The Seven Doctors Project: Creative Writing As Inspiration And Intervention

November 30, 2008 at 12:50 pm

A pair of round glasses on a sheet of writing, Wellcome Library, London, Photograph 2004

Commentary by Steve Langan, author of a collection of poems, Freezing (New Issues Press, 2001) and a chapbook, Notes on Exile and Other Poems (Backwaters, 2005); executive director of ALS in the Heartland in Omaha, Nebraska; teaches in the University of Nebraska MFA in Writing Program and is working on a Ph.D. in literature and medicine.

A "Typical" Night

I just returned from a meeting of the Seven Doctors Project, a writing group I started at the University of Nebraska Medical Center to see what would happen if I encouraged mid-career physicians to begin, return to, or sustain projects in creative writing. I pair each willing doctor with a local writer who serves as his or her mentor and guide. Tonight, even I feel like writing. I usually come home from work, check e-mail, check it again, worry about stuff I couldn't finish at work, eat dinner, pitch in on the dishes, worry about not writing my dissertation, yell at my son for not getting his homework done, walk the dogs with my wife, watch The Daily Show, then crash. But not tonight. Dr. M., who works in the E.R. and tends the grapes in his small vineyard when he has time, presented two poems, a weak tamed-down narrative about being stuck for two long days on jury duty and a stunning lyric, his version of the Garden of Eden, which included an expected mention of the loss of innocence (though it had a "nice twist," another doctor mentioned, that made it "seem fresh").

"Have we lost our innocence?" his colleague, the internist Dr. K asked. "Is it because we know too much about the secrets of the body?"

We flowed into and through this conversation. Nothing is off limits in this space we've established. Trust has been developed. With the doctors in the room, we reviewed some of the stark facts of their specialized training, and one of the doctors said, "I think we are people who used to be more fun." We had a lot of laughs tonight, too. One of the participants admitted to having a crush on one of the writers! This is intimate work, revealing, potentially life changing. I've been trying to deny its power, but it's no use. The evidence has been collected. Even in our tucked away classroom on this undernourished campus in our middling state, the lives of many of the doctors have changed, it seems, as a result of being part of this writing project. That's what they keep telling me. And all I'm asking the doctors to do is to write poems and stories (their mentors help in a variety of ways, including emphasizing the need for revision) and submit them to the group during their designated week for all of us to discuss. We don't dismiss "reflective" work, but it's not our aim. We hold each other to trying to make the best poems and stories we canausing the aesthetic principles that are at the core of teaching and learning creative writing as our foundation and default. That's why the writers have been indispensable. Further, if "therapy" comes out of the writing project, that's not our fault. Whatever energy or therapy or good feelings the doctors receive from being part of the projectadoing this writing in earnest and turning it inashould be attributed to the rigor that the writers have helped enforce and the high standards that we seek and help maintain.

The Players

I've worked with a public health doctor who just earned her MFA in poetry, a convert; a plastic surgeon with a background in music composition who has become fearful of writing and so dedicated herself to writing poetryaand submitted a poem that included a stanza about how she only worries about her patients; an oncologist who loves the band Genesis and puts on his headphones once a week and jams on his Hammond organ; a transplant doctor who has completed one novel and has another in progress; a psychiatrist who wanted during college to be a poet…who wrote his first poems in many years, including a poem about his relationship with his powerful father; an OB/GYN who started by wishing to narrate incidents from his career…and began to consider some of the opportunities for metaphor that fiction allows and demands; the Chief of Infectious Diseases, who has dedicated about an hour during his workday to sitting in his office writing poems; the concerned internist, who taped a poem she loved onto the door of her officeathen, five minutes later, fearing being labeled "creative," tore it down; and the E.R. doc, who recalled for us when life used to be more fun. Their average age is 52. If we're not being generative in mid-life, Erik Erikson said, we may lapse into despair. I even invited a university lawyer, who in the early Sixties helped edit an avant-garde literary journal, to participate. We don't discriminate. These men and women have become as real to me as characters in an engrossing novelawhich means, to me, they have more roundness and substance than many of my acquaintances, family members, colleagues and neighbors. They've been telling us more. It seems, for the members of the Seven Doctors Project, a lot depends on, using a word coined by Samuel Beckett, saying and writing what is "ununsaid."

The Inner Voice

Through literature, and especially through the lyric poem, one gets to hear the "inner voice." It becomes necessary, even addictiveaan antidote for many of us to the language of the academy, politics, government…and church, school and the workplace. I've encouraged mid-career doctors to take time out of their busy lives ("Busy little me," one of the doctors referred to himself in his poem) to indulge the inner voice and work to place it on the page. They say writing makes them "happy" and gives them "energy"; they can't wait until next week. Confronted by the power of poems and storiesatheir own and othersathe doctors have been forced to pause to make a variety of evaluationsaabout themselves and their profession, primarily. They've developed friendships with their mentors and other members of the group. Some of the doctors say it's nice to have something to talk about other than work with colleagues. They see each other in the halls and chat about the poem they're working on for next week. Poetry has become a secret handshake. And it has resumed its original place, as agent of inspiration, for the doctors and the writers. Writers learn over time to achieve effects (which is not the same as being driven to make something new because you have to, because you have no other choice). So it has been inspiring to the writers to watch the doctors revel in the deep thrill of the new.

The Background; Mentorship

When I had the hunch and presented the idea to my advisor, I figured the doctors would hate the project and start squirming in their Gucci loafers. Distracted doctors, their beepers hemorrhaging, and all of them late for class because they couldn't resist billing one more hour. Even if they hung in there, I assumed they would present themselves as irritating showboats and know-it-alls unwilling to accept the writers' suggestions. Instead, I've developed deep affection for each one of the doctors, all of whom have worked hard to improve their work and participate in a conversation that has not always made sense to them. The subtext of creative writing theory and practice is "freedom." The quest for originality is necessary and a movement toward the sublime. Further, ambiguity has bearing in medical diagnosis, it seems, but is not something one frivolously rolls around in. Making the instant correct decision about a situation is king. After a long day, it was fun to watch the doctors start to delve into the text in front of them…and make an instant and simultaneous collective decision in response to the questions the writers began to ask them about what they were reading. Whoa! we frequently cautioned them. Let's take a little time here to think of all the possibilities, okay!

At this point, deep into phase two and assembling participants for phase three of the Seven Doctors Project, even I can't really deny its genuine effects. From observations, interviews with my subjects, responses to assessment questions and word of mouth, the project has helped and inspired my subjects at work and at home. We keep being congratulated for the project, and we keep congratulating ourselves. But maybe it's just a placebo, I keep thinking, or a niche that we could've filled with woodworking. Sure, the writers are wonderful, gifted and helpful, but I know all of them well enough to know some of their insecurities. They aren't publishing enough, they aren't smart enough, they'll never finish that story, collection of poems, novel. A writer's well-honed inner voice repeats, I'm a fraud, an imposter, a dilettante.

The project allows the writers to have a deadline for new work (the writers submit during the same week their "student" submits), but it's more than that, really. How often do any of us get to show doctors what we can do? The writers get to turn the tables on the doctors, and the doctors not only get to wonder what it's like to live more fully in the realm of the imagination, they get to practice doing this work, too, and play the role of the artist at least once a week and during time they squirrel away to work on their writing. Except for in one pairing, the writer-mentors have become heroes to the doctors. They wonder how the writers think. They've started to consider what the writers would say in response to the text they're working on…and revise accordingly. A recurring comment made by the doctors after their poems and stories have been workshopped is to give all the credit to their mentors.

In Conclusion

I'm not a social scientist or anthropologist or genuine medical humanities advocate or strict devotee. At this point, I'm not really an academic thinker at all. I've collected information and results on the study, but I'm just learning how to put it into serviceable academic order. And I'm certainly not a physician. As I shadow my subjects at work (partly as a way to learn more about the medical system but mostly to determine how they do their challenging work with such skill and creativity on a day to day basis), I'm sometimes asked if I want to become a doctor. My tongue in cheek response has been, "No, thanks. I have enough problems."

On the page and also in our conversations, I keep hearing, more than a minister or therapist or shrink might, the challenges of the doctorsathe mistakes they've made and witnessed, the things they wish they were able to accomplish, the holes in their lives. I feel privileged to have become their interlocutor, a role I've assumed, I think, because, really, what kind of threat is a poet to a doctor? Plus, as I said, I care about them. I really do. And I used to be afraid of doctors; I used to think, as a character in one of Denis Johnson's stories, says, that "Good health depends on the ability to fool doctors," I'm grateful to be able to present, along with my writer-colleagues, the practice of writing and the imagination as a kind of intervention in their lives. The doctors have taken the medicine; they keep following our orders. They continue to refer us to their colleagues, who call me to ask if they can join us at the next session.

Toward the end of class last night, I asked Dr. M. what it felt like to present his poems to the group. He told me he had been nervous all day. He was relieved, he said, after we finished talking about his poems. Which is a good outcome, because, though we admired his courage and the fact that he took a lot of time to do his work, one of the two poems wasn't very good at all. It needs a lot of work. He told us he'll try to revise it; his mentor reminded him that he's there for him. As we came to the end of our two hour gathering, time that members of the group keep telling me flies by, Dr. M. said, "You know what it felt like? I felt like one of my patients sitting on the table in a gown with my backside exposed." Oh, the joyato be that vulnerable again, even a little desperate and in need!

The Story Always Comes First

October 17, 2008 at 1:00 pm

A pair of round glasses on a sheet of writing, Wellcome Library, London, Photograph 2004

Commentary by Jay Baruch, author of Fourteen Stories: Doctors, Patients and Other Strangers (Kent State University Press, 2007). Assistant Professor of Emergency Medicine and Director, Ethics Curriculum, at the Warren Alpert Medical School at Brown University


Question: What do you call physicians who write?

Answer: Physicians.

This particular quip rings funny to me-and perhaps only to me. It riffs off of Kurt Vonnegut, who swathed this gem in toilet tissue in his book Timequake.

Question: What is the white stuff in bird poop?

Answer: That’s bird poop too. (1)

Like a skilled physician who distracts the patient to minimize the pain of injection, Vonnegut knows how to bury sharp insights in silliness so the reader never feels a prick.

Regardless of the color, whether it lands on your head or windshield, its still bird poop. That’s how I feel about being a physician/writer. One part cannot be extracted from the other. There are no smooth fascial planes along which to dissect, no separate and distinct blood supplies. Principles and moral values guiding my bedside responsibilities and behavior somehow feed into the slow meandering act of writing about them. I have trouble finding a physical and emotional distance that is far enough from this moral tug.

How does this commingling manifest itself?

When I write doctor stories, I write fiction. Over the years, this unconscious decision has nonetheless been buttressed by three dominant justifications: patient privacy, trust and potential abuse of the physician/patient relationship, and my belief that the story always comes first.

Thieving and the Physician/Writer

I’m very uncomfortable writing non-fiction or creative non-fiction (a genre I’m still trying to understand). Writing about "real events" and "real people" from my role as a physician makes me feel like a thief. For me, you can dress up real patients, bend and twist them like balloon animals to alter identifiable details, and yet fail to alter enough core narrative slivers. It’s not only what’s changed, but what remains that’s concerning. The female in life becomes a male on the page, the Latino kid on crutches is now a Korean in wheelchair, the bald guy preens about with a Mohawk. But too much faithfulness to the real, protection of the factual, the writer risks missing dustings of critical evidence, like fingerprints, or hair and skin spiraling with DNA.

Why this thieving feeling?

The physician-patient relationship is tender and complex, charged with issues of vulnerability and power. Privacy and confidentiality are ambiguous and complicated values in today’s society, especially in a time of media overexposure, reality TV, and the "Wild" Wild Web. The house of medicine is one arena where foundational values and laws from Hippocrates through HIPAA have clearly drawn the lines around privacy and confidentiality.

Question: What do you call patients in medical narratives?

Answer: Patients.

The Emergency Department: Writing and Rapid Trust

I often wonder if my specialty and sphere of medical practice deepens my sensitivity to the moral issues at play in the physician-patient relationship when I’m writing. Part of the demands of emergency medicine involves caring for sick strangers. A large part of that challenge involves building rapid trust. Not many people know about my creative work, but local reputations develop. I don’t want to risk the perception from patients that I might use them for personal purposes. I don’t want patients to guard sensitive medical information valuable to their care out of fear the physician/writer is listening with different ears. Patients must feel like the subjects of my gaze and attention, not as objects.

After all, I’m billed as a physician, someone bound by the Hippocratic Oath (or at least a less misogynist version of it), someone duty-bound to place patients first. The ID hanging from pocket reads MD, not PRESS. A stethoscope hangs over the back of my neck. I don’t carry a long, skinny reporters’ notebook. I don’t wear a coffee-stained sport coat. I wear a coffee-stained white coat.

Jack Coulehan and Anne Hawkins have written cogently about the ethical considerations facing physicians who write about their patients and the potential impact on the physician-patient relationship. (2) How would the patient react if he or she learned they were written about? Rita Charon has argued passionately that patients own their stories. Respect for patients demand they give consent for use of their stories. (3) I’ve beenA rereading their profound work and those of other health care providers and scholars the past few months as part of a project on the ethics of medical blogs. I recently lectured to medical students on this subject, and grappled to find a closing nugget for them to chew: The best I could do was this: Physicians must care for patients on the page, too.

The acute, short-lived, compressed form of my physician/patient relationship poses certain challenges to obtain permission. So I try to avoid the need for permission altogether.

The Medical Story as a Black Box

But more than the many moral concerns stated above, my decision to write fiction is dictated by the demands of the particular stories I’m trying to write. Fiction permits me imaginative freedom to plunge into confusion and discomfort, to ask questions that typically pull me far away from the real in attempts to pin down certain truths.

What is driving my desire to tell this story? Whose story is this? What’s at the heart of this story? How much and what part of this story earns space on the page, and what lives above the words, a past and present only I’m privy to. Once I make these decisions, write drafts, change my mind and kill more trees, I ask these questions again. Why am I writing this story?

George Saunders, fiction writer and essayist, describes art as a black box into which the reader enters in one state of mind and exits in another. The reader should exit a story altered somehow, feeling that something "undeniable and nontrivial" had happened. (4) The writer doesn’t get points for accuracy, for filling the box with facts and details. The writer must aspire for a more transformative experience. The poet Tess Gallagher alluded to this when describing the purpose of language in poetry. "To enter emotional spaces on terms that are original." (5)

Emotions pull me into a story, as well the desire to understand particular human behavior and to effectively communicate that which surprises and disturbs me. The medicine practiced in my stories must be accurate. But the characters and events, the narrative bones, aspire to a "story truth," more than a "happening truth." (6)A Tim O’Brien, in his stunning book, The Things They Carried, argues that if the reader identifies with the plight of the characters, it shouldn’t matter whether events are true. The truth is felt in the reader’s gut. Sometimes invention is necessary to clarify and explain. (7) It might be the contradictions between what happens, what is expected to happen, and perhaps, what should happen. I set off on unexplained and unexplainable detours. The factual details fall away. What remains are inventions, people and conflicts and histories absent at the beginning, fueled by tension and emotional engines.

The Importance of Wandering Far From Where I Started

I play with points of view, which removes any pretension of veracity. An example: many versions of my short story, "Road Test," were written through each character’s eyes, only to come to life when I realized this ER story belonged to the janitor. Only through his eyes was the conflict between the homeless drunk and the young doctor drawn most acutely, permitting the reader the most intimate and unbiased access to the complicated and often ugly thoughts and emotions that compelled me to write this story. It reads as a "real" event. The doctor and the homeless man weren’t drawn from particular people, but their actions and feelings and fears are painfully real.

Recruiting different voices in medical situations opens the story to moral opportunities. When the writer is a physician, the patient’s experience is channeled through, and controlled by, the physician. The narrative choices belong to the one with a stethoscope and a pen. One of my great challenges in the writing craft is developing the empathy, the curiosity and confidence to inhabit lives most unlike my own. Should I fail to create convincing characters, it’s not for lack of interest or desire, and I hope my respect for these persons seeps through.

Fiction gives me room to wonder and wander. I’m allowed to shape a medical situation, hold it up to the light and twirl from side to side. Take the man dying of cirrhosis, his domineering wife hot with disdain for doctors and demanding narcotics for her husband’s pain. These two individuals are at the center of my story, "Thin Walls."

Even the most unlikable people harbor a measure of kindness, and finding it is my mandate as a writer. Many difficult patients and family are sympathetic, calm and reasonable people who become unhinged or uncontainable only when they encounter the health care system, or the person in the white coat. Maybe every test I run brings them one step closer to bankruptcy. Maybe the wife’s scared to lose the love of her life. Maybe her pushiness is the only semblance of control left to her. Maybe she and her husband share an unhappy marriage. Now he’s dying, ramping up the misery?

The start of any medical story, at the bedside or on the page, always begins elsewhere. The "real" medical incident that set me off writing this story happened almost two decades ago, a moment that somehow, in the discovery of writing, led me to the two people mentioned above. I was an intern, holding a young child brought to the hospital for neglect. I don’t remember the details of the case. I remember the child’s empty eyes, the way his inert body slipped through my arms, his frail body awkward and surprisingly heavy.

I imagine what my invented characters would say if they read about themselves. I don’t necessarily want their approval-I’m often hard on them-only their acknowledgment that I had been fair and honest, that due diligence had been done to understand as completely as I could unflattering and embarrassing behavior.

Fiction and the Physician/Writer: A Weak Crutch?

There are limitations in writing fiction. Making up experiences might fail the reality test, be viewed by some as lacking validity. Physicians who write in non-fiction genres often become central characters in their work. That takes a great deal of honesty, courage, and skill to compose such narratives. I respect and admire many physicians who have created books that glow with compassion and insight. Perhaps I open myself up for criticism by removing myself from the action, by dispersing dark moments and emotions onto other characters, and making these fictional others bear my burdens.

Critics might also argue that writing fiction doesn’t absolve me entirely from accusations of feeding off my physician-patient relationships in my creative work. Henry James wrote of the "perfect dependence of the 'moral" sense of a work of art on the amount of felt life concerned in producing it," and the "kind and degree of the artists’ primary sensitivity which is the soul out of which its subject springs." (8) The intensity of a clinician’s work, the consuming, unshakable nature of the interactions, contributes to my "felt life."

In Conclusion: The Physician/Writer is Still a Physician

I want my characters, and my work, to resonate with readers, because they are all potential patients. Should readers come to my emergency department, I hope they will be comforted to learn that this writer will be caring for them, and they will trust the physician.

The process of writing fiction allows me to discover emotional truths about characters and myself that would have remained unearthed had I obeyed a chronological or factual accounting of events. Referring back to Saunders’ metaphorical black box, I aspire for readers to enter a story and emerge altered in some way. For me, that can only happen in the work of writing drafts, and remaining open to possibilities. The journey takes me to an unexpected territory far from where I began, from the place where words are chosen with great care, from my pressed white coat, my hospital ID hanging for all to see.

Endnotes


1. Vonnegut K. Timequake New York: G.P Putnam’s Sons, 1997 p.142

2. Coulehan J, Hawkins AH. Keeping Faith: Ethics and the Physician-Writer. Annals of Internal Medicine 2003;139: 307-311.

3. Charon R. Narrative Medicine: Form, Function, and Ethics. Annals of Internal Medicine 134;2001: 83-87.

4. Saunders G. "Mr. Vonnegut in Sumatra" in The Braindead Megaphone. New York: Riverhead Books, 2007. P.78

5.A A Piece of Work: Five Writers Discuss Their Revisions, ed. Jay Woodruff.A Iowa City: University of Iowa Press,1993. p.68

6. O’Brien, Tim. The Things They Carried New York: Penguin Books, 1990.p.203

7.A Ibid, p. 180.

8. James, Henry. Preface, The Portrait of a Lady. New York: Modern Library Paperback Edition, 2002: p. xxiii.

My Story, Your Attention, Our Connection

September 25, 2008 at 4:10 pm

Patients waiting to see the doctor, with figures representing their fears.

Commentary by Deirdre Neilen, Ph.D., Associate Professor, Center for Bioethics & Humanities, SUNY Upstate Medical University, Syracuse NY, and editor, The Healing Muse

We are finalizing our eighth issue of The Healing Muse, and I find myself again caught in the web our poets and writers and artists are spinning. No matter that this is probably the eighth or ninth time I am reading their words or looking at their images. Each one springs before me as an entity, a being in search of something or someone to complete its quest for authenticity, its demand for understanding and mutual recognition.

As a journal dedicated to exploring issues of illness, disability, and medicine from all sides of those experiences, The Muse provides a unique forum for conversations and discussions that can seem difficult to initiate. When a diagnosis of cancer is given or when someone we know has a mental health crisis, we often have an initial sense of fear. We hesitate to say the wrong thing; we worry that our words might worsen the impact of the situation. We want to help, yet we too might feel the despair that lurks just behind the diagnosis. And inevitably, we feel totally and horribly alone. This isolation is one of the worst aspects of illness and medical treatment. The Healing Muse represents one poignant and powerful solution to this alienation; it can even open up a dialogue between patients and clinicians.

People have asked those of us who put together the journal if we don't feel overwhelmed by the sadness of the poems and stories. They wonder how we "market" The Muse. Who really wants to read about radiation or chemo treatments, about physicians who can't save patients, or parents who can't save their children? Does anyone honestly want to know that his doctor can feel inadequate and furious all within the same second?

Narratives and Medical Students

To answer these questions, let me don the other hat I wear at my university, that of humanities professor in the college of medicine. With one of my physician colleagues, I teach a humanities elective once a year that is open to our medical students, our nursing students, and students from two private universities in the city. We have taught Death and Dying, Images of Medicine in Film and Literature, and AIDS in Literature. Each time we teach, we are struck by the medical students' hunger for discussion about medicine's more hidden aspects: the dying process, the fatal prognosis, the side effects of treatments, the chaotic relationships that can accompany the patient, the ethical dilemmas that no antibiotic can answer.

It is within literature that their questions and their attitudes can begin to be answered and explored. When I bring them an essay, "The Bruising," by Dr. Thomas Gibbs which appeared in Muse 6, I am giving them the opportunity to watch a physician make the connection between his pregnant patient who will die from acute myelocytic leukemia and the death of his own mother from leukemia many years earlier. They see the physician "trying to prevent the panicked look" he sees in a young couple's eyes as he prepares to run the tests that will confirm his suspicions; they eavesdrop his interior thoughts as he realizes that this young couple had "walked into the room with a future" and suddenly everything is different. Our discussion centers on the physician as a bridge between the life they knew before and the unknown outcome awaiting them with treatment.

What intrigues the students and most readers I suspect is that Gibbs does not make the diagnosis his most powerful image or conclusion. He lets us know the ending is not going to be a felicitous one, but what emerges as the more important part of the story is how the young couple and the physicians and the nurses met this most unwelcome death. The wife expresses her husband's and her desire that everything be done to save her baby. The nurses make sure that the couple is given as much privacy and quiet time alone as possible. In addition to his regular visits, the physician asks the nurses to call him whenever there seems to be a change, good or bad, in the patient's condition so that he may provide whatever solace he can conjure. Once this leads him to a late night visit to McDonalds for a strawberry milkshake, the same kind he remembers bringing his mother when her lips were ulcerated from radiation. He recognizes that although so much more is known about the disease and so many more people have been helped, in this case, with this patient, he is again facing an indescribable loss. Thus, our physicians-in-training learn about bedside visits and about complementary treatments that won't be found on insurance forms or hospital billing codes.

And the students see that it is Dr. Gibbs who calls the code after the C-section brings a healthy son into the world a little bit before his mother must leave it. When he goes to the calling hours, Dr. Gibbs tells his readers that "obstetricians aren't supposed to lose patients" and confesses that is why he chose this specialty. But our students are learning that all physicians and all of us will stand at some point in the presence of death and how we handle that perhaps defines us in quintessential ways. In this instance, Dr. Gibbs and the nurses find themselves marking the anniversary of the patient's death each year with some poetry and some conversation. It has been 7 years now, and he sees this ritual as one of the ways we insist upon a recognition that we matter, that we were here only for a short time and yet we were loved.

If in our medical education, we are almost solely fixated on disease properties and drug and surgical interventions, we will not be prepared very well for those times when the black bag runs out of tricks, when disease proves more powerful than goodness or justice or mercy. Journals like The Healing Muse remind us that healing can occur even in the presence of bad outcomes and that good writing can, as Rafael Campo said, "make empathy for human suffering, if not entirely comprehensible, then at least clearly and palpably evident."

Patients Owning Their Narratives

When we do readings here in Syracuse or when we travel to other venues with The Muse in hand, we encourage our listeners to write for us too. We have found an enthusiastic audience in those who have experienced illness or who have cared for loved ones with illness. Their stories and poems can offer details that flesh out a patient's history or chart. In the poem "Shaking," for example, the reader learns that the speaker is not just a woman who suffers intermittent seizures after her brain surgeries but rather a mother who's concerned that these seizures are frightening her children. In sixteen short lines, she reveals her fear and her neurosurgeon's careless disregard of this fact as he mockingly re-enacts how her arms flail when an episode occurs. There is no more dramatic or concise way to convey the importance of listening to a patient; the students are as shocked as the patient when they realize that the physician has only scared the patient and furthered her isolation.

Our new issue includes an essay by a person who received electric shock treatments to relieve her depression. We enter her world and come away wondering as she does, is this truly the best we can do for each other? It is not only the treatment that her essay questions but the way we provide such treatment that makes us cringe. Her words and images are powerful testaments to the human spirit, and they connect her to us, bursting through the isolation her illness seemed to force upon her. Like the current running through her nervous system, her essay jolts us into awareness and dialogue. We see her, truly see her, and by the essay's conclusion, we know something important about her. And we wonder how much of this her clinicians know.

Some might think it ironic that medicine could use literature to return the profession back to its focus on the patient. Managed care and technology have pushed clinicians away from people and into numbers, statistics, and machines as supposedly more reliable gauges of health. The growing body of literature from physicians and lay people, however, shows that people are pushing back. We find in journals like The Healing Muse and in the columns of medical journals evidence that the desire for connection and the benefits derived from it are real and affecting.

"Tell me a story," a child says to a parent, and the magic begins. Later, the child will ask "Tell me a story about when I was little," or "when I was born," and again the weaving together of our past and present begins and helps to create our sense of self. We see ourselves reflected in the stories told by those who care for us, who love us. And when we are sick, our families want to tell our story to the doctors and nurses, to the therapists, to anyone who comes to give us the magic of the pill or the treatment. We believe that if they know us more intimately, they will care for us more carefully, and we will surely improve.

The power of language is such that it can introduce strangers and within minutes transform them into people who find themselves curious about each other, whose curiosity then compels them to go further into the story, and who finally may end up caring deeply about each other. Is this not a possible description for good medicine?

Buy two copies of the new Muse and call me in the morning.

Writing And Medicine: Making It Up As You Go Along

February 26, 2008 at 10:21 am

A pair of round glasses on a sheet of writing, Wellcome Library, London, Photograph 2004
Commentary by Perri Klass, M.D., Professor of Pediatrics and Professor of Journalism at New York University, and Medical Director of the national literacy program, Reach Out and Read

Many many years ago, I think back when I was doing my residency, someone asked me to talk about the connectionsaor the differencesaor maybe the balance between writing and medicine. I was neckdeep in medicine, of course (or maybe it would be a truer metaphor to say that I was often out of my depth), and I was trying to write both fiction and nonfiction, as I could, along the way. I was therefore a de facto expert in what writing and medicine did or did not have in common, but as is so often the case with de facto expertise, it was a long way from anything I had actually thought through, let alone tried to articulate.

But though it may not be quite as effective as the knowledge that one is about to be hanged, the need to prepare a lecture does concentrate the mind, and so I eventually sat down to make some notes to myself about writing and medicine. Since much of my non-fiction writing at the time (and still) was drawn pretty directly from my clinical experiences, I put that to one side, and instead found myself thinking specifically about the ways in which writing fiction brought experiences and intellectual sensations and challenges into my life. And I came up with three ways in which I decided to argue that writing fiction balanced out residency. And now, a couple of decades later, I still find myself reaching for those ideas, whenever it comes time to discuss writing and medicine, two subjects still much on my mind, and much in my life. And I have to admit, I find myself wondering whether I reach for them because they happened to be the three points I invented for myself under pressure, when I had a lecture to give, or whether they were the three points I invented in the first place because they so resonated with the different parts of my lifeaand my brain.

Putting It Into Words

First of all, I said, in medicine, words mattered for the information they conveyed. If you could get the information across, if you could identify the correct term, you were using words appropriately (and "appropriate" is still one of those words that I never use without feeling I am taking refuge in a mildly unpleasant piece of pseudo-medical jargon). You don't have the luxury of using words for the sake of beauty or harmony or impact as part of daily clinical medicine; you wouldn't choose to spend twice as much time (or space) discussing a clinical situation, just because you had thought of an interesting and novel way to use language, or a less-than-straightforward structure in which to tell your story. On the other hand, there is no limit in fiction save the boundaries of your own genius (or lack thereof); the way you use your words is all. Go ahead and tell the story backwards, or inside out, go ahead and let the real story unfold by implication, make it as simple or as complex as you like, make your sentences deliberately brusque or stunningly lyrical; make your story structure as direct or as oblique as you like. The only limitation is your talent, the only measure is your success. Using the language in a bold new way may turn out to be a wonderful ideaaor a disasterabut the choice is yours.

Second, I said, medicine was a culture of availability, of turning yourself outwards and listening for various kinds of calls and cries. Clinical practiceaand most especially residencyawas about being on-call, being on the spot, being findable and reachable and moving fast when someone needed you. I invoked the beeper, of course. I described the "fishbowl" on the pediatric ward where I trained, the many-windowed room where residents sat to write up charts, easily and deliberately visible to every passer-by. Writing fiction, on the other hand, means shutting yourself alone in a room, looking deeply into what is there in your own mind, your own imagination, your own experience. Instead of listening for beepers going off and questions to be answered and cries of distress, you turn your attention to characters and stories that no one else can see or hear, until you have made them real.

And finally (and this was my socko finish), when you write fiction, you get to choose the ending. You get to decide who lives and who dies, who has what we would call (in the language where "inappropriate" means anything from wrong to crazy to rude) a good outcome, and who has a bad outcome. And the single harshest lesson of medical training, after all, is that while of course you do your very best, you don't actually get to determine the outcome and choose the ending.

Telling Stories About Telling Stories

Well, a couple of decades later, I still write fiction. And I still value it for what it adds to my life, for the ways it pushes my brain out of intellectual routines and into unfamiliar pathways. But even as I occasionally go on citing my three distinctions, I've come to believe that they are oversimplifications which shortchange both the complexities of practicing medicine and the challenges of writing fiction.

Take language. It's true enough that language carries a different value in fiction, where there is always the possibility of finding language which transports or shatters, shocks or overwhelms. And after all, if you were a writer of genius, you would find that languageawriters of genius somehow manage to do just that. But language in clinical practice is much more than the efficient coding of patient histories into the formula of case presentation and progress note. Language in clinical medicine is also the currency of communication and explanation, and it encompasses tragedy and confusion, resilience and generosity. I think about the many ways over the years that I have tried to find words to convey unwelcome information, and the many ways that parents have found to evoke their lives and their emotions and their questions. Sometimes there have been questions and comments that stayed with me for their poignancy or their beauty or their unexpectedness, like the teenager who asked me, "What do you do when your body really wants to do something and your brain isn't sure?" I have come to realize that the language of the exam room is the language of people narrating their lives, making up their own stories, or finding ways to articulate and examine the stories in which they find themselvesaand that the language there, as much as in anything a writer sits down to write, cannot be separated from the story.

Or consider availability, collaboration, inward-ness and outward-ness, whatever you want to call it. I think I always knew this was a somewhat false distinction; I would never write fiction if I did not spend time out in the world, mixed up with other people and their lives. It's true that sometimes writing can serve as a retreat, an interval of consideration and examination, even meditationabut I've never been a writer able to write out of the rich and glorious furnishings of my creative imagination. The inside of my head is hung with the scavenged scraps and the mismatched patches of my daily life, and what I do when I "turn inwards" in that rather affected phrase of mine is take the time to look more carefully at what I've carried home.

And finally, there's that issue about choosing the ending. Every writer who has struggled with fiction knows that isn't necessarily true. Characters don't do what you tell them to, or you find yourself disliking someone you had created and expected to find wholly admirable, or you watch in shock as two of your characters inexorably move into a doomed and destructive relationship. I mean, probably if you write certain kinds of formula stories, your characters do as they're told; if it's a romance novel, and the talented, spirited, but cynical and defensive heroine (oh, and beautiful, did I mention beautiful?) takes a job as sous-chef to a demanding, brilliant, but severe and critical chef (oh, and he's amazingly handsome, did I mention amazingly handsome?), and they dislike one another on sight…..well, probably they will behave themselves and fall passionately in love among the saucepans by page 120. And that's fair enough. But characters have a disconcerting way of speaking up for themselves ("The hell with the chef; I think I'm falling for that punked-out waitress with all the piercings!"). I have several times had the experience of coming to like and understand my villains much better than I had ever meant to do, or even worse, watching my heroes and heroines evolve at least a little in the direction of villainy, as it turned out their motives were less pure than I had planned, their standards of behavior a little less lofty.

So yes, when you write fiction you get to choose the ending. But it isn't always the ending you thought you were choosing, or the ending you wanted. In the writing of fiction, as in the practice of clinical medicine, you can learn a lot by listening carefully and watching closely. And I'm not sure there's really a good or useful distinction between the language of daily life and the more writerly language of literature; stories cannot be dissected out from the words used to tell them. And every story, as it is formulated into words, carries the potential to shake you up or shock you or move you in a variety of directions. It's about listening carefully to the characters, and valuing words in many different ways, it's about figuring out the ending, whether or not it's the one that you were hoping for (or that the characters were hoping for), and perhaps it's also about understanding, as a doctor or as a novelist, how your own limitationsalike your own abilitiesaare part of the language and the story and the outcome.

A Psychiatrist and a Poet

December 8, 2007 at 5:42 pm

Brain and Perception

Commentary by Ron Charach, M.D., Toronto psychiatrist, poet, and essayist.

To be both a psychiatrist and a poet is either a dual calling or a double whammy, depending on what you choose to emphasize. Such a medical/literary hybrid has surely won the sweepstakes in the personal sensitivity department. I am often asked whether being a psychiatrist helps me to be a better poet, though the reverse question is asked less frequently, especially since I don't do 'poetry therapy' in my psychotherapy practice. Before answering the question, a little more wordplay on the dual title may be in order.

One raises fewer eyebrows if one says "I'm a psychiatrist who also writes poetry" than if one says, "I'm a poet who does psychiatry on the side." The obvious difference in job security and monetary status of the two activities might lead to offbeat explanations like, "I couldn't make a living as a psychiatrist, so I went into poetry for the money" or, "Poetry is my day job, but I do psychiatry out of love."

There haven't been many psychiatrists/poets writing in English, at least not to the point of publishing (as opposed to self-publishing) several books. In the United States, people like Richard Berlin and Ronald Pies spring to my mind. A few others are represented in the anthologies of world physician poetry, Blood and Bone and Primary Care, published by the University of Iowa Press.

The late/great American poet Robert Lowell had a psychiatrist - er, actually, he had cause to visit his mother's psychiatrist, Merill Moore- a man who penned verse in what he nicknamed his 'sonnetarium'(oooh) at the back of his New England home. In other languages, Sweden's Tomas Transtomer, who had a psychology background, saw patients, and specialized in writing about people on the brink of doing something truly desperate, or at least, transformative.

I started writing in deadly earnest in pre-adolescence, and entered many essay and poetry-writing competitions, usually getting an honourable mention or placing second or third, which only whet my appetite to try harder. After being a psychiatrist for the past 27 years and psychotherapist for the past 30, I would say that practicing the craft has given me a good ear for dialogue and monologue, for how people actually talk and think. Dream analysis has also sensitized me to the value of using dreams as bridges to more fully understanding people’s fears, preoccupations and goals.

Psychiatrists from the past whose work informs my own include Freud, whose main prize, the Goethe Prize, was in literature, not medicine, and the late Heinz Kohut, whose nearly unreadable books nevertheless are rich in their appreciation of the powers of the literary imagination and very rich indeed in their conception of the needs of a viable self. I also get a lot of tips from more prosaic theorists like Aaron Beck, who invented cognitive therapy.

Being a poet informs my work as a psychiatrist insofar as both callings focus intensely on language and its many layers of meaning.The mind is hard-wired to make and to understand metaphor, something the neuroanatomists have only begun to study. Many of my poems are about medicine in general and psychotherapy in particular, and I would refer the reader to rather amusing if vaguely unsettling pieces on such procedures as "MRI" and "Colonoscopy", both poems written from the perspective of the wary physician/patient who 'knows too much'.

Anyone who would like to see the many subjects which a psychiatrist/poet might take on is invited to look at my latest book, Selected Portraits, published this autumn by Wolsak and Wynn, which contains poems about relationships from my first six collections.

I would offer a caveat for those who want to join me in the dual calling. Being a psychotherapist is especially hard on the back, given the relatively fixed postures one must sit in for large portions of the working day. Being a writer can also be hard on the back; ask Philip Roth who often works at a stand-up desk. Poets, of course, have it easier than novelists, but the physical issues add another form of double jeopardy to the work.

Psychiatrists and psychoanalysts are often talent manques, men and women who are reluctant to come out from behind their therapeutic neutrality. They get few opportunities to assert themselves as people with strong opinions and viewpoints, at least not in the consulting room, where to do so might be inappropriate. I work a lot with adolescents, who have ‘automatic shit detectors’ and tend to appreciate frankness. Knowing I am a poet, other physicians often send me referrals who are actors, screenplay writers, even the occasional poet.

The patients I write about are composite creations, actual patients sometimes serving as springboards for fictional portraits that may include auto-biographical takes on the poet and his own family. It might sound overly cautious, if not downright paranoid to state, at the end of a book of poetry which everyone knows to be a work of fiction, "No character in this book is identical to any living person", but I've often been tempted to do exactly that. In the end, though, I find the first-person-singular voice to be very effective and collar-grabbing and am usually willing to run the risk of the reader's deciding that the views presented in the poem are identical to that of its creator. Consider it the third hazard of this unique double calling.