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The Evolution of the Medical Narrative: an Interview with Dr. Abigail Zuger

Apologies for missing my usual weakly post. Among the things I’ve been working on (when I should have been memorizing interluekins or parts of the thalamus) is the below interview with a visiting profesor at Stanford. It marks the first time I’ve writen up a formal interview. I found Dr. Zuger’s views facinating and whole process wonderfully educational. The dead-tree version of same will come out from H&P, SMS’s med student publication, sometime in the next few months.

From an inner city infectious disease clinic, Dr. Abigail Zuger witnessed the AIDS epidemic arrive and spread through an unwitting New York City. The experience moved her to pick up a pen. Her earlier work culminated in Discover and The New York Times articles, her later in a well-received book entitled Strong Shadows: Scenes from an Inner City AIDS Clinic. Subsequently she became a medical columnist for the Times, where she explored everything from state-of-the-art research to the ravaged healthcare of post-communist Russia. Lately, Dr. Zuger has focused on the recent proliferation of doctors qua writers as a book reviewer for the health page of Science Times. During all of this, she has still found time to practice and teach clinical medicine in New York. Fortunately, Stanford was wise enough to bring her west for a semester as the second Visiting Medical Humanities Fellow in English and Human Biology. Recently I sat down with Dr. Zuger to discuss why so many doctors are writing and what it means about the profession.

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You’ve mentioned that during your training, you put writing aside despite your newspaper experience as an undergraduate and your work with Time-Life Books. You’ve also mentioned that you discourage residents from seeking to publish articles about their patients. What is it about publication that might be dangerous for a developing doctor?

There’s an old quote; I think Alice McDermott said that “A good writer sells out everybody he knows, sooner or later.” And I don’t think writers are out only for themselves, but a good writer will always betray his subject to some extent, because you’re trying to tell a story. You have a plot in your mind. You have a moral. You have something you want to say. And if you’re writing about things that are going on in the hospital, there will be a conflict of interest, particularly because you’re writing about your own patients, particularly because you’re young and impressionable. You will be on the outside looking in; you put yourself on the outside looking in at yourself and at your patients. And when you’re learning to be a doctor, that’s not the best place to be. You have to be in there, with your patients, 100%. So I would say the current vogue of being a writer of being a doctor all at once-and there is something to be said for writing: it’s great for decompressing-but writing for publication is something different all together. There’s writing for yourself, and there’s writing to get published and mold the way the world looks at you and your stories. And that is something I think is better left to a later stage when you are more balanced in what you are doing as a doctor. So you’re not put in such a precarious position of trying to learn medicine and comment on it at the same time. Now that said, I’m sure lots and lots of people will disagree with me. But, speaking for myself, writing just wasn’t a possibility during my training.

So about the increasing number of writer/doctors these days, do you think the all-consuming focus during training might lead so many doctors to write?

I would say probably. But there is also the urge to be creative, which in medicine is becoming increasingly stifled by algorithms and evidence-based medicine. That, in the grossest way, limits the creative aspects of life.

One of your Times articles about the proliferation of MD authors prompted an interesting letter-to-the-editor by a doctor named Catherine Dubeau. She writes, “Unfortunately, the medical narrative is under threat now by the electronic medical record. I have already seen medical students and residents losing the art of following patients’ stories and developing their own ”history” of patients’ complaints as they scroll through pull-down menus, click on check-off boxes and use word processors to copy the same note day after day. It leaves one to wonder whether this generation of trainees will ever produce a [Jerome] Groopman or a[n] [Atul] Gawande to tell us stories in the future.”

Oh they will. Sure they will. It’s just that the narrative value of hospital charts is gone. And the biggest shame I see is not the loss of the medical notes, which were often unremarkable. But the nursing notes usually gave one most of the color of what was going on with a patient every day. Those are almost completely gone in computerized hospitals. It’s dreadful from an artistic point of view, which is that a lot of the color is gone from the chart. And it’s dreadful from a medical point of view because they provided such a human depiction of the patient, and that is just gone. It’s a disaster.

Do you think the appearance of so many writing doctors is in some way related to the appearance of so much new technology in hospitals?

I do think it is related. I think, on one level, it’s a rebellion against the computerized pushbutton algorithms. But there were always doctors writing. A large part of it is that we live in an age of memoirists. Richard Seltzer was one of the first back in the sixties. In his piece called, “The Exact Location of the Soul,” he starts out asking why a surgeon should write when there are too many words already. And there’s a lot to read there. It bears reading about forty times to get to all the layers. But one of the reasons he gives for writing is that medicine can be pretty cut-and-dry unless we reach for something higher.

But you have noted that recently there are more medical narratives in print, Gawande and Groopman and so on. What do you think is the driving force behind that?

I wrote an article about this that never found publication. It was very much in the first person. And in it I explained that as far as I was concerned, doctors were writing so much about medicine because they were trying to apologize. Nowadays, medicine can be a miserable process to take part in. It can be miserable to be a patient, miserable to be a doctor. The whole thing has just spiraled out of control, and sometimes the best way to try to explain that what is going on is really not the doctors’ or the patients’ fault is to write. And I think many of the doctors who are writing are trying to do that, they’re apologizing. I remember interviewing Jerry Groopman and hearing him say that medicine was a broken machine and how you fix it is by writing about it.

That is a fascinating observation about the apology. I think there is a lot of wisdom in it. Do you think that is why so much of medical writing focuses so intensely on the author?

I wouldn’t say it’s only egoism. Most medical writing should never be published; it’s written as a therapeutic tool by whoever is writing it and is very legitimate in that way. And the same is true from the patient’s point of view. There’s much research showing that writing about illness really can alleviate some of the symptoms.

So perhaps there are two species of medical writing, that written for personal therapy and that written for publication. Do you think the two are related?

Yes, the people who can do it very well can do both. A surgeon named Pauline Chen comes to mind as just such an example. Her book, Final Exam, an excellent book, not only got a lot of things off of her chest but connected to a lot of readers. In that way, the book is a kind of phoenix rising from the ashes of burnout.

To go back to medical narratives in the hospital, I recently read a JAMA article by a Dr. Harold Horowitz on the changing roles of attendings. Horowitz notes that when he began as an attending, he was a fount of knowledge for the residents. But now with PubMed and Up-to-date on every resident’s PDA, he rarely provides facts but rather helps residents interpret those facts. What effect do you think that change has had?

It is very true that there is a huge amount of data to find. And in the past everyone was absorbed in finding the data; there wasn’t much worry about what to do with it, because there wasn’t very much of it. But now it’s everywhere, and we have to use it to form out medical narratives wisely.

Well, thank for such an interesting interview. I’ll look forward to seeing more of your writing in the Times.

It was my pleasure.

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With the national debate on healthcare reform gathering steam, the coming years promise to be especially formative. As students and practitioners, we are likely to enter a medical culture in flux. Whereas previous generations inherited a fairly uniform tradition of the medical narrative-through the aforementioned nurse’s notes and a slowly evolving medical culture-we are likely to inherit a plurality of medical narrative traditions. As in all societies, flux creates an opportunity for improvement or loss. That being so, our generation will face the challenge of cultivating the medical narrative despite the increasingly capricious winds of technology and policy.

For the interested, Stanford offers a range of opportunities to study the medical narrative both from the physician’s and the patient’s perspective. These include Dr. Zuger’s Human Biology class “Writing Medicine”, Dr. Shafer’s medical school class “Creative Writing for Medical Students”, and Stanford Cancer Center’s seminar: “Words that Heal: A Writing Workshop for Men and Women Living with Cancer.”