Making the first cut in a surgical patient shares something with writing the first line of an essay, says surgeon and writer Richard A. Selzer, M.D., HS ’61.
“You are making an incision when you sit above a blank page,” says Selzer, the nationally known author of 13 books of essays and short stories, mostly about medicine. “Call it blood and ink,” he says. “That’s the story of my life.”
When he first began writing seriously in the mid-1970s, Selzer recalls, “My colleagues in surgery found it mystifying. They said, ‘What’s the matter with you? Isn’t surgery enough for you?’ ... I was alone.”
No longer: Yale-trained physicians have increasingly combined medicine and writing. Notable among them are National Book Award winner Sherwin B. Nuland, M.D. ’55, HS ’61; memoir writer Dora Calott Wang, M.D. ’90; her classmate, journalist and author Randi Hutter Epstein, M.S., M.D. ’90; poet Dagan Coppock, M.D. ’04; and The New York Times Magazine columnist and author Lisa Sanders, M.D. ’97, HS ’00. They say that their understanding of medicine informs their writing. And except for Epstein, who never intended to practice medicine, they all find that their writing has provided insight into their work as physicians.
The prevalence of great physician-writers suggests an affinity between medicine and writing. Among the best-known practitioners are the Russian short-story writer and playwright Anton Chekhov; the poets John Keats and William Carlos Williams; and Sir Arthur Conan Doyle, who created Sherlock Holmes and his physician sidekick, Dr. Watson. Contemporary physician-writers include Oliver Sacks, M.D.; Jerome Groopman, M.D.; Atul Gawande, M.D.; and Abraham Verghese, M.D., author of the popular novel Cutting for Stone. Khaled Hosseini, M.D., wrote The Kite Runner; Robin Cook, M.D., writes medical thrillers; and the late Michael Crichton, M.D., wrote popular fiction on everything from dinosaurs to marijuana smugglers to extraterrestrial plagues.
Staying sane and the urge to write
Selzer began writing when he was a medical officer in the Army in Korea during the mid-1950s. “In order to keep my sanity,” he says, “at the end of every day, I would write down what happened.” On returning to New Haven to begin his surgery residency, Selzer says, “I completely forgot about this journal. I was busy learning to become a doctor and had no intention of being a writer.”
And then in the mid-1970s, halfway into his 25-year career on the Yale faculty, Selzer again felt the urge to write. “One day the gate to my imagination sprang open,” he says. “It was an awakening, an epiphany. I began to see my life in literary terms. I began writing furiously.” Between 1976 and 1982, he wrote three of his best-known books: Mortal Lessons: Notes on the Art of Surgery; Confessions of a Knife; and Letters to a Young Doctor. His writing, he says, “is unconscious. It just pours out.” When he finds a passage of prose or poetry that strikes him, Selzer says, “I write it down and study it.”
Although Selzer bases his stories on his own experiences, he says, “I give myself all the freedom in the world to make things up. But each story has a grain of truth. I’m not really interested in the facts. I’m interested in the truth, which lies beneath the real. It is the real real that lies beneath the real.”
Selzer describes writing as “the reason for which I was born.” He continues to write, using Yale’s Beinecke Library as an office. His latest book, Diary, was published by Yale University Press last spring.
Finding a second calling
Sherwin Nuland became a surgeon, as he describes it, “quite simply because it’s such great fun.” But when he sat down to write a series of biographies of historically important doctors more than two decades into his career, he found a second calling. Now he is internationally known as a writer and scholar. The biographies became his first book, Doctors: The Biography of Medicine, published in 1988. His best-known book, How We Die: Reflections on Life’s Final Chapter, won a National Book Award in 1994 and was on The New York Times’ best-seller list for eight months. Nuland’s work includes short biographies of Leonardo da Vinci and the 12th-century physician-philosopher Moses Maimonides. Nuland also wrote a memoir, Lost in America: A Journey with My Father, which he says may be his best work.
The surgeon’s schedule presented opportunities for Nuland to write: during delays between cases, usually unexpected, he would retreat to the library and write. “The Medical Historical Library is two football fields away from the operating room,” he says. “I just never wasted any time.” Because few physicians have such gaps in their day, he says, “I couldn’t have done this if I was in pediatrics or internal medicine.”
Nuland says writing informed his life as a surgeon. “I wrote for about six or seven years before beginning to do it full time. There’s no question that writing, as well as the research and contemplation required to do it, gave me a much greater perception of what we call the human condition; helped me to understand the perspective of patients and families; and acquainted me with the uncertainties of medical knowledge and clinical decision making.”
When surgeons and writers make decisions, Nuland says, they draw on everything that’s occurred in their lives up to that moment. But whereas a surgeon in the OR deliberates before making a choice, “In writing, you’re not nearly as aware that you’re making decisions. You’re allowing your unconscious mind to float free.”
At 80, retired from surgery since age 61, Nuland continues to study and write—with time off to luxuriate in the company of visiting grandchildren. He reads aloud each newly written paragraph to make sure that he’s considered the nuance and resonance of each word. “You’ve got to be absolutely meticulous. You’ve got to hit that thing right on the head.”
Nuland also requires himself to be meticulous about facts. “The danger for medical writers is distorting things to make for literary effect.” Over time, he believes, a reader will recognize and resent distortions.
He imagines that reader as “a person very much like myself who has had a different life experience from my own.” Of his own experiences, Nuland values, above all, his 35 years as a surgeon. Although he hasn’t entered the OR for nearly 20 years, he views healing the sick as “the greatest satisfaction of life.”
“To carry a sick person through the burden of illness is a gift to the person who does it.”
“Doctors have not been well”
Dora Calott Wang’s memoir tells the story of an intimate relationship and how a third party damages it: the relationship is the one between doctor and patient, and the interloper is the insurance industry.
A psychiatrist at the University of New Mexico, Wang uses her personal story to describe the changes wrought by for-profit health care. “I thought memoir was a form begging to be applied to the telling of history,” says Wang. Her 2010 book is The Kitchen Shrink: A Psychiatrist’s Reflections on Healing in a Changing World.
“I wasn’t interested in the traditional doctor narrative about the romance of healing the patient, where the doctor is almighty and the patient is vulnerable. I wanted to write a different kind of doctor narrative, because the truth is the medical system and doctors have not been well,” she says. “It’s ridiculous that doctors should go through all this training and have to defer to the decisions of insurance clerks.”
Wang was already interested in writing while in medical school, and the medical school chaplain, Alan C. Mermann, M.D., M.Div. ’79, encouraged her to take a year off to earn a master’s in English at the University of California, Berkeley. Selzer introduced her to the idea of writing at night. To write Kitchen Shrink, she slept from 8 at night until 2 a.m., then worked on the book for six hours before starting her day as a doctor (and mother) at 8 a.m. “There’s this excitement of getting up early and seeing what’s going to come out on the page.”
Wang wrote 40 drafts of the book. “It’s not linear. ... You change one thing, and the whole book changes. It’s like a river: you do something upstream, and everything downstream gets affected.”
Wang sees a correlation between seeking truth as a psychiatrist and seeking it as a writer. “A lot of my work as a psychiatrist is to get patients to see the truth. I think it’s time we tackled the truth of what’s happened to the medical profession. What does it mean that the insurance industry holds the purse strings on medical decisions? After all, our medical system is the moral infrastructure of our country, where life-or-death decisions are made each moment. Like a patient in denial, our nation needs to face the truth. How can anything in this nation be healthy until we’ve healed the medical system?”
Despite her frustrations, Wang says, “I still think we’re in a very privileged position of seeing so much of life and gaining the wisdom from knowing so many lives in intimate detail.”
A career in medical journalism
Randi Hutter Epstein had already been accepted by the Columbia University Graduate School of Journalism when she arrived in New Haven for her medical school interview. She expected to be rebuffed when she told the admissions committee that she did not plan to become a clinician but rather to write about medicine. Instead, she found encouragement. And she got in.
By the end of her second year, however, Epstein had qualms. “I thought if I’m not going to practice, I should drop out of med school.” Robert H. Gifford, M.D., HS ’67, then the associate dean for student affairs, refused to let her leave. “He said, ‘What you gain from being on the wards during third and fourth year will help you with your writing.’ ”
After graduation, Epstein worked as a medical reporter for the Associated Press (AP) in London. “There were glimmers where I thought maybe I could practice and write. But I think my heart was in reporting and investigating, which is so time-consuming and I never thought I’d be able to do it all—have a full-time practice, write reported pieces, and raise my children,” says Epstein, the mother of four children. “I’m incredibly impressed with the doctor-writers who are balancing it all.”
She faced culture shock working for the AP. As a medical student, she says, “I was very used to talking about ‘maybes’ and gray zones.” She quickly discovered that wire service writing is “black and white.” “It scared me at first,” she says, “because nothing is certain.” And although her editors scanned her prose for style, “no one checked my facts. … But I did, relentlessly. My professors continued to be my professors. I learned so much from them while I was at Yale, and then I relied on them when I got my job at the Associated Press. I had a lot of their home numbers, and I’ve woken some of them up, saying, ‘I need a quote, I need your advice; I’m on deadline!’ This was before e-mail.” In addition, she says, “I kept my medical school biostatistics book by my side. There were certain epidemiologists I knew really well.”
Now an independent journalist and author, Epstein contributes to the “Science Times” section of The New York Times and has written for publications including GlobalPost, Psychology Today, and The Washington Post. She finds satisfaction not only in providing information about medical topics but also in creating a sense of community among readers. She remembers in particular a story for the Ladies’ Home Journal in which she wrote about women with autoimmune diseases. Readers told her that they “felt validated, with their fears and worries, when they read about these other women going through the emotional turmoil of living with these chronic diseases.” Her first book, Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank, was published in 2010.
Dedicated to a poem
When Dagan Coppock is working on a poem, it follows him everywhere. Feeling this presence is what Coppock calls being “dedicated to a poem.”
“It moves in and out of your consciousness during the day,” says Coppock, who recently left a primary care practice near Boston to spend two years in Botswana as a preceptor for Beth Israel Deaconness Medical Center training program. “If you don’t write it down, you’ll forget it. I think that poets in the course of living are always on guard for inspiration,” he says. “They are looking for the clues, the god in the gaps, in every moment. If a poet suddenly thinks his love is like a red, red rose, he wants to know why—what’s the connection? A poem is like a bit of detective work to connect the dots between the two apparently disparate aspects of a metaphor.
“A doctor is a detective, too. … A doctor tries to make a diagnosis or sort out some other problem, and a connection can seem just as revelatory or inspirational. Maybe I’m biased, but I think that primary care providers get more chances at such moments.”
Coppock never considered making poetry his career. “I always thought that it was never enough to be only a poet. You have to be a mechanic and a poet, a teacher and a poet, a chef and a poet, a doctor and a poet. ... it doesn’t matter. You have to be something else—something which gives impulse to your writing. Besides, I would have been too lonely being a writer alone.”
Between college and medical school Coppock traveled to Nigeria on a Fulbright grant to write poetry and study the poetry of traditional healers. “When I came to Yale med, I needed a reader, a mentor, someone to help me find a community. Dr. Selzer was that person. With his help, we started a writing group. It kept me sane and healthy and circumspect during medical school.” Coppock co-edited a collection of poetry by medical students and residents titled Body Language: Poems of the Medical Training Experience, published in 2006.
He sends his poems to medical journals rather than literary magazines—his work has appeared in JAMA: The Journal of the American Medical Association and in the Journal of General Internal Medicine. Poetry in medical journals, he believes, validates the connection between medicine and the humanities. Especially as doctors are pressured to do more in less time, he says, “Medicine can become a very automatic field, where we don’t reflect.” Poetry, he says, “forces you to think about things.”
What might be missing from life
In the late 1980s, CBS television producer Lisa Sanders was on the banks of the Nantahala River in North Carolina taping a show on whitewater rafting with health reporter Bob Arnot, M.D. Suddenly Arnot disappeared.
When Sanders spotted him again, Arnot was on his knees beside the churning river, doing CPR. Sanders was surprised by the rush of admiration she felt as he revived a woman who had nearly drowned.
“It was the first time I’d thought about what might be missing from my life,” she says. She’d won an Emmy Award and had worked in news for three major networks, but Sanders left a 12-year television career to study medicine in 1992.
As it turns out, internal medicine has reconnected her with journalism. Since 2002, Sanders has written the “Diagnosis” column for The New York Times Magazine. The column allows her to think about what she finds most compelling about medicine: the complex deliberations that lead to diagnosis. Before studying medicine, she’d imagined diagnosis to be formulaic: plug in facts, find answer.
Each monthly column tells the story of a patient with a constellation of baffling ailments. The story moves from mysterious symptoms to false diagnoses to resolution. Since March, the column has also appeared online (minus the correct diagnosis). The first time the column went online, 1,400 readers contributed guesses in less than two days. That response pleases Sanders: “I want this to be a conversation.”
The column brought her back to television when producer Paul Attanasio asked Sanders to serve as technical advisor for a new medical drama “about an irritating, arrogant, drug-addicted doctor who hates patients and loves diagnosis.” “That’s not going to fly,” she remembers thinking.
It flew: House M.D. has been an international hit on Fox since beginning its run in 2004. Sanders invents medical problems for the show’s characters. And although she also reviews scripts for medical accuracy, she doesn’t mind the liberties that House takes with matters of law: House frequently orders his team to break into patients’ homes to find clues to their ailments. “I think it’s a very good metaphor for the probing, impertinent questions that doctors ask—for that violation, that intimacy with a stranger, that is part and parcel of going to see a doctor,” says Sanders. That intimacy, she says, “is why that trusting relationship has to be there.”
Sanders often writes before dawn. She enjoys the silence of the house and the absence of inquiries about errant items of clothing and similar matters from her two teenage daughters. Rising early allowed her to write her latest book, Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis, while keeping up with her day job teaching Yale residents and seeing patients at Waterbury Hospital.
Just as seeing patients provides material for Sanders’ writing, writing informs her work as a doctor and reminds her that seemingly routine symptoms sometimes signal something unusual. “We have a limited number of symptoms and a vast spectrum of diseases,” she says. “Writing reminds you every day that there’s something interesting happening. It may remind you that curiosity killed the cat—but satisfaction brought it back.” YM