Why we write (and how we can do it better)

Five common errors

I commonly see five errors that doctors make when they start writing. These observations begin with elements of craft and narrative competence, but then move into murkier territories of a particular brand of medical narcissism, hunger for publication and wobbly ethics. I’ll summarize them briefly, then ask a question which I believe we should pose routinely to ourselves and to our colleagues whenever we share written stories about our patients.

1) Doctors have been taught to cut to the chase, so they usually do a lot of “telling” and not enough “showing” when they construct stories. Their narratives can be terse, pragmatic and mimic a case presentation rather than invite us into a new world. We need sounds, dialogue, colour, scents and images to enter the story. Readers, like patients, want to know that they are in good hands and that important things are not being missed.

Question: Why write this story about this patient and why now? Why do you care so much and why should we?

2) Doctors favour tidy endings, epiphanies and accounts of patients who exhibit courage and triumph over adversity. These have become the tropes of illness narratives, but they don’t capture the chaos and suffering of medical practice or of real life. Readers want to be shaken and left with a challenge, dilemma or new take. Doctors sometimes use their writing to pat themselves on the back, celebrate successes or privilege narratives of people just like themselves. Such selective recounting and editing is seldom fully conscious or intentional. Stories about the disenfranchised and our clinical “failures” are much more honest and compelling. They are more difficult to write (and lead us to more unsettling reflection), but are more interesting to read and to leave a lasting impact.

Question: What am I trying to accomplish with this story? Does the ending ring true?

3) Doctors may forget whom they’re writing for. Processing a personal dilemma or using writing as a reflective, therapeutic tool has great value, but that doesn’t make the story comprehensible or even interesting to someone else. I’ve read a lot of submissions that were spontaneous and raw, but were not ushered through the exigencies of craft to the next level of becoming a real story. There was no reader in mind when the story was constructed; it was written for the physician-self. The piece may contain clichés, medical acronyms and excessive technical detail and assumes these fully set the stage. On the flipside, some of the most compelling stories we’ve received at our journal have been written by physicians who have to re-enter and re-imagine the medical world they once inhabited after falling ill themselves. 4 Everything becomes new, foreign and menacing, and seen with new eyes. We as readers are taken on a journey.

Question: Whom is this story for: myself as learner, for a patient I wish to remember and honour, or for a literary reader who wants to be entertained and transported?

4) Neophyte physician writers may lack humility and patience. They are used to being right, calling the shots, seeing results and manifesting their authority. Many don’t accept that they are beginners with respect to writing and that creative talent (and the muses themselves) simply won’t be rushed. This reminds me of a story told by Margaret Laurence, a Canadian novelist and author of The Diviners. She was at a dinner party, sitting next to a neurosurgeon who, without guile, told her that he planned to write novels once he quit surgery. Without missing a beat, Laurence replied, “What a coincidence — when I stop writing, I plan to take up brain surgery.” Lesson learned.

Question: Where am I in my writing and where do I need to go? Can I accept being a beginner who has lots to learn about a new craft?

5) The final common error is more serious and needs to be viewed through the lenses of ethics and professionalism. Doctors may think that stories heard in their offices belong to them. If they can be shared in case conferences, they can be published as memoir, poetry, essay or nudged into fiction (with merely the slightest of changes to identifying details). This notion is deeply flawed and suggests a conflict of interest. Stories are co-constructed and permission from the patient or his family must be sought out (and documented) if the medical encounter is to be morphed into a published form. (My own experience is that patients feel honoured that their story will be shared and may benefit others. Some write rebuttals or parallel pieces. Some want certain details changed. Seldom do they refuse to have the story appear in print.) Fiction-writing physicians, if they are honest with themselves, can usually identify the impetus for a story — a singular image, facial expression or a patient’s unique way of saying something. Part of craft is using that detail as a point of departure, then moving into something entirely new. You have to ask yourself, could anybody identify this patient/clinical detail or story/family if they read my piece? If you have doubts that your writer’s hat is taking precedence over your physician one, then you need to edit, revise, re-tell or get the opinion of a trusted colleague.

Part of physician grandiosity involves rationalizing that minor changes suffice to render the tale fictional or suggesting that “the patient will never read this anyway.” Not so in a plugged-in, Internet world. (Not so in a litigious world either —I’ve heard of doctors’ personal reflection notes or parallel charts being subpoenaed as a part of a discovery for litigation. Check your clinic’s policy on where and how such notes should be kept, and whether their very existence should be referenced in the chart.)

Encouraging (or forcing) the sharing of stories among students and colleagues invites questions about boundaries, confidentiality, respect and potential stigmatization. Something can’t be untold once it’s out there. Pseudo-therapy is not the goal of this type of reflective writing, and the vulnerabilities of the teller and the maturity of the group must always be respected. (Writing is generally self-dosed in that people tell what they can or what they’re ready for. Forcing premature closure or probing threads not yet conscious to the teller can do damage to both the story and its teller.)

Question: Whose story is this?

Finally, I worry that we may come to use stories as a balm for what ails our profession. Band-aid narratives make us feel good about what we do. We publish them in faculty or hospital magazines (although some of these institutions embrace less than admirable practices). We placate, have our alter-author-egos stroked, and are placated ourselves. Stories can also be about control (propaganda being the perfect example). Once we pay more attention to patient narratives, how will we select, shape, manipulate and edit them and to what end? It’s not up to us to determine what they mean or influence how they end, even as we see the plot unfolding.

Final Question: Writing and sharing stories has made me more reflective and narratively competent. How am I using this new skill? Is patient care being served 5 or is this more linked to physician control, entitlement and advancement for me as an aspiring author?