The Story Always Comes First

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 been  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)  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

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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 Piece of Work: Five Writers Discuss Their Revisions, ed. Jay Woodruff.  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.  Ibid, p. 180.

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