Why Narrative Matters

MCL Backstory

By Dan Dohan

“The Importance of Narrative ” was born of frustration.

Narrative, or qualitative, research can be rigorous, well cited, and influential. Researchers in medicine and health policy, however, generally prefer numbers to narrative. Their journals hesitate to publish narrative research.

Editors who are wary of qualitative research may be comfortable publishing anecdotal commentaries. Some journals carve out special sections to do so, e.g., “Narrative Matters” in Health Affairs and “A Piece of my Mind” in the New England Journal of Medicine. These commentaries are typically written by people with no expertise in qualitative research: experienced (quantitative) researchers share wisdom; clinicians and practitioners share experiences; and students and trainees share revelations. This anecdotal commentary may be widely read and influential.

Like all narrative, qualitative research and anecdotal commentary have power in the real world. In political debate, it has been said that “one compelling anecdote (true or false)…can vaporize a mountain of data and careful policy analysis.” Narrative is also powerful in the clinic. Patients use stories to talk about their health. Clinicians draw on their own experiences as they guide patients’ care – sometimes clinical experiences and sometimes personal. These stories and experiences are also aspects of narrative.

Because narrative is powerful, it is important to wield this form of knowledge responsibly. Qualitative researchers are trained to create and share narrative knowledge responsibly. Hence my frustration. The medical and health policy research communities have placed the power of narrative in the hands of amateurs.

This unfortunate situation does not reflect ill will or hostility. Rather, I think it reflects the awkward relationship between narrative and scientific scholarship. Journal reviewers are scientifically trained, but they do not typically learn the tools to constructively assess a qualitative study. Most journal editors lack the experience to guide reviewers in distinguishing good qualitative work from not-so-good. Yet, readers value narrative insights, and publishers value readers. A non-science narrative section where amateurs share anecdotes – clearly segregated from the journal’s science – is an excellent solution to this publishing challenge. It fulfills readers’ appetites and publishers’ desires. Unfortunately, it marginalizes qualitative research and researchers.

Narrative insights are too important to be treated this way. In the last few decades medicine and health policy have acknowledged the importance of qualitative research, but they still frequently confuse narrative research and amateur anecdote.

Medicine and health policy are not the first disciplines to grapple with how to make sense of narrative research. For most of the twentieth century, qualitative research was customary in sociology and political science. But in the 1980s, desktop computing enabled new quantitative techniques, and the disciplines saw increasing opportunities to numerically measure concepts that had previously been addressed qualitatively.

A decade-long "methods wars" followed – finally petering out as social scientists recognized that numeric and narrative data should not be reduced to each other. This required an appreciation within the disciplines that both approaches can produce novel insights as well as banal platitudes. Both can be done rigorously or sloppily. Both methodologies can be applied with integrity or hypocritically. Each could be well-suited depending on the research objective. In short, qualitative research is not simply an approach to be taken (grudgingly and apologetically) when numbers are not available. It must be undertaken and judged on its own terms just like any other research.

Medicine and health policy will never have methodology wars; numerics are already hegemonic. But narrative is perhaps even more important in these fields than in the social sciences. Clinical judgement and policy debate require narrative interpretation. Patients convey their health with stories and anecdotes, not lab values or MRIs, and they base their medical decisions on the narratives they have about themselves and their futures. Clinicians and policymakers embrace the idea of evidence-based practice, but even when evidence is available — and it often is not — it oftentimes fails to change how clinicians practice and how politicians govern. For all these reasons, narrative is too important to leave to amateurs.  “The Importance of Narrative” calls for professional narrative research in medicine and health policy and suggests what such professional work might look like.

When science is done by professional narrative researchers, it looks quite different than when it is done quantitatively. Numeric researchers have protocols to guide data collection and analysis. Qualitative scientists recognize that pre-established protocols rarely fit their varied questions, settings, methodologies, and epistemologies. They eschew protocols in favor of processes that allow them to collect and analyze data more flexibly. The aims and outcomes are the same whether numeric or narrative: to report systematic findings rather than arbitrary ones. But quant and qual navigate to this destination by different routes. This is one source of confusion in medicine and health policy.

Another source of confusion is that qualitative research lends itself to many types of scholarship. Some qualitative studies aim to generate systematic and generalizable knowledge. Some richly describe experiences from the actors’ perspectives. Other studies generate critical work by documenting the suffering caused by power and inequity. People are storytellers. It is hardly surprising that scholars, like people everywhere, find diverse ways to put narrative data to use.

Such confusions are not, of course, the only barrier to a greater role for narrative research in medicine and health policy. These fields can be parochial – just like any discipline. Though doctors and policy-makers rely on narrative every day, they can have trouble acknowledging this. Stories, not just randomized trials or cost-benefit analyses, shape their fields. But asked how narrative matters, they may (improbably and implausibly) insist “not at all.”

Medicine does its work by giving us bioscientific models of our bodies. But it struggles with the fact that our bodies spend so much time and energy weaving stories to make sense of the world. Some of the most consequential dynamics in these fields lie outside the grasp of quantitative science. This is inconvenient “The Importance of Narrative” urges medicine and policy to neither ignore nor resist this reality but rather to lean into it.

Today, medicine and policy are increasingly aware that individual health reflects social dynamics. Systematic narrative inquiry is a necessary tool for understanding social worlds – the worlds of patients, communities, and healthcare itself. Medicine and health policy ignore this at our peril.