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On Being an MD-Writer


On teaching creative nonfiction writing to Columbia University medical students...
From this recent essay:

"But why write? I need to demonstrate to them, a rightly skeptical audience, that the narrative method is a valid method in its own right."

"In brief, the world of medicine they face—and will be facing over the half-century of their careers—is a new New World. What they can observe in their day-to-day work truly is ‘news,’ much more than what is Tweeted or Facebooked or flashed in newspaper headlines or on the TV news"

How to Both Doctor and Write

(c) David Hellerstein, MD

How did you get interested in being a doctor and writer?

For me it was hardly a matter of choice. Becoming a doctor was something almost necessary in my family, in which both of my parents were doctors as were my grandfather, great-grandfather and many others. In college, I rebelled against my apparent destiny and became passionate about writing. I left school and began a sort of literary apprenticeship. And yet the life of the writer seemed insufficient, and I decided that I wanted to become a doctor as well. My model was William Carlos Williams, the poet who was also a practicing doctor in New Jersey. Many of my premed friends were also interested in literature, but I found that they almost all stopped writing during the first few years of medical school. I kept writing, though: it was something I had to do.

How did you learn to write?

From reading, reading, reading incessantly from the time I was eight or nine years old. In high school I read the works of Saul Bellow and Gunter Grass and many nineteenth century novels, in college I read the English and American novelists from 1800 to the present, and in medical school I kept reading, mostly short story writers including IB Singer, Isaac Babel, Flannery O'Connor, Frank O'Connor, VS Pritchett, Cynthia Ozick, and others. I was trying to write seriously as well, beginning in college. During college I left school for a year and focused on trying to become a writer. (That is a whole story in itself). Then, after going back to medical school, I was fortunate enough to be admitted to the graduate fiction writing workshop at Stanford, where I met writers such as Alan Gurganus, Tobias Wolff, Vikram Seth, Ron Hansen, and many others.

They were all serious, at times frighteningly so, about their craft. I read their work, and occasionally dared to submit my own works to the writing workshop. There was always the humbling moment when one realized the vast gulf between what one had intended and what one had achieved.

It goes without saying that the most important things I learned from my fellow-writers in California was that rewriting is critical. That and reading one's own work aloud. To take what you had written and then to read it out loud was the best way, as far as I could tell, to find one's own voice. If you couldn't read it aloud, if you couldn't breathe the phrases, then there was something wrong with it. It was repetitive, or boring, or it didn't sound like you. And every writer wants to find his or her voice--that is the beginning of style.

How did you get published?

I kept writing throughout medical school. I wrote stories, novels, essays, and kept a voluminous journal. The experience of attending medical lectures and then beginning to see patients--and at the same time having the wonderful opportunity to reflect on and write about becoming a doctor--was wonderful. To many of my writing colleagues, my medical experiences seemed at times "too real"--and to many of my medical school colleagues, the day to day pressures of learning biochemistry or anatomy may have made literary reflection impossible or seemingly foolish. But to me the hectic life of the hospital and the quiet of the writer's study were synergistic. I began taking materials from my medical school journals and trying to make sense of them--the death of a patient with leukemia, the hospital stay of an immigrant's baby, the exam-room conversations in gynecology clinic. They seemed remarkable to me. I submitted one essay, "A Death in the Glitter Palace," to Harper's, an essay about a patient with Hodgkin's Disease who developed leukemia as a result of her chemotherapy. And the editor there suggested that I try the North American Review, which was known for publishing literary nonfiction.

A miraculous event--the North American Review's editor, Robley Wilson, agreed to publish that essay. Not only that, he asked me to write for his magazine on a regular basis, to contribute a column. By that time I was finishing medical school and had accepted a position as intern at a hospital in New York. I was ecstatic. Arriving in New York, I began writing more articles, and submitted them to other magazines, including Harper's, Esquire, and Ms., and was amazed--I kept getting published.

How did you get an agent?

My agent contacted me on the basis of my first published work, the essay "A Death in the Glitter Palace," which additionally won a prize as best essay in the Pushcart Press anthology of 1980-1981. My agent convinced me that I should not merely write one essay after another but that I should think of trying something larger…perhaps a series of essays for a collection, or a nonfiction book. (In general, even among writers there is a debate about the benefit of having an agent. For magazine work, the economics aren't favorable for agents to even be involved, but once you have a book idea, agents can be helpful in a number of ways, including working with you to structure your book proposal, and figuring out which editors might be most receptive, not to mention negotiating contracts. There are other writers who do it on their own, and perhaps hire a publishing lawyer to help with the book contract. In my own case, having an agent who was actively involved in shaping my work was very helpful).

How did you put your books together?

The first book, Battles of Life and Death, evolved as I went through medical school and residency training. My journal was an invaluable source of material, often containing experiences and impressions which had entirely disappeared from my mind. The intensity of day-to-day experience as a medical student and resident can be paradoxical, in that they may be so intense as to practically preclude their recording. I kept writing, and after a while I had a dozen or more "good" essays. I put them in a logical order, and wrote a brief proposal, and sent them on to my agent.

How did you sell your book to a publisher?

My agent did all the work. The only input I had at this point was that I had also started a novel, and I asked him whether we might do a two-book deal, that is, sell both the essay book and my first novel at once time. Again amazingly enough, this worked: Houghton Mifflin was interested in publishing not only Battles of Life and Death but also Loving Touches, my first novel, a black comedy set in a psychiatric hospital in New York City.

How do you find time to write? When do you write?

As a doctor who has always worked full time, and yet who has been able to publish several books, along with essays, stories, and professional articles, I am often asked that question, and I never have a good answer. Of course it is best for any writer if he or she can find a regular time to write. The people who ask this question with most urgency are fellow physicians, or physicians-in-training, medical students or residents. How could any doctor find a regular time to write? At some phases of my career, I have indeed had regular times to write. On some rotations there is "library time," and who knows if you are reading a medical journal or writing a short story? Other times, there is practically no free time in which one is not exhausted or overwhelmed. And yet, there is always some down time--between cases, waiting for the patient who hasn't shown up, during a particularly dull medical lecture at weekly Grand Rounds. For a doctor, there is often no extended time to write, but there is practically never "no time" to jot some notes. And notes can be the start of an essay or a story, and eventually a book.

One other thing of note is that doctors are fabulously hard workers, and many doctors juggle research, practice, teaching, administration, and writing. Perhaps not creative writing, but some sort of writing nonetheless.

How do you "switch gears" from doctoring to writing?

Many people assume that this is difficult, but to me it is no different than the scientist who is also a classical musician coming home and sitting down at the piano. If you practice enough, so to speak, writing becomes something that you do. Also, in some way, I think a writer is constantly writing, day and night. It is just that there is only so much time in which the computer or IPad is at hand. I often have "written" much of an essay in my mind during a car ride or while listening to the latest scientific update on some medical or psychiatric disorder; only later am I able to put it down on paper.

Look at William Carlos Williams's Autobiography. He was an inspiration to me as a doctor-writer, although there are so many others. He has a great section about this:

"Five minutes, ten minutes, can always be found. I had my typewriter in my office desk. All I needed to do was pull up the leaf to which it was fashioned and I was ready to go. I worked at top speed. If a patient came in at the door while I was in the middle of a sentence, bang would go the machine--I was a physician. When the patient left, up would come the machine. My head developed a technique: something growing inside me demanded reaping. It had to be attended to. Finally, after eleven at night, when the last patient had been put to bed, I could always find the time to bang out ten or twelve pages. In fact, I couldn't rest until I had freed my mind from the obsessions which had been tormenting me all day. Cleansed of that torment, having scribbled, I could rest."

These days, with word-processing programs that keep several documents open at once, this is not so difficult to do, mechanically at least. And of course with IPads, IPhones, Droids, Blackberries and all our other amazing new devices, you can easily adapt them for literary purposes. Instead of IM’ing your friends or emailing your significant other, you can do your writing inconspicuously in the hospital cafeteria or the on-call room. Plus, there’s the Cloud. I love the Cloud -- whether Dropbox or Google Drive or whatever – with its infinite online storage, accessible from anywhere! The Cloud makes it incredibly easy to keep your documents at hand in a way that doesn’t depend on what device you may be typing on.

But I still like the idea of Williams’s typewriter that dropped – bang! -- into the top of his desk! Wouldn’t that be a great retro device to have in your office?

What have you learned about how other MD-writers do it?

Over the years I have met and talked to and sometimes interviewed many doctor-writers. I have interviewed Robert Coles and Lewis Thomas and Oliver Sacks, and talked at length with other doctor writers. We are all very different from each other. Some of us practice medicine, others do research or hospital administration, others are "non-practicing" doctors. Abraham Verghese, Oliver Sacks, Perri Klass, Danielle Ofri, and I are all on medical school faculties. Ethan Canin, on the other hand, worked for a number of years as an ER physician, but as far as I can tell he now devotes himself to writing, and is on the faculty of the University of Iowa’s writing program. One MD writer I know, the physician poet Rafael Campo, is on the Harvard Medical school faculty and has negotiated for a ‘writing day’—every Friday, he devotes himself to poetry. We doctor-writers still tend to work in isolation even more than most writers, who have contacts in English or creative writing departments. Usually a town or hospital has at most one of us.

There is only now just becoming a critical mass of doctor-writers, so that for instance at Columbia College of Physicians and Surgeons, where I hold an appointment, there are half a dozen of us. What we have in common, despite our differences, is a fierce dedication to a dual craft, and an admirable instinct for survival.

What is the importance (if any) of being a doctor-writer?

When I was in medical school, in the late '70s, my writing made me a rather unique creature in medical school class. I knew a few other would-be doctor-writers, and only occasionally met one of these strange zebras, at a conference, or a book-signing. Now, though, there seem to be doctor-writers everywhere. Not only Sacks and Richard Selzer and Robert Coles and the late Lewis Thomas, but Abraham Verghese and Ethan Canin and Perri Klass and a host of others.

There are medical humanities – or Narrative Medicine -- classes in the curricula of many medical schools. There is a growing realization of the value of reflection upon what doctors do. Doctors (and other health care providers, and patients as well) have unique access to new types of experience. The miraculous advances of medicine in the past fifty years have introduced us to new worlds that were never imagined before. New dilemmas and problems and complications emerge at a baffling pace. The doctor, who lives in this world, these worlds, has the opportunity to report back from the frontier, to say what it is that is coming to our lives. This is not an indulgence, in my view, it is not a luxury. I view reflection as a necessity. In order to be a good doctor, I believe it is essential to be able to reflect upon what you do. To be able to imagine what your patients experience, and to think about the larger consequences of your work.

One of the great mistakes American medicine made in the 1960s and 70s was to over-enthusiastically embrace the scientific model of medicine. Science is essential to medicine, but it is not all of medicine, and catastrophes and problems of all sorts have emerged as a result of the too-narrow education of a whole generation of doctors. For instance, major problems in health economics and the distribution of care in this country. For instance, doctors who are cold and seemingly unable to communicate with patients. For instance, doctors who have ignored patient preferences about death and dying, or who are unable to properly treat their patients' serious pain. For instance, researchers who have abused and exploited patients in the course of pursuing medical progress. There is no shortage of examples of such things, and no shortage of topics for literary-minded doctors (and patients) to explore and to write about. And that is why I think we are in for a renaissance of doctor-writers, something that the world has never before seen.

Any other advice?

Literary-minded pre-meds and medical students, and practicing doctors as well, often approach me, confiding their ambitions to write books. How do you get published? I am asked. Should I get an agent? How do I write a book proposal? I try to be polite, but really I think they've got it wrong. And, alas, I believe they never like my answer. But here goes.

I think that the place to start, as much as there is one, is with an observation, a thought or two written into a journal, whether in a notebook or some hard drive, and to continue this or weeks and months and years. And a stack of books closely read, and perhaps a writing group, a circle of disinterested but honest colleagues. And then perhaps a small magazine or newspaper, somewhere.
(Or, perhaps, if you’re aware of its multiple potential risks, you might begin blogging about your experiences -- though I believe that the unfiltered world of blogging may not be the best way to become a writer since there’s no editor looking over your work before publication).

Eventually if you are lucky, you will get a few readers. And then more small appearances. Between the first jotting and the end-product of a book lies an odyssey of the sort described above, a sort of internship or residency in letters. A book is an end-product of an evolution, of the development of a writer; it can't be forced. First become a writer, then the books will come.

Blog postings by David Hellerstein MD about writing