A Brief Take on Genetic Screening

History of Current Complaint:

A forty-seven-year-old white male, 6′ 4″, 165 pounds, new to this service, presents with ­chronic belief that medicine and narrative are inextricably linked. Patient has no history of delusional disorder and claims to be on no present medication.

And then what happened?

From the earliest campfire fable, this question has united hearers and tellers, doctors and patients, readers and writers. And from the earliest diagnostic chart, our need to know What happens next? has slammed up against that classic source of dramatic tension: knowing what’s coming does not shield us from living it.

We humans remember in story, anticipate in story, dream, explain, learn, and love in story. As patients, we grow ill and recover, rally and fade, all experienced as narrative excursions inside wider story frames. So it hardly diminishes the rigorous, empirical, and context-free nature of medical diagnostics to say that medical practice is a narrative art. From taking the history and physical to signing off on the postmortem notes, doctors read, and then help arrange, relevant clinical data into a series of causes and effects that forms a ­linear, ­time-driven story. Diagnosis and treatment are sometimes a detective novel, sometimes a domestic drama, sometimes a good old psychological character sketch.

Every decent plot consists of exposition, complication, crisis, and denouement. And those four points on the classic tension graph define three regions under the curve: Aristotle’s old beginning, middle, and end. But as Frank Kermode points out in The Sense of an Ending, to our eternal, private, bodily dismay, we are each born in the middle of things, live in the middle of things, and die in the middle of things. To create a more satisfying story, we do everything in our power to read into the history around us a plot more harmonically tuned to our own. By imagining how things beyond us will end, we give shape to the endless middle that we otherwise inhabit. Life is the act of revising our lives.

So all good writing is rewriting. The art of medicine, too, must be a rewriter’s art. Its chief goal is to open up the patient’s story, to give new plot to possibility and new possibilities to the plot. But a patient’s story about medicine sometimes risks imagining that its job is the elimination of all constraint. In good narrative, constraint is the mother of possibility, not possibility’s opposite. When anything can happen, nothing tends to. It’s only when we begin to consider all the places our own story cannot reach that we find the means to bring it where it needs to go.

At its best, predictive testing seeks to...