On Being a Physician-Writer
GIVING YOURSELF PERMISSION TO WRITE.The New Physician
My life as a physician-writer began with Cha Nan.
A young Vietnamese woman dying from acute leukemia, Cha Nan (as I will call her) was my patient on the oncology ward where I was doing a medical school rotation. Every day I talked to this articulate young woman, and I drew her blood when she spiked fevers, listened to the rales in her chest that indicated pneumonia, and tried unsuccessfully to get marrow out of her fibrosed hipbone. And finally, when there was no hope left, I wrote the order for the morphine that helped her die.
For months afterward, I struggled with Cha Nan’s death. What killed her was an iatrogenic illness, a disease caused by treatment. Her leukemia apparently resulted from the successful treatment of her primary disorder, Hodgkin’s disease. The irony that miraculous high-tech medicine caused her death haunted me. Finally, being of a literary bent, I began writing. What was it like to take care of and lose such a patient? What did it say about the miracles of contemporary medicine?
The essay I wrote about Cha Nan, “A Death in the Glitter Palace,” was eventually published in a literary magazine, the North American Review, and later became the opening chapter in my first book, Battles of Life and Death. And it launched me on a strange sort of career as a physician-writer.
Today many medical schools have courses on medical humanities, and there are numerous distinguished physician-writers--including Abraham Verghese, Ethan Canin, Sherwin Nuland and Oliver Sacks--who are making insightful and elegant contributions to our literary culture. But when I was a medical student 20 years ago, the idea of having such a career was, at the very least, unconventional. Sure, there were writers: Robert Coles, Lewis Thomas and the famous physician-poet William Carlos Williams. And I did receive some encouragement from teachers and colleagues. More common, though, were reactions like that of the hospital administrator who stopped me in the hospital lobby one day.
“Who gave you permission to write?” she asked. If she had any say in the matter, she said, no more writing physicians would ever get admitted for training at her hospital.
I took her question very seriously at the time; I didn’t want to get thrown out of my residency program. And I still take it seriously today. Why should a physician consider being a writer? Why should he write about the experience of doctoring, about caring for patients, about working in hospitals and in other health-care settings? Is writing a frivolous pursuit? Is it somehow subversive, as the administrator’s accusation implied? Or is it somehow important, central to the purposes of modern medicine?
I view writing as a type of exploration. Whether you are jotting down your thoughts in a private journal or crafting an essay for a magazine, the literary process is a type of discovery. It doesn’t presume to replace scientific observation but to supplement it, to provide a different type of perspective on the life-and-death experiences that we physicians encounter every day. Because medicine is changing so rapidly, physicians (like other health-care providers and patients) have unique access to new types of experiences. Whether in surgical intensive-care units, community health clinics or molecular biology laboratories, medical advances plunge us into worlds never before imagined. New dilemmas, problems and complications emerge at a baffling pace.
In order to be a good physician today, it is essential to be able to reflect upon what you do. You must be able to empathize with your patients’ experiences and think about the larger consequences of your work. One way to accomplish this is by writing honestly and candidly about your experiences at the patient’s bedside, in the operating room or in the clinic. Being a writer can make you a better physician.
One of the great mistakes Western medicine made in the 1960s and ‘70s was to over-enthusiastically embrace the scientific model. Science is essential to this field, but it is not all of medicine. An entire generation of physicians trained in this model have been perceived by patients as emotionally cold and indifferent, and sometimes unable to communicate. There are innumerable consequences to this, including: ignoring patients’ preferences about death and dying; inadequately treating serious pain; and exploiting patients in unethical research. Scientific medicine has no shortage of what Paul Newman in the 1967 movie “Cool Hand Luke” called “a failure to communicate.”
That is why I am encouraged by the growing realization within the medical community of the value of reflection on what physicians do.
But beyond the question of “Why?” comes the question of “How?” How can one practice medicine and write at the same time? And, “When?” When in a physician’s busy schedule is it possible to find the time to write?
William Carlos Williams, the modernist poet with a busy medical practice in Rutherford, New Jersey, had a great answer to this dilemma. In his Autobiography, he writes:
Five minutes, 10 minutes, can always be found. I had my typewriter in my office desk. All I needed to do was pull up the leaf to which it was fashioned, and I was ready to go. I worked at top speed. If a patient came in at the door while I was in the middle of a sentence, bang would go the machine--I was a physician. When the patient left, up would come the machine. My head developed a technique: something growing inside me demanded reaping. It had to be attended to.
These days, with laptop computers and PDAs, such multitasking is easier to do. No one knows what you’re scribbling during a tedious grand rounds lecture. While you are waiting for your next surgical case or a patient who is late, no one can tell that you’re writing notes for your next scientific paper or ideas for a short story. However busy, one always has some downtime in medicine. And many physicians are fabulously hard workers--juggling research, practice, teaching, administration and so on. So for many of us, it is possible to add writing to that list.
But how do you “switch gears” from doctoring to writing? If you do it enough, writing just becomes a part of what you normally do. I wrote much of my books--A Family of Doctors (a memoir of the five generations of physicians in my family) and my new novel, Stone Babies--in my mind during committee meetings or while listening to the latest scientific update on some medical or psychiatric disorder. I imagine, I jot notes all day. Only later am I able to put it all down on paper.
But the hardest part, if you’re interested in writing for publication, is becoming a good writer, learning the craft of writing. In my own case, I was reading incessantly from the time I was 8 or 9 years old. In high school I read the works of Saul Bellow and GŸnter Grass; in college I read the English and American novelists from 1800 to the present. In medical school I kept reading, mostly short stories by writers such as Isaac Babel, Flannery O’Connor, V.S. Pritchett and Cynthia Ozick.
While in medical school, I was fortunate enough to be admitted to the graduate fiction writing workshop at Stanford University, where I met Allan Gurganus, Tobias Wolff, Vikram Seth and Ron Hansen. I read their work and occasionally dared to submit my writing for review. There was always the humbling moment when one realized the vast gulf between what one had intended to write and what one had achieved. The most important thing I learned from my fellow writers was that rewriting is critical, and reading one’s own work aloud is essential. If you couldn’t speak it, if you couldn’t breathe the phrases, then there was something wrong with it. It meant it was repetitive or boring, or it didn’t sound like you. And every writer wants to find his voice--that is the beginning of style.
I have been approached by literary-minded physicians-in-training and practicing physicians who confide in me their ambitions to write books. They frequently ask: “How do you get published?”; “Should I get an agent?”; or “How do I write a book proposal?”
I try to be polite, but really I think they’ve got it wrong. The place to start writing is with an observation--a thought or two written in a journal--and to continue this for weeks and months. Add to this practice a stack of books closely read, a writing group and a circle of disinterested but honest colleaguesÉand if you’re lucky, you’ll eventually have a small magazine or newspaper publication somewhere. You will have real readers, and you’ll be on the way to being a real writer. Between the first jotting and the final book lies an odyssey, a sort of internship or residency in letters. A book is an end product of an evolution, of the development of a writer; it can’t be forced. And if you want to be a physician-writer, you will have to find a way to do all this while still seeing your patients. It’s not easy, but neither is it impossible.
But first you have to give yourself permission to write.
Physician-writer David Hellerstein is clinical director of the New York State Psychiatric Institute. He is the author of Battles of Life and Death, A Family of Doctors and Stone Babies.