, especially if they've never heard it before, has to process it linearly, not reflecting on it and sorting it and weighing it and judging it until it's all been received in the brain. At least, not until they've heard many stories that sound the same.

    I enjoy reading about neural crest. There's no better "body story" I can think of, than this one, from embryology. Here are little neural cells that decide to leave home and go wandering. They move away from the neural tube and seek their fortunes in remote hinterlands, subject to all sorts of dangers. Read all about their "Declaration of Independence" and "Neural Crest Migration: How to Survive, Move and Develop in a Hostile Environment." They make all sorts of things out there in the body, and if they don't successfully get to where they are going, you can end up with great albino patches on your skin, or megacolon, among other things. They comprise the entire peripheral nervous system and all the ganglia, plus most of the head/face, connective tissue and all. Believe it or not. Pretty cool story.

    The people who study genetic control have used storytelling to make their points about what they observe/conclude genes do, and designate very imaginative names to their favorite genes. Hedgehog, snail, the list goes on. These people don't seem to worry overmuch or excessively ruminate over whether or not they are being appropriate. They give the information as exactly as they can, and at the same time try to keep their listeners/readers from falling asleep.
    <hr> Posted by Jon Newman (Member # 3148) on <script language="JavaScript1.3" type="text/javascript"> document.write(timestamp(new Date(2005,10,18,22,43,0), dfrm, tfrm, 0, 0, 0, 0)); </script> 19-11-2005 05:43<noscript>November 18, 2005 10:43 PM</noscript>:

    Perhaps it is not story or evidence that is the problem but rather the lack of reflective listening (or reading) in general. Besides the early training I mentioned earlier, the only thing I can think of is to promote an atmosphere that allows for such a thing to take place.

    jon
    Last edited by bernard; 29-12-2005, 06:01 PM.
    Simplicity is the ultimate sophistication. L VINCI
    We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances. I NEWTON

    Everything should be made as simple as possible, but not a bit simpler.
    If you can't explain it simply, you don't understand it well enough. Albert Einstein
    bernard
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