The day I graduated from medical school, a family friend who’s a nurse handed me a gift-wrapped megapack of Bic pens. “You’ll need these,’’ she explained. “Doctors write a lot.’’
In the 25 years since, keyboards have mostly replaced pens, but what she said has held true. Daily, I write visit notes, progress notes, admission notes, death notes, and letters to patients and colleagues. There are few other professions whose members do so much writing.
And - surely this is no coincidence - is there another profession outside of writing that has produced so many great writers? Rabelais, Keats, Oliver Goldsmith, Thomas Browne, Chekhov, Conan Doyle, Somerset Maugham, Carlo Levi, William Carlos Williams (who wrote poems on prescription pads), and Walker Percy were all physicians. Today, it seems, more doctors are writing than ever.
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All doctors - whether they are published authors or not - share a common narrative heritage: the case history. The case, an arcane and rather stilted recounting of a patient’s symptoms, physical signs, and lab data, has been taught to every first-year medical student for well over a century - and has roots going back at least to ancient Egypt, from where the oldest known written medical histories survive. One such case, written on a papyrus in hieroglyphs, translates roughly: If you examine a man with a head wound and the skull isn’t split open then you should apply meat, grease, honey, and lint every day until he recovers. If you go to the emergency room with a closed head wound today, the treatment will be a bit different but the format of the written record of your case will resemble that of the unfortunate ancient Egyptian’s: identification of the patient followed by a description of his particular problem, and then a proposed plan.
The format of the case history is nearly as rigid as that of the sonnet or villanelle. First comes the “chief complaint’’: A 60-year-old man comes in after one hour of chest pain. Next is “history of the present illness’’: He’d felt well until earlier in the day, when he became short of breath while shoveling snow. Then there’s the “past medical history’’: He’d had hypertension for many years, as well as diabetes and high cholesterol. And, finally, after an accounting of the patient’s lab and X-ray results, comes “assessment and plan’’: The patient was admitted to the coronary care unit where he was found to have had a myocardial infarction.
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Anyone who’s ever taken a creative writing class will see the similarities between this and the structure of many stories: the chief complaint is the exposition, where the main character is introduced. The present illness is the central conflict. The past medical history is the back story. The assessment and plan is the denouement.
The basic premise of the case is that the details of an individual’s experience merit close attention, because they lead the doctor to the appropriate diagnosis and treatment. Medical students learn to be doctors by writing and reciting countless cases. The report assumes that one person’s story matters. In this sense, case histories resemble fiction and, interestingly, the form fully developed during the same period that the novel did, beginning in the 18th century.
Modern case histories have been stripped of much of the personal and psychological detail, drama, and sense of the narrator that usually characterize fiction and were evident in the writing of the great 19th- and early-20th-century clinicians, reaching their apotheosis with Freud, whose narratives are prose masterpieces more likely to be read today by English majors than psychiatric trainees.
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The patient anecdote - really a case - is often the centerpiece of prose by doctors writing today, including two of the most popular: Atul Gawande and Jerome Groopman. Neurologist Oliver Sacks has mined the literary uses of the case especially profitably. Sacks turned to writing when his formal accounts of patients with an unusual form of catatonia met with tepid reception by medical journals. He expanded those cases to include details about the patients’ family lives, digressions into history and philosophy, and explorations of his own feelings. The result was “Awakenings,’’ published in 1973 and now considered a classic of literary nonfiction.
In the last century, as medical technology has evolved, the case history has atrophied. Even in the years since I graduated from medical school, detailed accounts of a patient’s illness have been abbreviated - and why not? If you can order an MRI that gives the diagnosis the night the patient is admitted to the hospital, then why belabor the story? And if you can “cut and paste’’ the patient’s medical history from electronic records, then why knock yourself out composing your own?
The loss is not only of richer prose, but also a diminution of one of the doctor’s main vehicles of empathy. Doctors speak of “taking’’ a patient’s history, and “presenting’’ it to colleagues. The story becomes a commodity. We appropriate it; we write it down, interpret it, repeat it. It becomes, in part at least, ours. This may sound paternalistic, and it is - if you look at your own medical chart you’ll be maddened to see how doctors never quite get your account of your experience right. And there is now, consequently, a corrective trend toward patients and doctors writing the medical record collaboratively, online.
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But the taking and recording of a history is also a way for the doctor to internalize the patient’s experience, to fully understand it, to feel it. And one can’t help but believe that the staccato writing with which we now fill medical records gives physicians fewer opportunities to fully engage our patients than the more leisurely clinical notes of our forebears did.
Perhaps so many doctors are writing literature today as an antidote to our increasingly rushed and technological medical practice. There’s less time or incentive to include, in the modern case history, vivid descriptions of a patient’s appearance, details about his occupation and family life, or musings about what might ail him, than there were 100 years ago.When Oliver Sacks showed his friend, W.H. Auden, film clips of the stiff and mute patients about whom he wrote in “Awakenings,’’ he asked the poet “What do you think they lack?’’ “Music,’’ Auden replied. Doctors who write literature supply the grace notes missing from today’s medical records, recapturing the music of the human condition.
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Suzanne Koven is a primary care internist at Massachusetts General Hospital and writes the monthly In Practice column for the Globe. She can be reached at inpracticemd@ gmail.com and her website is www.suzannekovenmd.com.