Against 'Medical Story Telling'
The other week my friend was in my room, combing through my bookshelf for something to read while I sat reading on my bed. The two of us, having known each other long enough to abandon all pretenses of that ritual politeness that plagues acquaintances, periodically leaf through each other’s books, trying to gauge what the other has been thinking recently. For us, marginalia and dog-eared pages provide us just enough context to inform ourselves on each others’ lives, even before we start talking. I exited for a moment to handle some errand, and apparently left not enough marginalia in my absence, because when I got back a few minutes later she was standing nervously by my writing desk, and suddenly blurted, “I opened your diary for a moment but then closed it before reading anything because I felt so guilty!” (Which really sounded like one long word, having said it practically in one breath).
I of course forgave her, and we got to talking as usual, but I began to wonder exactly why she felt the need to apologize to me. The answer seemed obvious: she was guilty for having read my stories—meaning, the stories in my journal were personally private. Then, however, I started to think about my practices in the hospital this past year, and how they measured up to my friend’s totally honest and fair mistake. As a full-time medical student and when-I-have-time writer, I often dream that I could spend as much time writing fiction as I do writing medical notes in the hospital. Often, however, and with a dangerously increasing frequency, I find myself doing both at the same time: in the hospital I get reprimanded for taking too long on my notes, having to ornament them with irrelevant dialogue and superfluous detail—this 76-year-old, frail man, with yellowing, stretched-out skin, covering him loosely like one of his many hospital blankets... Too long. Not at all pertinent. Cut it out. And back at my writing desk at home, as hard as I try to block them out, the day’s scenes and stories flood back to me, and the obtuse, cold medical jargon of note writing sneaks its unwelcome head into my every sentence.
Still, as futile as it seems, I make an effort to separate the two, both in my mind and on the paper. And over the past year, as the (slightly censored) saying goes, I have gotten better at not sleeping where I eat—I’ve learned to write like a machine during the day, and like a human at night. But in my pursuit to understand the difference between these different modes of writing, and in my practice of separating the two syntaxes from each other, I’ve found myself confusing the ethics of both. The place of narrative storytelling in the practice of medicine is unshakable. At the center of every hospital room, and at the core of every interaction taking place within it lays a story to be told, simply waiting to be collected. For in bed with each patient lies a lifetime of action and drama that, whether the patient is aware or not, comes ready-made for the page.
The once healthy and capable, now helpless, completely dependent on the care of others—it’s the stuff of legends: the Achilles heel, the tragic comedy, and the epic, all rolled into one. No wonder physician-writers and psychologists have for decades made entire livings selling their patients’ stories to audiences. Patient’s like Bulgakov’s bloody amputees, Freud’s Anna O, Sacks’ Mr. I—these real people capture the minds of readers almost as well as their fictitious counterparts. Maybe even more so, however, as we the reader know that behind each of these pseudonyms lays actual flesh and blood; the knowledge that their suffering has been lifted directly from real life gives us all the more momentum to turn the page. Over the course of a physician’s career one will encounter thousands of such tales; after a while, it only makes sense that we start retelling them for a little gain.
The same can be said for every person walking on earth, however; patients are not somehow special in this regard. Each person carries a unique suffering on his or her shoulders, and each could be made easily into a feature-length film. What patients do have, and what is unique to their particular station, is a certain vulnerability and defenselessness to theft. They are both ready and apt to have their suffering stolen right off their backs. In fact, they are coming to us in order to have it taken, in hopes that it will help them heal. At no other intersection in society does one get to peer so deeply or personally into another’s most intimate life, other than family or spouses. Even they would seldom ask some of questions we doctors feel justifiably entitled to. What are your sexual practices—and with whom? Who would you trust most in your family to execute your will? How is your relationship with your father? Now as a doctor, it is true that these questions may very well be necessary to ask: they may impact our clinical decision-making, drug choices, even prognosis—but often times they simply do not. I’m currently midway through my psychiatry rotation, and so maybe my anxiety about note writing is just medical students’ disease, but so far, most of the questions that I see asked in the hospital don’t impact the patient’s management at all, nor do they ever even masquerade as such. I understand the need for completeness in the realm of diagnostics, but when most of this sensitive information isn’t used for the patient’s diagnosis, nor even their benefit, it makes one start to wonder what it is really being used for.
Lately I feel like its only use is for what I call medical gossip, which is what physicians like to do during group meetings and rounds—the sharing of and commenting on patients’ family, social, and personal situations without explicit intention to use the information for clinical decision-making. A particularly difficult patient in the hospital for chronic kidney disease is brought up at rounds: a “frequent flier,” the attending remarks, “rough home life, mom left when he was thirteen, can’t quit drinking for his life.” The whole room winces—they know the one. The other doctors express their sympathies for the one who’s unlucky enough to have him. “Definitely a tough one,” someone says. And while yes this happens everywhere, clinical settings or otherwise, one would think that doctors would use their power and privilege over patients to protect secrets, not leverage them. Here I’d like to make a distinction between actual story telling and medical gossip. While the former exists for its own sake (Bulgakov, for example, writes dramatized accounts of anonymized patients), the latter exists solely under the pretense of actual clinical care, and is neither anonymous nor dramatized. It’s this type of narration that not only harms the patient for literal reasons, the “tough” patient with a “rough home life” almost certainly receiving worse care than their peers, but for humanistic reasons as well.
E.B. White’s beautiful short story, “The Second Tree from the Corner,” published in The New Yorker in 1947, follows a man named Mr. Trexler over several office visits with a psychiatrist. In a classic depiction of old-school medicine, the psychiatrist blows “[plumes] of smoke toward the rows of medical books” from his pipe, and asks Trexler “what do you want?” Of course this question has nothing to do with Trexler’s chief complaint, and in the end, after Trexler refuses to answer, the psychiatrist decides in a moment of clarity, “There’s nothing the matter with you.” Despite his “reassurance” that Trexler is okay, however, there’s no doubt here that the psychiatrist is asking Trexler questions simply out of personal curiosity, with no actual intent to treat his supposed illness. Later, Trexler wanders on the Upper East Side of Manhattan, remarks how the evening light gives a “high lacquer to the brick and brownstone walls,” and the “street scene a luminous and intoxicating splendor.” He meditates on the psychiatrist’s line of questioning, and finally decides that:
“[He] knew what he wanted, and what, in general, all men wanted; and he was glad, in a way, that it was both inexpressible and unattainable […]. He was satisfied to remember that it was deep, formless, enduring, and impossible of fulfillment […]. Trexler found himself renewed by the remembrance that what he wanted was at once great and microscopic, and that although it borrowed from the nature of large deeds and of youthful love and of old songs and early intimations, it was not any one of these things, and that it had not been isolated or pinned down, and that a man who attempted to define it in the privacy of a doctor’s office would fall flat on his face.”
Trexler was lucky that he was able to rise above the hungry, seeking eyes of his doctor—many much less triumphant victims fall “flat on [their] faces,” as Trexler would have it.
Today, as clinical care becomes increasingly atomized and depersonalized within the world of electronic health records, there has been an effort to revive the humanities within medicine. Columbia University recently opened a masters program for ‘Narrative Medicine.’ More and more medical schools are integrating the art of story telling into their curricula. Even The New Yorker, which seventy-six years ago published E.B. White’s story about a man who feels threatened by his doctor’s efforts to narrativize his life, just recently put out an article titled, “Why Storytelling Is Part of Being a Good Doctor.”
In light of this recent push, we must stay aware of the damage that story telling can inflict upon our patients. The humanities may be part of being a empathetic clinician, but now more than ever should we seek to understand the difference between actual story telling and just plain medical gossip. We must stay vigilant about both what we ask of our patients, as well as what we tell our colleagues.
Although she isn’t a doctor, nor does she wish to be in the slightest, my friend’s apology holds an important lesson for all of us who do. She recognized that her desire to understand me, although completely human, wasn’t fair or ethically just. And as much as she was embarrassed for having almost read my book of stories, so should we be just as diligent in the handling of our patients’.