The Scream

Edvard Munch is the artist for our times, isn’t he? If the year 2020 were a painting, it would have to be The Scream. We are hoping 2021 will be more serene, but who knows what horrors may be lying in wait.

You are all intimately familiar with the fearful, crazed iconography of Munch’s masterpiece: the sexless twisted skull, the wide sightless eyes, the ovoid mouth caught mid-scream, the writhing psychotic colours, the disconnect from everybody else on the bridge, perhaps even on the planet. This is an image wracked with anxiety and uncertainty, swirled in oil and staring straight into our own disquiet and unease.

Munch was a curious character. Hardly unique for an artist of genius, you say, but even still, Munch pushed through many boundaries of normality. When describing the inspiration for The Scream, Munch told the story of walking across a bridge at sunset with two friends. Out of nowhere, a vision simply seized him. The “air turned to blood”, and “the faces of my comrades became a garish yellow-white.” He describes hearing a huge endless scream, coursing through nature. This representation of the abstract would carry Munch through the rest of his career. He succinctly encapsulated his ethos in the sentence, “I do not paint what I see, but what I saw,” which leads us into the Emergency Medicine part of our column.

What we experience as individuals has enormous influence on our interpretation of matters. Anecdotes have power. Story and narrative, however, make uneasy bedfellows with medicine. For much of history, story was all medicine had, as elegantly put in the New York Times (Thernstrom), “Once upon a time, until the last century or so, doctors had little in their tool bags except their humanity with which to channel that mysterious thing we call a healing encounter: that charged interaction – personal and impersonal, physical and spiritual – upon which so much depends. Now that blood tests have replaced bloodletting, how can we make that interaction be more rewarding?”

Story was, of course, superceded by evidence-based medicine.  Research. Data. Numbers derived from populations that did not bend to the whim and whimsy of once upon a time. Over the last few decades, however, narrative medicine has returned to the party, flouncing its way back in past the doormen and proclaiming its importance. It complements our knowledge, it brags, allowing a holistic and intuitive approach to patient care. We are now positively encouraged to tell stories while educating; to incorporate individual patient’s experiences into our understanding of population science.

Prudence tells us, though, to be wary of the anecdote with its seductive power. It is likely humans are hardwired for story. It makes good evolutionary sense, that as we developed into communities, reliant on each other for safety, food, sharing of tasks, we needed stories about the behaviour of others in order to understand social cues and relationships for survival. We know that learning facts when there is an emotional association, such as the tension of a story, or a striking visual metaphor, means a manifestly stronger memory is linked to that fact, with much easier recall and integration.

Herein lies the problem with story, the case of N = 1. It becomes enfolded into our own knowledge, wrapped in memory, indistinguishable from hard facts. It becomes what we saw, as opposed to what we see. It feeds into our biases, as much as we believe we are above them. Stories are a haven and a playground for our own biases. A place where our prejudices can run wild and build associations in our brain; friendships and bonds that can be difficult to break. Take the example of your own recently departed president, and his conversation with Dr Fauci. Forty-Five ‘knew’ that certain treatments worked. “Boy, this convalescent plasma is really phenomenal … Oh, no, no, no, no, no, no, no, this stuff really works.’ Or the example of people becoming converts to tPA in stroke because they’ve ‘watched people get better on the end of a needle.’ These individual stories, associated with emotion and tense narrative, can become branded into our cortices, hard to uncouple when tedious data sets disagree with it.

Far be it from me, a hapless lover of story and fiction, to suggest that story is not vitally important. Somewhere, however, lies a delightful medium, where truth and beauty play equal roles with its opposite number, unimpeachable fact.