Stories as case knowledge: case knowledge as stories

Every case contains a human story of illness and a medical story of disease, which together cover person management, case management, health system management and self-management. Much of that management can be learned via a thorough set of stories of typical and atypical core cases compiled by clinical teachers. Stories provide a highly flexible framework for illustrating the lessons of experience, the tips and traps for young players, and the dilemmas requiring careful judgement in the trade-offs between benefits and risks. Listening to real stories unfold is much more fun than being lectured (and better remembered).

Stories illustrate 'what can happen' in a case as a guide to 'what to do'. A story begins with a real world situation with some predicament and a (causal) sequence of events or plot in which things are resolved one way or another. Patients tell their illness story; their clinician translates that into a disease story. Stories sort out what is important in such a predicament, consider the strategy and tactics of what to do, and speak about the outcomes. Each local situation provides relevance, context and circumstantial detail. Stories about case management can encapsulate practical knowledge, logical deduction, judgement and decision making, sharing with the student all the ingredients that develop expertise. Sometimes it is the plot that is important, sometimes the detail, sometimes it is the underlying message, the parable that resonates with the listener's experiences and feelings.1 Stories can also accommodate the complexity of multiple variables and the influence of other stakeholders, the uncertainties and dilemmas within the trade-offs, and the niceties of 'informed judgement'.

This paper makes four points. First, clinical stories recount pointed examples of 'what happened' that expand our expertise in handling 'a case like that'. Second, cases are the unit of clinical work. Case stories expand the dimensions and details of case knowledge, case-based reasoning and case management. Carefully collated case stories can comprise the 'real life' clinical curriculum. Third, stories provide a framework for 'web' or 'net' thinking that links all the objective and subjective details within the multifaceted complexity of case management. Fourth, personal stories explain how both numerical and non-linear influences determined what decision was actually made in that case.