AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. July 2011, Volume 13, Number 7: 494-498.

Medicine and Society

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Vulnerability in Physicians’ Narratives

Readers, whether critics, the general public, or health care professionals, respond emotionally to physicians who reveal themselves literally and metaphorically in their writing.

Susan Sample, MFA

A man donning blue scrubs and bonnet ties a mask over his face on the cover of Better: A Surgeon’s Notes on Performance. Turn the book over, and the physician in the photograph is recognizable as author Atul Gawande. Contrast that cover art with the front of Final Exam: A Surgeon’s Reflections on Mortality, where two hands clasp, anonymous except for the cuff of a white coat covering one wrist. On the back, author Pauline W. Chen is pictured in street clothes. Though critics did not comment on the illustrations, they did compare the two essay collections—both published in 2007; both written by young physicians—in side-by-side reviews [1, 2]. While Gawande’s work drew praise, some was tepid: “Atul Gawande is more interested in behavioral tendencies than emotional ones” [1]. “He has loaded his book with lofty-sounding ambitions, but no matter how sharp the writing,” argues one reviewer, “the ultimate result is banal” [3]. Pauline Chen, on the other hand, “does do better…. Chen’s elegant medical memoir offers a series of extended meditations on mortality—and by extension humanity—that stay with you long after you’ve finished the book” [4].

These two reviews illustrate a message that is relevant to physicians-authors as well as those considering writing about their experiences in medicine: the more personal the writing, the more personal the response. Readers, whether critics, the general public, or health care professionals, respond emotionally to physicians who, like Chen, reveal themselves literally and metaphorically through their stories. Rather than donning their professional mantles, as Gawande does, physician-authors who acknowledge their vulnerabilities as human beings “touch” their readers in the fullest sense of the word. They make contact emotionally and intellectually, and, in so doing, communicate on a most intimate level. Vulnerability is the threshold where all writers must stand to create meaningful narratives that not only help to make sense of our experiences, but also profoundly affect the lives of others.

Powerful Threads of Personal Narratives

We live through stories, with stories, for stories. We also live out stories, ours and those of others. As medical sociologist Mike Bury notes, “The telling of stories, whether about oneself or others, is universal…. Not only do language and narrative help sustain and create the fabric of everyday life, they feature prominently in the repair and restoring of meanings when they are threatened” [5]. Physicians Tricia Greenhalgh and Brian Hurwitz situate narrative even more centrally in the practice of medicine: “Not only do we live by narrative, but, often with our doctors and nurses as witnesses, we fall ill, get better, get worse, stay the same and finally die by narrative too” [6]. In setting out the premise for their book, Narrative Based Medicine, Greenhalgh and Hurwitz claim that narrative “provides meaning, context, and perspective for the patient’s predicament…a possibility of understanding which cannot be arrived at by any other means” [7]. Thus, they argue, physicians and especially medical students need to study narrative to better understand patients and their stories. This viewpoint is shared by Rita Charon, who has developed “narrative medicine,” a model of medical practice based on narrative competence [8]. When physicians learn to “listen to the narratives of the patient, grasp and honor their meanings, and be moved to act on the patient’s behalf,” they can “practice medicine with empathy, reflection, professionalism, and trustworthiness” [9].

Why This Story? Why Write Now?

In the process of studying narrative, physicians, as well as nurses, social workers, and others directly involved in patient care, often find themselves writing narratives of their own. Although Charon does not delve into the writing processes of health care professionals, she does note that creating narratives is “an avenue toward consciousness, engagement, responsibility, and ethicality” [10], all noble motivations for writing personal narratives. For several years, an intensive writing workshop was held for internal medical and pediatric residents from three Yale-New Haven Medical Center training programs to determine whether creative writing would help “trainees address conflicting emotions about their professional roles and cultivate a curiosity about their patients’ lives beyond their diseases” [11]. Results showed that writing “created a sense of community among participants, enhanced both self-awareness and awareness of their patients’ lives” [11]. Along with empathy and engagement, however, an “unanticipated effect” was reported: those in the workshop experienced the therapeutic effect of writing due to “a shared vulnerability” [12]. What the medical educators evaluating the workshop seemed to have overlooked is that “stories tell us not simply what has happened, but what kind of person the narrator is” [13].

Personal narratives are personal; they reveal who we are. Returning to the book reviews cited earlier, we find Gawande, author of Better, described as “the Harvard-trained surgeon, writer and medical golden boy [who] thinks he has the answer” [3]. His narratives “feel less like dialogues between peers or with interested patients than guides for other MDs, how-to tracts advising them on how they too ‘might make a worthy difference’” [3]. His writing takes a “corporate” view of medicine, which aligns very well with his book’s purpose: to identify specific ways in which physicians can perform their jobs better.

Chen’s motivation for writing lies at the other end of the bell curve. She wants to explore a central paradox of medicine: how a profession dedicated to saving lives silences discussion of death, which could humanize both patient and physician. Her narratives, according to one reviewer, reveal Chen as courageous—“She tests her convictions, questions, her motives, her values, and allows herself to take pause, to listen to the patients, to their needs and frustrations”—as well as honest—“She also does not spare details on her own perceived shortcomings…. She most often uses examples of mistakes and near-misses from her practice” [14]. It would be unfair and incorrect to equate either author with the perceptions of selected critics, but the reviews remind us that a writer’s motivation shapes not only the direction of her narrative, but public response to her story as well.

Danielle Ofri probes her own authorial motivations in a column in The Lancet [15]. “Writing would make me a more sensitive physician,” she muses. “I would become a better listener, more attuned to the fine details, more aware of the intricacy of the patient’s life beyond his or her presenting complaint. I would expand my focus outside of the paltry constraints of illness and appreciate the grand tapestry that is a patient’s life in its entirety” [15]. Yet Ofri is circumspect even with herself: “I think that we who write need to accept the idea that, to a large degree, we do it for ourselves” [15]. Which is not to say that such motivation is neither honorable nor admirable. On the contrary, Ofri eloquently justifies writing personal stories about patients with a rationale that reaches beyond medicine and touches the universal nature of all narrative to which Bury alludes: we should, she says, when writing always remember to “ask ourselves if we have made a connection that is healing” [15].

Doctor, Disrobe Thyself

Once the surgical mask has been untied, the white coat left behind in the clinic, how does one find the threshold of vulnerability from which to write? First and foremost, Ofri calls for physician-authors to be honest: “We cannot hide behind the Hippocratic oath when our pen meets paper that is not the medical chart” [15]. The same maxim can be found in most every book discussing the craft as well as the art of writing. “The struggle for honesty is central to the ethos of the essay,” notes Philip Lopate in The Art of the Personal Essay [16]. “Some vulnerability is essential to the personal essay. Unproblematically self-assured, self-contained, self-satisfied types will not make good essayists” [17]. Natalie Goldberg is more direct. “Lose control,” she says bluntly in Wild Mind. “Say what you want to say. Don’t worry if it’s correct, polite, appropriate. Just let it rip” [18]. What results from writing that is candid, honest, and vulnerable is not self-centeredness, but intimacy, note Brenda Miller and Suzanne Paola: “you and the reader will find yourself in a close, if not intimate, relationship that demands honesty and willingness to risk a kind of exposure you may never venture in face-to-face encounters” [19].

It is a relationship much like that between doctor and patient. “We must probe the patient’s story as gently as we palpate their abdomen,” writes Ofri, “never going beyond the point of wincing, never causing pain for pain’s sake” [15]. Successful writing, like a physical exam, depends upon gaining trust so we may touch another. In the exam, “physician and patient are no longer strangers but are bonded through touch,” writes physician-author Abraham Verghese [20]. “That bond moves the patient toward healing—not just of the body, but of the psychic wound that accompanies physical illness.” In writing personal narratives, medical students, residents, and physicians can “understand and identify with the ambitions, sorrows, and joys of the people whose lives are put in their hands” [21] when they allow themselves to feel. Then they can also find new meaning in their personal experiences. And, in the process of telling their stories with honesty and full self-disclosure, physician-authors can make contact with readers, touching lives in profoundly human, and healing, ways.



References

  1. Are they human? Economist. April 4, 2007: 83.
  2. Ratner L. The doctor stories. The Nation. June 11, 2007:32-34.
  3. Ratner, 32.
  4. Ratner, 34.
  5. Bury M. Illness narratives: fact or fiction? Sociol Health Illn. 2001;23(3):264.
  6. Greenhalgh T, Hurwitz B, eds. Narrative Based Medicine: Dialogue and Discourse in Clinical Practice. London: BMJ Books; 1998.
  7. Greenhalgh, Hurwitz, 6.
  8. Charon R. Narrative Medicine: Honoring the Stories of Illness. New York: Oxford University Press; 2006.
  9. Charon R. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. 2001;286(15):1897.
  10. Charon (2006), 131.
  11. Reisman AB, Hansen H, Rastegar A. The craft of writing: a physician-writer’s workshop for resident physicians. J Gen Intern Med. 2006;21(10):1109.
  12. Reisman, Hansen, Rastegar, 1111.
  13.  Greenhalgh, Hurwitz, 232.
  14. Suh GK, reviewer. J Palliat Med. 2007;10(3):817-819. Review of: Chen P. Final Exam. A Surgeon’s Reflection on Mortality.
  15. Ofri D. Physician writers: Danielle Ofri. The Lancet. 2003;361(9368):1572.
  16. Lopate P. The Art of the Personal Essay: An Anthology from the Classical Era to the Present. New York: Anchor Books; 1994: xxv.
  17. Lopate, xxvi.
  18. Goldberg N. Wild Mind: Living the Writer’s Life. New York: Bantam Books; 1990: 3.
  19. Miller B, Paola S. Tell It Slant: Writing and Shaping Creative Nonfiction. New York: McGraw-Hill Books; 2004: ix.
  20. Verghese A. A touch of sense. Health Aff (Millwood). 2009;28(4):1181.
  21. Verghese A. The calling. N Engl J Med. 2005;352(18):1847.

Susan Sample, MFA, is a program associate in the Division of Medical Ethics and Humanities at the University of Utah School of Medicine in Salt Lake City, where she teaches reflective writing to medical students and facilitates literature discussions with physicians. She is also a doctoral student in communication and rhetoric, researching the role of physician narratives in end-of-life conversations.

Medical Students Learn to Tell Stories about Their Patients and Themselves, July 2011

The Art of Writing Patient Record Notes, July 2011

Multiple Exposures—Reflective Writing in the First Year of Medical School, July 2011

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