What Does It Mean To Be A Doctor and a Writer?
Four Physician-Writers on Their Craft
In this roundtable, four doctor-writers—Gavin Francis (Shapeshifters: A Journey Through the Changing Human Body), Sandeep Jauhar (Heart: A History), Paul Seward (Patient Care: Death and Life in the Emergency Room), and Jamie Weisman (We Are Gathered)—discuss their craft, their practices, and what it means to be both.
In what ways does writing help you practice medicine and in what ways do you think it might hurt?
Jamie Weisman: William Faulkner said something to the effect that writing is a discovery process. When I start writing an essay or fiction I am never sure where the story or ideas will go, what will be the most important plot point or turn of phrase, and I think the same is often true for my patients. They have no way of knowing what detail is the key to understanding their disease. When I was a medical student, we were taught to ask open-ended questions. The first example was “What brought you to the clinic today?” (the joke was always that the patient would say, “the bus.”). Those open-ended questions are the same ones that start out an essay. For that matter, the questions posed to us in this Lit Hub piece are designed to be open-ended, and I am genuinely curious to hear my colleagues’ answers. So the short answer for me is that writing reminds me that I have to start somewhere with questioning but that the place I end up might be somewhere else entirely. I would also add that, literature shines a penetrating light on the lives of people I might not otherwise ever know, from Faulkner’s tortured Southerners to Nabokov’s repulsive Humbert Humbert and Toni Morrison’s brave and enduring descendents from slaves.
In terms of how writing might hurt medicine, there’s the obvious answer. Time spent writing or reading for pleasure is time not spent reading journals, seeing patients or volunteering indigent care. My skills as a doctor are in high demand, and if I wanted to participate in an activity that is demanding with little financial rewards, I could absolutely spend more time working for free, teaching or traveling to areas of underserved populations. One thing I love about medicine is that I am always learning. The pace of new discoveries in genetics and biochemistry is dizzying, and I could always read more.
Gavin Francis: Reading and writing helps us explore ways of being human, offers us a glimpse of the lives of others, broadens our circles of awareness. At its best you can say the same of medical practice—it offers privileged opportunities to see into and attempt to understand how other people see and experience the world. I love Osler’s old dictum that “it is much more important to know what sort of patient has a disease than what disease the patient has.” Medicine and literature share a kind of synergy in that way, and so it’s my impression that being a writer can only be beneficial to my work as a physician. It works to deepen engagement with the big questions of life—the ones that my patients are often struggling with themselves.
Paul Seward: Perhaps the greatest help was rest and solace. I find writing to be a solitary sport, a conversation with an invisible imaginary friend. And even when I am writing about medical practice, it is a practice that has been filtered through my thoughts, and my memories, and thereby reconstructed into something more coherent than it is in real life. I met an Episcopal priest once whose hobby was making clocks. He did all kinds, Desktop, Cuckoo clocks, wall clocks; you name it. If it could be encased in wood and ticked, he had probably made one. I asked him what I was about clocks that fascinated him. He said he really had no idea. All he knew was that, after a rough day in the pastor business, he could go upstairs to his workshop and lose all track of time. That’s writing for me.
Gavin Francis: I love the story of the clocks—thank you for that. It’s a seductive idea, that you can lose yourself, and lose track of time, in the construction of devices meant to track it. I don’t feel as if time disappears when I write, but certainly feel as if time writing is not away from medical practice—but reflecting on it, and deepening engagement with it. Refreshing and restoring and nourishing for another day in the clinic. A friend who works as a specialist academic commented: “It’s not such a bad model—to spend a day at the coalface of medicine, seeing patients, and then a day thinking about what you’ve done.” Sadly the time pressures of medicine mean that the division between writing and practising is rarely that balanced.Writing helps me reflect on and make sense of my experiences as a doctor.
Sandeep Jauhar: Writing helps me reflect on and make sense of my experiences as a doctor. When I started writing, I usually wrote about things in the hospital that upset or confused me. Why are we putting a feeding tube into that elderly man when he says that eating—tasting food—is the greatest pleasure in his life? Would it not be better to let him eat, even if it meant he could aspirate the food and die of pneumonia? These are the sorts of conundrums that I wrestled with as a resident and propelled me to start writing. And the reflection encouraged me to practice more deliberately and humanely.
Of course, when you are in the midst of writing, there is a danger that you will view your participation in a patient’s care as part of a narrative that you have constructed. There is a danger that your actions will then become too deliberate, too self-conscious, that they will serve the demands of a story and not a patient. One must always guard against this possibility.
Jamie Weisman: I agree that when I write about medicine it helps me sort out my feelings and my conflicts, but writing fiction is my true literary calling. There’s a lot of medicine in my writing—my readers frequently have to tell me to tone down the doctor-ness or make it more accessible—but then again there’s a lot of illness and death in all writing, no? So I can clearly see how medicine helps me as a fiction writer—it opens a treasure trove of stories—but it is less clear how fiction helps me as a doctor. The trope is it makes me more empathic, but I know many empathic, generous souls who are doctors and read nothing but science.
Do your patients know you are a writer and do any of them read your work or bring it up with you? How do you think that might affect the doctor patient relationship?
Gavin Francis: Quite a substantial number of my patients know I write, and as regards how it affects the relationship, I think we’d need to ask them. I don’t let it affect the way I engage with my patients at all. It can be embarrassing to get to the end of a testing consultation and have a patient pull out a book and ask if you wouldn’t mind signing it.
Jamie Weisman: Most of my patients do not know I am a writer, and I try to keep those two parts of my life separate. My patients are there for my medical knowledge, not my thoughts on art (or politics), but since my first book was a memoir about my own struggles with illness, predating becoming a doctor, some patients read that book and seek me out as a doctor. Sometimes that process leads to a great doctor patient relationship—they understand how confusing illness is and how even for people in medical families diagnoses can be elusive. But it can certainly be awkward since there is a level of honest and self-revelation—in non-fiction and in fiction—that means patients know more about me than they need to. They know I’m not perfect. They know I have thoughts on sex and infidelity and pregnancy that are entirely human but not at all relevant to the doctor patient relationship.
Sandeep Jauhar: Many of my longstanding patients know I write. Some have even brought my books to the office to have them signed. I am happy to engage them, but I try to toggle quickly from a writer-reader relationship to a doctor-patient one.
Jamie Weisman: I’m with Sandeep on this one. I try to make a pretty clear divide, and frankly I don’t have time in my busy clinic to have literary discussions. Not sure what I’d do if one of my patients asked me to their book club.
Maimonides. Keats. Somerset Maugham. William Carlos Williams. Anton Chekhov. There is a long history of writer-doctors. Does any of their work resonate or inspire you and if so, whose work and how?
Gavin Francis: Of the list above the one I come back to again and again is William Carlos Williams: his The Practice is a compact masterclass in conveying the way that medicine offers us practitioners immense opportunities to engage with the wealth and diversity of humanity. Williams knew that being invited into people’s homes, at the extreme moments of their lives, is a privilege and a gift; he felt honored, even restored and liberated, by the clamour and turmoil of a busy clinic. I love Mikhail Bulgakov’s The Master & Margarita too, though there are only hints in it of his medical experience. One of the finest examinations of clinical practice I know was written in collaboration with a family physician, but the words were set down by John Berger—his A Fortunate Man captures the sense that there are many kinds of doctors, and one of the most fruitful ways to approach medicine is to see in it opportunities to witness the breadth of possibility inherent in human life.
Jamie Weisman: I love William Carlos Williams’ doctor stories for their brute honesty—his anxiety and anger and compassion when he has to wrestle with a child to treat her diphtheria is something I think many doctors can relate to. But of all of them Chekhov is my favorite and my inspiration. He rarely wrote directly about medicine, but medicine suffuses his wrting, from the many characters who are doctors or who are suffering from illness, to the inescapable fact that our lives are bracketed, and death comes for the rich and poor, the best and the worst of us. In his stories and plays, while his characters are so often bogged down in relatively minor concerns and gossip, it’s as if they are literally painted on a canvas with their date of death. Doctors are constantly reminded that we have limited time and that the body is fragile. We learn to compartmentalize this knowledge so that it doesn’t cripple us with fear and anxiety, and some of us feel it more acutely than others. When I read Chekhov I feel that the sense of time and frailty is so much a part of his existence and it leads to a depth of compassion I can only dream of and constantly reach for.Doctors are constantly reminded that we have limited time and that the body is fragile… When I read Chekhov I feel that the sense of time and frailty is so much a part of his existence and it leads to a depth of compassion I can only dream of and constantly reach for.
Paul Seward: Do not forget Rabelais—and above all, Conan Doyle. He, more than any of the others, used his practice of medicine very directly in his work, to the point of making the first-person narrator of his stories a practicing physician. On the other hand, the reason his stories are so good is not because they were medically informed—that was just window dressing and tricks—but because of his wonderful ear for character and personality. If he had been a sailor he still would have been a great writer, but then Watson would have wound up as Starbuck, Holmes would have been Ahab with Irene Adler as the White Whale.
Gavin Francis: It’s said Arthur Conan Doyle based Holmes on one of his clinical mentors, the Edinburgh surgeon Joseph Bell, who showed such extraordinary attentiveness to the minor details of each patient’s clothing, expression and bearing, that he could predict their occupation in a glance. That kind of curiosity about humanity—the awareness that details matter—is fundamental both to medicine and to the kind of writing I enjoy. One of my favourite passages in William Carlos Williams’s work is when he spells out how medical work nourished and sustained the passion for humanity that made him write: Was I not interested in man? There the thing was, right in front of me. I could touch it, smell it. It was myself, naked, just as it was, without a lie telling itself to me in its own terms… it was giving me terms, basic terms with which I could spell out matters as profound as I cared to think of.
Sandeep Jauhar: I am well aware of the grand tradition of writing in medicine and have enjoyed many of the doctor-writers mentioned, especially Chekhov. I also enjoy writing that is about doctors. One of my favorite pieces is also John Berger’s A Fortunate Man, about an English country doctor. It is still the best thing I’ve read about general medical practice.
Medicine is often described as an art not a science. In what ways do you find practicing medicine artful and is there a science to the art of writing? For that matter, what is the difference between art and science?
Gavin Francis: I’ve never found the distinction a useful one—for Hippocrates medicine was a techne, a word that meant something closer to what we describe as a craft, a knowhow, or even a technique. I like that medicine doesn’t need to be either—its work is the relief of human suffering, and that intention is carried in the meaning of words like “patient” (meaning “sufferer”) and “physician” (meaning someone who works with, or engages, with nature). To be a physician is to engage yourself with the nature of illness, and the nature of humanity, and that is neither fully an art nor a science. Much of diagnosis is about pattern recognition, and approaches the patient the way that an art critic would approach an artistic work, with highly attuned observation and looking for missteps, or a fray in the weave of a narrative. And the best doctors are those that can figure out how each patient will best receive a diagnosis, and how best to try to manage it—and that is a kind of art. But if you don’t have a grounding in the ways of science—of what’s dependable and verifiable—I don’t think you could work effectively or reliably as a physician.
Paul Seward: Medicine is not a science. Scientific studies can be done on medical patients, but that is not the practice of medicine. For me, medicine is a craft, a skilled trade, even if we do dress it up in a priestly suit. We take the facts and technology which science has discovered, and practice with them over and over again—not to create something new and artful—but rather something that has been perfected by many repetitions. In doing that, we are artisans, not artists. I see writing in much the same way. The artistic part is real, but the more important work is craftsmanship. I start out as an artist—Jackson Pollock specifically—grabbing bunches of words and throwing them at the screen, doing my best to judge nothing and withhold nothing. But then, when I have a big messy mass of inspiration piled on the screen in front of me, then I take out the sandpaper and begin the craft of hours and hours of putting words together smoothly.
Jamie Weisman: I think of science in terms of experiments. You set up the hypothesis, the framework for testing that hypothesis and you create an experiment the results of which should be replicable by any other person with the same ingredients and tools. I’m a dermatologist, though, so I know how far medicine is from that construct. We brag in dermatology that we have the most diseases of any speciality because we can see the disorder with our naked eyes, we can biopsy and describe pathology and we can give the disease a name, but that doesn’t mean we know why the patient has the disease or what it means beyond historical pattern. In most cases of medicine, objective or scientific findings like blood counts and biopsies are only a few pieces of the jigsaw puzzle. The art comes from asking the right questions—of the patient and ourselves—to figure out a few more puzzle pieces, but in the end there are always pieces missing, As far as science in writing, both science and writing require discipline, an open mind and a willingness to fail.
Sandeep Jauhar: Much of medical care is discretionary. Of course there are established protocols but it is not algorithmic. It’s a bit like chess: the openings have been worked out but you can still improvise. This is what I think of when I think about the “art” of medicine. How you talk with your patients, guide them, advocate for them, is up to you. Similarly, writing, unquestionably an art, benefits by obeying certain guidelines. You must make choices, but some choices are better than others. So, as for science, there are standards for good writing, too.
Jamie Weisman: We all seem in agreement about medicine as an art, but I know in the U.S. and the U.K. there’s a strong push towards standardization. The same protocol for stroke, heart attack, leukemia etc, and the zeitgeist in medicine now is that these protocols will lead to better outcomes. Obviously no one would ever want to standardize art, but seeing all of you agreeing that there is so much art to medicine, adaptation to each patient, different lines of questioning, I wonder if this push towards standardization will backfire and lead to worse results, or if we’re overstating how much art there is to our chosen profession.
Did you want to write before you became a physician or was it your experience as a physician that inspired you to start writing?
Paul Seward: I have always been writing, but nothing that anyone read. When I was in high school I wrote bad verse and little short stories. In college my writing was mostly focused on the fine art of writing papers, so that I could get good grades, so that I could get into medical school. Also, I wrote stacks of mediocre poetry, all dedicated to the general topic of not being in the dreams of the women of my dreams. That literary phase ceased when I met my wife. For the rest of the time, I have written unpublishable short stories here and there—all long gone; one unpublishable novel, more poetry, and volumes of philosophic speculation on the nature of consciousness and the Self. I even published a couple of those articles. I doubt that anyone actually read them. My reasons for wanting to be a physician were not so much literary as philosophical and practical: It seemed a good way to learn about what human beings were and then act on that information; and I couldn’t think of anything else I would rather do.
Gavin Francis: My first two books were travel books—the first was a narrative journey through the European Arctic (True North), and the second was an account of living in Antarctica for fourteen months, just a few hundred miles from the South Pole (Empire Antarctica). So writing for me came after writing about travel and exploration. There’s a lovely passage in Salinger’s Seymour: An Introduction where Seymour writes to his brother something along the lines of: you were a reader long before you were a writer—so write the book that you most want to read. That’s what I’ve always tried to do with my books—write them for my own enthusiasm and passion, each are books that, at the time I wrote them, are the ones I’d most want to pick up in a bookstore and read.
Jamie Weisman: Clearly all of us had a love of literature which translated to a desire to put pen to paper before we became doctors. And echoing Chekhov’s famous line that medicine is his wife and writing his mistress, the practicalities of medicine—as a defined career path with financial stability as well as intellectual and emotional rewards—called to all of us. I am not sure when Paul or Gavin decided to become doctors. I grew up in a family of doctors—father and grandfather—and we used to joke that for a certain generation of Jewish kids (boys really), the parents felt you could be anything you want when you grow up, and by that they meant any speciality within medicine. I went off to college to study literature and to write, and I do not think I would have become a doctor if I had not been felled by illness myself—the transition from patient to doctor is the subject of my first book. So my short answer to this is I wanted to be a writer long before I wanted to be a doctor, but I love being a doctor.
Gavin Francis: Thanks for those reflections—there had never been any doctors in my family before I qualified, but as a schoolboy it seemed to me a profession, or rather a trade, that offered so much: and understanding of the human body and its failings, an appreciation of the complexity of anatomy and physiology, a skill that would offer employment anywhere in the world, an opportunity to meet men, women and children from every kind of background and be able to do something very practical to help. And it’s natural for doctors to be storytellers I think—we have to appreciate the salient features of so many other stories every day, and we have to use stories to explain to each patient how we imagine them finding a way through their illness. In her book on Ovid’s Metamorphoses the writer and mythographer Marina Warner said of stories “they offer a way of imagining alternatives, mapping possibilities, exciting hope, warding off danger by forestalling it, casting spells of order on the unknown ahead.” And I’m convinced that at its best, the same can be said of medicine.
Sandeep Jauhar: Growing up, I was very interested in writing and journalism. But my father, a hard-nosed scientist, always viewed writing as an avocation. His favorite saying was “Nonscience is nonsense.” So I went to college and studied physics. It was my experience of a dear friend’s illness that turned me to medicine. By then I was well aware of the great tradition of writing in medicine and hoped to pursue it in some form. My brother jokes that I am the only doctor he knows who went to medical school to become a writer.
Gavin Francis is a physician and the award-winning author of four books, including Adventures in Human Being, Empire Antarctica; and True North. A regular contributor to the London Review of Books, Guardian, and New York Review of Books, Francis lives in Edinburgh, Scotland.
Sandeep Jauhar, MD, PhD, is the director of the Heart Failure Program at Long Island Jewish Medical Center. He is the author of Doctored and Intern and writes regularly for The New York Times. His new book Heart: A History, will be published by FSG on September 18. He lives with his wife and their son and daughter on Long Island.
Paul Seward has been a physician for nearly fifty years, and has spent the majority of those years working in emergency rooms on both coasts. He is a graduate of Stanford University and Harvard Medical School, and did his internship and residency in Pediatrics at UC San Francisco. Seward is an Emeritus member of the American Academy of Pediatrics and the American College of Emergency Physicians. Now retired, he and his wife live in Vermont.
Jamie Weisman is the author of the memoir As I Live and Breathe: Notes of a Patient-Doctor. She runs her own private dermatology practice just outside of Atlanta, Georgia, where she lives with her husband, two daughters, and Great Pyrenees puppy. Her new novel, We Are Gathered, is published by Houghton Mifflin Harcourt.