A Road Well Traveled: The Physician-Author and the Continuum of Story

By

Charles Atkins, MD

“There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.”

                        --William Osler

            It’s no accident that there are so many physician authors, from Somerset Maugham and Arthur Conan Doyle to modern best-sellers like Robin Cook, Tess Gerritson, Michael Palmer, Michael Crighton and F. Paul Wilson.  As I pursue dual careers of author and psychiatrist I realize that this connection is logical and rooted in our profession’s reliance on stories: hearing them, using them and telling them.  How we get from one end of the storytelling spectrum to the other is a well-trod road that takes us from the clinical record through authoritative non-fiction to the mainstream novel.  

            It starts with the doctor’s training.  We learn to take a history.  “So, what brings you in today?”  It’s the simplicity of an open-ended question that invites any response.  “I’ve had a cough that won’t go away,” “I got this rash after I came back from Vegas,” “Every time I walk up a flight of stairs I feel heaviness in my chest.”  The answers come with emotion and body language; we observe it all: the pain, the fear, the embarrassment.  We shape the story, and even enter it, as our attitude and willingness to listen have a strong bearing on whether our patient will trust us enough to give us the truth, the whole truth and nothing but the truth.  The more interested, relaxed and non-judgmental we are, the greater the chances of getting the information.  We generate hypotheses about the cough, the rash, and the heaviness.  We ask more questions, “How long have you had the cough?” “What happened in Vegas?”  “Tell me about the feeling in your chest.”  We’re careful not to jump too quickly to a diagnosis, as missteps in the gathering of a history lead to wasted time and bad treatment.  A cough could be the common cold, or the only symptom of a malignancy.  The rash could be from the detergent used on the hotel’s sheets or a psychosomatic concern over an extramarital liaison.  Is the chest pain indigestion, angina, panic?  Ultimately, it’s the physician’s skill in taking and interpreting a history that is our single most-important tool.  It’s all about gathering the data, interpreting it, and putting together a story that makes sense.

            As I think back through medical school and residency, I can see that I was taught basic truths about the nature of story that have helped me both clinically and as a writer:

• Common things are common; when you hear hooves, don’t think zebras.
• Consider all angles, who, what, when, where, why?
• Don’t jump to conclusions; generate a differential.
• Consider your reader.

            Once we’ve fleshed out the story, it’s time to write it down.  As medical students and trainees we learned how to present and write up a case.  I remember how as a med student I would be assigned a patient in the emergency room, work them up, and then, with little or no sleep, present them to a room full of other trainees and a Chief of Services who delighted in grilling us.  He wanted the whole story and he wanted it with multiple possible endings.  “So Dr. Atkins, please enlighten us with the story of your patient, Mr. Jones…”   

            I presented in the time-honored way.  It’s clinical, it’s dry as dust, but it is a story.  “Mr. Jones is a 42 year old never-married Caucasian man who presents with three days of sub-sternal chest pain that he describes as, ‘crushing, like something is sitting on me’.  It’s worse with exertion, is relieved with rest and radiates to his jaw, but not down his arm…”

            Learning to obtain a history and present a case—in both written and oral fashion--lays much of the groundwork for the doctor-writer.  Obviously, there’s a difference between what and how we write in a medical record and what’s likely to become a blockbuster novel, but similar skills are required for both.  I’ve come to view these different approaches to story as points on a continuum.  On one end we have the most-objective clinical reporting and on the other, personal narrative and finally fiction.

            Similar to popular non-fiction and fiction, the medical record as a repository of story serves multiple purposes and has multiple readers.  All of which must be considered when leaving a note in a medical record.  The histories we write lay out the clinical data upon which we arrive at our diagnostic impressions and conclusions.  Our notes reflect why we’re prescribing various treatments and whether, and how, they’re working.  Our charts must meet criteria for ‘medical necessity’ as defined by various insurers, Medicare and Medicaid should we wish to get paid and not get hauled into court for fraud.  We need to remember the Joint Commission reviewer who will look at what we’ve written to see that we’re staying current, are avoiding confusing abbreviations and are cognizant of all aspects of the human being—as defined in their hundreds of published standards of care.  What we write needs to be clear so that a colleague covering in the middle of the night knows what is going on.  Should there be a bad clinical outcome, the chart is a legal record where the written story is all that matters, ‘if it’s not in the chart, it didn’t happen’.

            Just as when writing a novel or non fiction book, I need to consider my readers whenever I document in a chart.  As someone who teaches clinical documentation I stress the importance of imagining everyone who could one day read your note standing over your shoulder: the insurance reviewer, the attorney for a patient wishing to sue you, the hospital risk manager, the patient’s mother, the patient, your colleagues, and of course, you.

            The medical record requires a particular type of storytelling.  It must be factual and free from editorializing.  Judgment-laden words and phrases like, patient is manipulative, non compliant, difficult, should be eliminated.  Just stick to what happened, what was observed.  Or as they say in writer’s lingo “show, don’t tell”.

            Even with this attention to the facts, the medical record is highly subjective.  When teaching, I’ll give a class of students the data from a single patient and instruct them to write up their formulation and present the case aloud.  If there are ten students I’ll hear ten different stories.    

From the case presentation or case study we come to the jumping off point that separates clinical writing from narrative and fiction.  For physician-authors this leap is not far or difficult.  Take the following examples of a standard History of Present Illness, which is then rewritten as a personal narrative (it could also be viewed as the inner monologue of a character in a novel).

Case 1:  Case Presentation:   

Patient is a 48 year old Caucasian man brought by ambulance to the emergency room following a near fatal suicide attempt by carbon monoxide poisoning in the context of multiple recent stresses—loss of job, separation from spouse and children and severe financial difficulties.  For the past four weeks the patient has experienced worsening symptoms of depression including diminished sleep with difficulty falling asleep, early morning awakening and mid-night arousal, feelings of worthlessness and hopelessness and increased thoughts of suicide with a plan to kill himself, which he attempted earlier today.  Client was discovered by a neighbor who was concerned by the sound of the car engine in the closed garage.

Case 1: Personal Narrative:

It’s so hard to find words.  Everything inside me feels dead.  I don’t want to write this, or think.  I’d like to go away and be done with everything.  I’m so sorry.  I’ve screwed up everything; my life…Peg’s the kids.  I can’t shake this, and they’ll be better off without me.  I should be looking for a job.  John told me the layoff wasn’t anything to do with my performance.  Others got laid off—I know this--but how do you not take it personally?  I feel like a total failure.  Like everything I’ve worked for all of these years didn’t matter.  You’re with a company for 20 years and they tell you it’s not personal when you have two weeks to say goodbye, clean out your desk, and go for job counseling, which was pointless.  I can’t sleep.  I lay there, the same thoughts over and over through my head, everything is coming undone.  Two month’s of not paying the mortgage.  I don’t have the money for the taxes.  No one’s going to hire me, not for anything close to what I was making.  I’m almost fifty.  My whole life is unraveling and there’s nothing I can do to stop it.  I get up and even the television is too much.  I can’t focus.  I hear Leno tell a joke, I used to think he was hysterical; it’s not funny, even though I hear the audience laugh.  I used to laugh all the time.  People would come up to me and tell me what a happy person I must be because I’m always smiling.  Every day, every hour I think about the car and how easy it would be to do this.  The weird part is that thinking about killing myself  doesn’t feel bad, more like a relief, just be done with it.  I think that’s what I’ll do.  I’ll do it in the morning.   

Once across this divide, how far we go as writers is limited only by our interest, perseverance, talent and skill.  My interest as a novelist has been to take psychiatric and forensic topics and explore them in fiction.  I picked the mainstream genre of the psychological thriller, ‘A’ because I like to read these, ‘B’ because they’re commercially viable and ‘C’ because as a psychiatrist I know something about human nature and why we do the things we do -- even bad things.  The medium of novels is ideal for in-depth exploration of complex subject matter.      

For the would-be doctor-writer, there aren’t a lot of absolute rules, but there are some helpful hints.  Go with your expertise and write what you know.  Beyond that most of the principles of clinical writing continue to apply, you need to think of your reader, and pay attention to the conventions of whatever genre you’ve picked.  Just as you consider the Medicare, Managed Care and Joint Commission reviewers when writing in a chart, think about who’s going to read your book and give them what they want. 

In novels the first goal is to entertain—why else would someone purchase one?  Because I write thrillers they need to generate tension, suspense and fear; they must snag the reader at the first page and not let up.  Beyond that I want to educate, both the reader and myself about topics I find interesting, confusing and important.  This is where clinical skill and experience can inform fiction. 

For instance, in my first book, THE PORTRAIT (St. Martin’s Press 1998) I wrote a thriller that had a hero with a serious mental illness, in this case an artist with Bipolar Disorder (manic depression).  I wanted to create an insider’s view of what it’s like to have a serious mental illness, to become psychotic, paranoid and even suicidal.  I chose a first-person narrative so that the reader could have this voice inside their head. 

“It was funny, the times I had been in the hospital; they didn’t seem quite real, that this, my real life, would be a memory, like a trick done with mirrors.  So many ghosts followed me—quick friendships on locked wards, endless mouth checks with hard-faced nurses.  The ghosts filled my paintings, worlds populated with earthbound saints and tormented devils.  My own Faustian dilemma became a little clearer each year.  If I took the pills, so I was told repeatedly, I could avoid the hospital.  I could also kiss painting good-bye.  So I juggled.”  

When I came to my second book, it was at a time when I was working with troubled teenagers who were coming for evaluations at the request of the court, the schools, or parents faced with an out-of-control kid.  RISK FACTOR (St. Martin’s Press 1999), allowed me to demonstrate in fiction the process by which a child grows up to become a sociopath.   I relied heavily on the theory of experimental psychologist John Bowlby, combined with what I was seeing in my clinical practice.  I created situations and a cast of characters that allowed me to show many sides of Attachment Theory.  My protagonist was a single mother of two working with troubled teenagers in both inpatient and outpatient settings. 

In a sense, the novel can be a delivery system for information.  Material that might otherwise be dry and conceptually difficult can be brought to life in ways that are crisp and evocative.

More recently, in the wake of 911, Hurricane Katrina and some personal tragedies, I took the topics of Trauma, PTSD etc. and wove them into a thriller, THE CADAVER’S BALL (St. Martin’s Press 2005/Leisure Books 2006).  I wanted to demonstrate through multiple characters how life-threatening events change us, how some people recover and others are destroyed by the experience.  In this case my protagonist is a psychiatrist who has been severely traumatized. 

“After a year of intensive therapy, I know this.  I feel it claw at my sanity.  Oh, God, make it stop!

My fingers claw at smoldering steel, as black smoke burns my eyes, “come on, Beth!”  I can’t see, I can’t breathe.  The smell of gas.  Help me!  Somebody help me!  She’s not moving, her hair caught in the shoulder strap?  I smash the window, but I can’t get the door.  She’s not breathing.  I suck in and put my head through shattered glass, my mouth over hers, tasting her lipstick.  Headlights come through the fog.  I stagger into the road.  My hands wave, “stop!”  The whites of a man’s eyes stare through the darkened glass.  “Please stop.”  He slows and I grab for the closed window; it’s cold against my blistering palm.  Why isn’t he stopping?  I bang my hand against his window.  “She’s dying! Help me!”  My palm print, smeared in blood, slips away; he’s speeding up.  I scream. A blue sparks turns to flames; it’s in her hair.  Help me!

            I startled and blinked as a hand tapped my shoulder.

            “Doctor Grainger.  Peter, are you okay?”

            I coughed and fought back the nausea that always comes.  “I’m fine,” I said, not knowing where I was, wondering how long I’d been gone. 

While the characters are products of my imagination, what they go through is real.  This is what I find most-exciting about fiction; we can get to truths about mental illness and human nature and present them in ways that are easily understood by the reader. 

When physicians span this continuum of clinical storytelling, from the medical record and case presentations to narrative and fiction, something has been completed.  It’s taking what we’re taught in our training and in our clinical practice and giving it life.  It’s a practical fusion of the science we learn as medical professionals and the art of being both a doctor and a writer.  Beyond that, pushing clinical material into the realm of fiction offers endless opportunities to gather insight into the wonderful complexity of being human.  For physicians, this is a well-trod path that’s worth the trip.  Our training as doctors starts us on the road; should we choose to follow, it brings us to the whole story, the whole person and the bigger truth.