How Doctors Tell Stories: Writing Through the Practice of Medicine

I’ve been lucky enough to intersect with Suzanne Koven in many different places: in the basement of the Brookline Booksmith back in 2014—as two writers chatting about empathy and medicine and personal narrative—or when I came to speak at Harvard Medical School in 2017, spending time with the incredible community of doctors and writers she nurtures there, getting to see first-hand a tiny fraction of all the people she has mentored and supported over the years; and getting to chat about the manuscript she was working on—the manuscript that would become this wonderful book, Letter to a Young Female Physician: Notes from a Medical Life.

But the conversation with Suzanne I remember most vividly was one that happened about six months after Suzanne and I first met, in the fall of 2014. I’d just come back from the ER, where I’d spent the night after collapsing in a movie theater lobby, and I was confused about how to make sense of the various things I’d been told in the hospital: I’d had a burst ovarian cyst, and some kind of infection they were having trouble figuring out. I’d never experienced so much physical pain in my whole life. And though I’d only met her once, I had this strange thought: I’d like to call Suzanne. It had to do with her warmth, her generosity, her candor—the immediate sense of ease I had with her, and the sense of care she radiated, which boggled my mind with particularly sharpened force once I realized how many people must feel this care from her (not to mention her patients!) if I—as a near-stranger—felt it from her so acutely. She helped me think through what was happening to me, make sense of what doctors had told me, and formulate a plan.

This memory has been with me quite strongly while reading her phenomenal essays, which are full of the acuity and generosity that have always felt so palpable in her presence. Her writing is full of humor, candor, by turns (and often simultaneously) beautiful and heartbreaking shards of narrative, about her own life and the lives of her patients and colleagues. She’s also got a killer sense of humor and a fantastic eye for detail. She describes herself at her medical school graduation with a “Boy George haircut shaved to the skull on one side, outsized disc earrings, and billowing two-piece chartreuse ensemble with enormous shoulder pads.”

I love this book because we get to spend time with that woman; and because we get to spend time with the retrospective narrator who looks back at her—and all her subsequent and prior iterations—with such gracious, tender, tenacious clarity. It was such a delight to correspond with Suzanne about the essays in the book, and the life they grew from.

–Leslie Jamison

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Leslie Jamison: I love the ways these essays hold so many aspects of your identity: doctor, daughter, mother, wife, patient, and colleague. We see you as a little girl going to the office of your doctor-father, wanting  “to witness at close range the freedom of men,” and we see you as a panicked mother, riding in an ambulance with your young son after seizures. How did you approach writing about times when various parts of your identity converged or collided?

Suzanne Koven: A friend asked me if I found writing this book therapeutic, which caught me off guard. And yet, writing a memoir, or a memoir-in-essays in this case, is therapeutic in the sense that in shaping a narrative of your own life, making a coherent story from its messy elements, you discover it’s not as incoherent or messy as you thought. The various parts of me turned out to be more aligned than I understood. For example, when my son was sick, the deepest feelings I had were those of a terrified mother. But I was a terrified mother who was also a doctor. So while the roles collided—I couldn’t resist snooping in his medical chart as I sat at his hospital bedside—they weren’t as different or, more accurately, as separable, as I thought they were.

LJ: What did you hope to illuminate by making your personal and professional selves porous in these pages—in a kind of constant conversation?

SK: I love the word “porous” here. When I started my career it was important to me, particularly as a young female physician, to be formal, to hold myself back. I wore a starched white coat, flinched when patients called me by my first name, and revealed little of myself to them. An older colleague often told me that “myself” was the most valuable tool I had as a doctor, but it took me years to have the confidence to loosen up and to bring that self to my patients. This relates to your question about conflicting identities. I’ve come to think that we don’t need to compartmentalize ourselves as much as we think we do. Also, I like spreading the news that doctors are just people.

LJ: You are spreading that news here so eloquently in this book! How did writing about these various aspects of your identity—mother, daughter, doctor—allow you to think about the ways that gender dynamics have inflected your life in medicine? Gender roles, gender scripts, gender prejudice?

SK: When I was a kid I thought all doctors were men and, aside from Bernie the school bus driver and a few other exceptions, all men were doctors. My father was a doctor, as were all the men in the couples my parents socialized with. I was enthralled with a photograph in an old Life magazine of a handsome country doctor on duty in the middle of the night, unshaven. So, in effect, as a cis girl I dreamed of becoming what I could not be. At first, I approached medicine in what I thought of as a “manly” way: I tried to be tough, uncomplaining, unemotional. And yet, I found out pretty quickly that the traits I thought of—again mistakenly—as “womanly,” warmth, empathy, etc. were the best of what I had to offer as a doctor. Adding to the confusion: my non-doctor mother, a housewife who entered law school in her forties, was a more potent role model for me when I was a young physician than my doctor-father.

Reading Janice P. Nimura’s excellent new biography of the Blackwell sisters I learned that 150 years ago female pioneers in medicine struggled with this conundrum: should they aim to be “just like men” (whatever that might mean) or claim that as women they brought distinct qualities to medicine? And even though now, as more women than men enter medical school each year, the old stereotype of the nurse (female) as “carer” and doctor (male) as “doer” is still deeply entrenched. I’d like to think we’ve gotten past this and yet we know from recent research that the behaviors and experiences of female and male physicians do differ on average.

For example, female physicians tend to spend more time with our patients and, in part as a consequence of taking that extra time, earn less money and achieve fewer academic promotions than our male colleagues. Why are we spending more time with our patients when we know that doing so will cost us income and status? Are we more accommodating or more self-sacrificing than male doctors? Or do we take greater pleasure in the bonds that those extra minutes reinforce?

I don’t know the answer and I’m uncomfortable generalizing about these differences even though I’ve read the studies that document them. I do know this: as my career progressed, I felt more and more comfortable bringing traits I’d once deemed “womanly” to my medical work. I’ve aspired to be more open and nurturing. I hasten to add that of course I have many male colleagues who epitomize this ideal.

LJ: How do you think your vocation as a doctor has inflected your craft as a writer? Not just the content of your writing but the form and texture of it? And how has your vocation as a writer—or the constant practices of observation and reflection that make you want to write—shaped the way you practice medicine?

SK: When I first started writing in my forties and started reading like a writer, I was most attracted to what I thought of as “masculine” voices whether or not they were male: Orwell, E.B. White, Didion. Intuitively, I wanted to be as a writer what I hoped I was as a doctor: warm, honest, empathic, calm, funny, and communicative but also strong and very much in control. I came to realize that “masculine” is a misnomer for these qualities in a writer or in a doctor. What I really meant—I now see—is that I wanted to be my best and truest self on the page and in the exam room, knowing I can never fully achieve this in either.

LJ: That’s fascinating—thinking about how both writing and medicine clarified your sense of the self you wanted to be. I’m also curious about how working in medicine changed your relationship to your own body, or your awareness of it? Has it likewise changed the way you see other people’s bodies—your family, your students’, strangers?

SK: Like many people, like many women, I developed early on the idea that my body was malformed. I was sure I had the widest hips, the weirdest hair, and so forth. This fiction, and it is a fiction, is hard to sustain when you have such an intimate view of so many bodies over so many years. Not only an intimate view of bodies, but of people’s self-consciousness about their bodies. It turns out everyone thinks they’re malformed in some way. Also, my work gives me a front row seat to the process of aging. Over the years my patients have helped me expand my once-narrow view of beauty to include scars, wrinkles, flab and other markers of survival.

LJ: Love the idea of reframing these features of the body—which we are conditioned to regard as imperfections—as markers of survival instead. I think your tender attention to the glorious fissures & glitches of our lives and bodies is part of why these essays are so funny! It’s one of the things I love best about them. At one point, describing the role of mnemonics in med school studying (for example, as a way of remembering the confusing carpal bones of the wrist: Scabby Lucy Tried Pissing Hours after Copulating Two Twins), you write: “Perhaps there are new mnemonics, now that the majority of students in American med schools are women? Scabby Lucy’s revenge.” Scabby Lucy’s revenge! Love it. Your humor is always delivering us deeper into the grit and complexity of experience. It’s never a deflection. Can you talk a bit about the role humor has played in your life as a doctor? And the role you see it playing in your voice on the page?

SK: True story: I was voted the funniest girl in my med school class though, as I often point out, the competition wasn’t that stiff. Doctors are a pretty serious lot despite the portrayals of dark humor in movies like M*A*S*H and books like The House of God. Joke-telling was an important part of the culture of my family when I was a child. The first grownup joke I ever heard was actually medical. I must have been about five when my maternal grandmother, who had an excellent sense of humor, told me the one about the man who goes to a psychiatrist because he can’t shake the belief that he’s a dog. The psychiatrist says, “Okay lie here on the couch and tell me about it” (Granny had explained about psychiatrists and couches) and the guy protests: “But I’m not allowed on the couch.” I thought this was hilarious. As a doctor, I often make humorous remarks and tell jokes to patients if I think this will help them feel less anxious. A few years ago, though, I realized that telling jokes involves control, that the joke teller knows what’s coming and the listener doesn’t. Knowing this made me question my own motivation for bringing humor into the exam room, and also made me more receptive to patients telling me jokes. I have a patient in his nineties who always comes to his appointments with a new dirty joke. I can’t help but think that part of the enjoyment he gets from this ritual is that in those moments before he lands the punchline he holds all the cards and our usual roles are reversed.

LJ: One of the things I love most about your writing is the specificity and vitality of your gaze. When you tell us about the blood-splattered scrubs of your childhood friend’s doctor-father, you describe him as “so dashing in his fitted cap, covered in blood, in a hurry, his whole body radiating urgency.” But I also love your reflective precision, and your attention to the sculpted and subjective nature of the stories we tell ourselves about ourselves, as when you realize you must have invented the blood on these scrubs, as your friend’s dad was a “medicine man” (a primary care doctor), not a surgeon. How did your friend’s father encapsulate your early ideal vision of a doctor—what was that ideal? And how has that ideal changed through your own years of medical practice? What do you make of that invented blood? How did you reckon with the subjectivity and instability of memory when writing about the past?

SK: Gathering observations and making a story out of them is not a bad description of what doctors—and writers—do. Doctors are trained to take what patients tell us, what we find by examining their bodies and minds, and what we learn from blood tests, xrays, and so forth and turn all that unwieldy information into a narrative that reveals a correct diagnosis and an effective treatment. One of our patron saints is Sherlock Holmes, who could figure out someone’s occupation, habits, mental state (and potential for murder) by looking at the wear pattern on the sole of his shoe (and, of course, Conan Doyle was a physician). Years before I became a doctor I was an avid observer and theorizer. I was the kind of kid who noticed that my playmate’s parents drank a different brand of coffee than my parents did (Maxwell House vs. Chock Full O’Nuts) and hatched a theory about why this was so.

The theory—that since the neighbor wasn’t Jewish Maxwell House must be a Christian brand and Chock full o’ Nuts a Jewish brand—was foolish, which I think I suspected at the time. And yet, my wrongheaded theory still helped me make sense of my world. In the book I tell of how I recalled my friend’s lean, handsome father coming home spattered with blood and how this image reinforced my idea of the doctor as strong, heroic, male. Decades later I mentioned this incident to my mother and she told me that my friend’s father hadn’t been a surgeon and that this scene I remembered couldn’t have happened. And yet that made it no less true, because the scene I remembered wasn’t about my friend’s dad; it was about me.

LJ: Much of the 2017 essay that inspired this book is about imposter syndrome, about confronting the space between an ideal doctor and one’s imperfect self. What role do gender—and race and class—play in imposter syndrome? And how has your relationship to being an “imposter” shifted as your career has continued?

SK: I write in the book that “shame incorrectly insists on its uniqueness” and this was certainly true for me and my imposter syndrome. I was convinced, when I wrote that essay, that I was the only medical school graduate who’d ever felt she didn’t know enough to be a doctor. I’d heard others claim to feel this, especially in medical school and residency, but I didn’t believe them.  The overwhelming response to the essay assured me that my shame wasn’t unique at all. I received so many messages from young female physicians, but also men, older doctors, and people not in medicine at all, who’d always had a nagging sense that they’d achieved whatever they’d achieved through luck or fluke, not talent and hard work. Many made the point that imposter syndrome is simply internalized bias. Women, people of color, LGBTQ people, immigrants, and others who have been told all their lives that they aren’t quite good enough come to believe the lie.

LJ: That essay went viral after its publication, and has been accessed nearly 300,000 times by readers all around the world. Can you describe some of the most meaningful and/or surprising responses you’ve received to it, and to your writing more broadly?

SK: Even though I tell the writers I mentor that the odd, idiosyncratic thoughts they have that they think no one else could possibly understand are what will likely resonate most with their readers, I’m always pleasantly surprised when my own odd, idiosyncratic thoughts resonate. I also find it surprising when readers tell me they find my stories about my own life helpful to them in their lives, even though I tell mentees that personal writing is an act of generosity, not self-indulgence (a particularly hard sell for healthcare workers who write). Some of the most moving responses I received to the essay on which this book is based were from female physicians working in highly patriarchal societies and from women of color wondering whether they should stay in medicine at all. I wrote in the book about a British medical student I call Rahmiya who dismissed the high praise she’d received for her work with patients and berated herself for the low grade she’d earned on a science test. She told me that after reading my essay she decided that her ability to connect with patients was something she should be proud of after all. This response filled my heart.

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Letter to a Young Female Physician: Notes from a Medical Life by Suzanne Koven is available via W. W. Norton.