Why I, a Physician, Write

“One would never undertake such a thing if one were not driven on by some
demon whom one can neither resist nor understand.”

 – George Orwell, “Why I Write”

I remember my first encounter with great literature. Before bedtime, my
father would read Great Expectations to me, using different voices
for different characters. I remember Pip and Miss Havisham, though I don’t
think I fully understood Miss Havisham’s peremptory and eery commandment
to Pip to love Stella. I remember the stygian scene with the convict in the
graveyard. I also remember reading Sherlock Holmes under my covers, enamored with his brilliance and the game that was afoot. I remember tearing through the Lord
of the Rings
books and the first few books of Robert Jordan’s The Wheel of Time
series. Great stories left a large impression on my childhood. The
thrill of diving deeply into an engrossing world still makes me a bit
giddy. Even when I read books far more socially complex now, books I would
never grasp as a young reader, like Thomas Hardy’s novels, I am reminded of the initial
excitement I once felt discovering new stories.

As a child, these stories didn’t remind me of my own life or people in my
life, they were just thrilling. I fantasized about writing my own stories
one day. I created comic books with different monsters, though my drawing
was appalling. I once sat down to hand-write my own epic fantasy story – I
don’t think I got very far. I suspect, then, that my desire to write and tell stories was present
at a young age. But I lacked the sedulousness to work on my drafts. I would write an essay for school or a story at home and
immediately hand it in or toss it aside, assuming that was the end.

Since then, of course, I have written more and learned more. The process
certainly has not gotten any easier, especially as time spent writing
crowds out time for other things in life like music, friendships, reading,
TV shows, and family. Indeed, the time invested has not been trivial. Just
as an example, I was covering the intensive care unit one night during my
first year of residency and during the few brief quiet moments of the night
I was reading a book about the psychology of the Nazi war criminals

for an essay for the Jewish Review of Books
.

Why do I attempt this seemingly crazy task? It is a question prompted by a recent fellowship
interview, when an interviewer asked me: Why do you write? And
what drives a physician (and there are many physician-writers) to write?

In 1946, George Orwell explored the reasons for his own writing in an essay entitled “Why I Write.” Orwell explains that there are four great motives for writing: egoism,
aesthetic enthusiasm, historical impulse, and political purpose. Writers,
he argues, “desire to seem clever, to be talked about, to be remembered
after death…. It is humbug to pretend that this is not a motive, and a strong
one.” Because of this, serious writers are “vain” and “self-centered.” Of
course, there is an element of solipsism in writing. No writer, physician
or otherwise, writes without anticipating some kind of audience. It does
help give our writing purpose, to know that it affects or influences
others. But such an aspiration is not unique to writers, as Orwell
concedes. All professionals – scientists, artists, politicians, etc. –
desire, to some extent, to be remembered through their research,
art, or deeds. No ambitious citizen can deny that this plays some role,
large or small, in what he or she does. But the entire writing motive is not
necessarily self-aggrandizing: Writers appreciate beauty, “pleasure in the
impact of one sound on another, in the firmness of good prose or the rhythm
of a good story.” An author, no matter what his or her topic, attends to
“aesthetic considerations.” And the content matters, too. Essayists,
novelists, political journalists all “desire to see things as they are, to
find out true facts and store them up for the use of posterity.” In other
words, they aim to portray the world as it is, to draw away the curtains.
And there is also a “political purpose” to this. Though writers do want to see things as they are, they also want to imagine the world as it might be
or “to alter other people’s idea of the kind of society that they should
strive after.” Orwell does not argue that one of these is more important
than the other: “These various impulses must war against one
another,…fluctuate from person to person and from time to time.”

Most of what Orwell says pertains to physician-writers. For some
of them, for instance, politics drives much of their work. Atul
Gawande, a surgeon and public health researcher, is a good example. Gawande’s books, like Being Mortal or The Checklist Manifesto, both agitate in some way for reform of our
medical system. In Being Mortal, he urges us as a society to rethink the way we take care of the elderly and those closest to death
such that we provide them with more independence and choice and less
invasive care. In The Checklist Manifesto, he discusses the
importance of checklists for the safety of patients in a hospital, in
particular during surgeries.

For most physician-writers, however, I suspect that the primary purpose is
to reveal to the reader what the world of medicine is like – a world that contains the kinds of riveting stories that fiction offers.

Physician-writers face unpleasant facts; or, rather, unpleasant aspects of
life. Most of the stories I relate on this blog are tragic in some way – some of this comes out of a frustrating sense of injustice, but a lot of it comes out
of a sense of the inevitability of tragedy and the beauty and rare success
coupled to that struggle. Thomas Hardy

reportedly said
, “The business of the poet and the novelist is to show the sorriness
underlying the grandest things, and the grandeur underlying the sorriest things.” The physician-writer shows the sorriness and grandeur underlying our physical life. In that sense, I write with a historical impulse, “to see things as they
are.” What is medicine really like? What does it mean to be sick and
helpless? What does it mean to be sick and poor? How do physicians react to
all of this?

Perhaps the thrill and romance from childhood stories has faded somewhat, but the hunger for nonfiction as a grounding tool has taken their place.
This blog provides, among other things, a way to impart the great
complexities of medicine and diseases, which are often only understood by
other physicians and the victims of those diseases.

I wish I could write a novel with the same flair for
storytelling and the same talent for diction and the same eloquence as
Dickens or Hardy. That I cannot is unfortunate. But stories about medicine
are powerful and the most I can offer. And I am “driven on
by some demon” to write about them; a purposeful struggle to put to the page these stories that are filled with
meaning, and that might otherwise disappear.

I will never retire this task, whether it’s through this blog or elsewhere. But as my career
advances I ought to give myself space to breathe. I start my
fellowship in neurovascular disease this summer and have an important specialty
board exam this year, both of which require, I think, all of my
intellectual energy. So things will be quiet on this blog for
now, but look for more in the coming year.

on Bleak House

I was recently telling a friend on Twitter who had just read Bleak House that when I first read it and got to the end I thought, “Is it over already?” Bleak House is 900 pages long. Why do I love it so much? This is hard to say.

It’s a book with a deep passion for social reform, and especially cries out against the condition of London’s slums. As Dickens wrote while working on Bleak House,

I have always been convinced that this reform must precede all other Social Reforms; that it must prepare the way for Education, even for Religion; and that, without it, those classes of the people which increase the fastest must become so desperate, and be made so miserable, as to bear within themselves the certain seeds of ruin to the whole community.

But a novel dedicated to such reform is a tricky thing to write, and will, as Dickens knew perfectly well, always be in danger of descending into preachiness or sentimentality. (A danger that Dickens often succumbed to, of course.) Dickens addressed this problem by a truly remarkable formal innovation, the division of the storytelling between two voices. The first narrator, who has no name and doesn’t participate in the story, offers a world-weary, cynical, sometimes embittered voice. Here he is from the book’s first chapter, describing Chancery Court:

On such an afternoon, if ever, the Lord High Chancellor ought to be sitting here — as here he is — with a foggy glory round his head, softly fenced in with crimson cloth and curtains, addressed by a large advocate with great whiskers, a little voice, and an interminable brief, and outwardly directing his contemplation to the lantern in the roof, where he can see nothing but fog. On such an afternoon some score of members of the High Court of Chancery bar ought to be — as here they are — mistily engaged in one of the ten thousand stages of an endless cause, tripping one another up on slippery precedents, groping knee-deep in technicalities, running their goat-hair and horsehair warded heads against walls of words and making a pretence of equity with serious faces, as players might. On such an afternoon the various solicitors in the cause, some two or three of whom have inherited it from their fathers, who made a fortune by it, ought to be — as are they not? — ranged in a line, in a long matted well (but you might look in vain for truth at the bottom of it) between the registrar’s red table and the silk gowns, with bills, cross-bills, answers, rejoinders, injunctions, affidavits, issues, references to masters, masters’ reports, mountains of costly nonsense, piled before them. Well may the court be dim, with wasting candles here and there; well may the fog hang heavy in it, as if it would never get out; well may the stained-glass windows lose their colour and admit no light of day into the place; well may the uninitiated from the streets, who peep in through the glass panes in the door, be deterred from entrance by its owlish aspect and by the drawl, languidly echoing to the roof from the padded dais where the Lord High Chancellor looks into the lantern that has no light in it and where the attendant wigs are all stuck in a fog-bank! This is the Court of Chancery, which has its decaying houses and its blighted lands in every shire, which has its worn-out lunatic in every madhouse and its dead in every churchyard, which has its ruined suitor with his slipshod heels and threadbare dress borrowing and begging through the round of every man’s acquaintance, which gives to monied might the means abundantly of wearying out the right, which so exhausts finances, patience, courage, hope, so overthrows the brain and breaks the heart, that there is not an honourable man among its practitioners who would not give — who does not often give — the warning, “Suffer any wrong that can be done you rather than come here!”

To this voice Dickens offers the strongest possible contrast, the unworldly, innocent, utterly (pathologically?) self-effacing Esther Summerson, who speaks like this:

I have a great deal of difficulty in beginning to write my portion of these pages, for I know I am not clever. I always knew that. I can remember, when I was a very little girl indeed, I used to say to my doll when we were alone together, “Now, Dolly, I am not clever, you know very well, and you must be patient with me, like a dear!” And so she used to sit propped up in a great arm-chair, with her beautiful complexion and rosy lips, staring at me — or not so much at me, I think, as at nothing — while I busily stitched away and told her every one of my secrets.

My dear old doll! I was such a shy little thing that I seldom dared to open my lips, and never dared to open my heart, to anybody else. It almost makes me cry to think what a relief it used to be to me when I came home from school of a day to run upstairs to my room and say, “Oh, you dear faithful Dolly, I knew you would be expecting me!” and then to sit down on the floor, leaning on the elbow of her great chair, and tell her all I had noticed since we parted. I had always rather a noticing way — not a quick way, oh, no! — a silent way of noticing what passed before me and thinking I should like to understand it better. I have not by any means a quick understanding. When I love a person very tenderly indeed, it seems to brighten. But even that may be my vanity.

The truth of the story Dickens wants to tell is found not in either of these voices but between them, or at their intersection. Neither is adequate alone. There’s a kind of implicit dialogue going on throughout the book between these two characters, a contest of outlooks, a fundamental disagreement about how to perceive and interpret the world. I think this is the single most remarkable thing about Bleak House.

Pynchon, literacy, and Dickens

For the print version of my review of Thomas Pynchon's Bleeding Edge I added a sidebar on Pynchon and literacy. Here it is:

None of the major characters in Inherent Vice and Bleeding Edge, and few of the minor ones, read books. References to television, music, consumer brands, and (in Edge) web-sites abound, and those references are sharply observed and often extremely funny. There's a brilliant riff in Inherent Vice on how Charlie the Tuna, in the old StarKist commercials, is complicit in his own exploitation; and an ongoing joke in Bleeding Edge involves Maxine's husband's addiction to a biopic channel, with such memorable films as “The Fatty Arbuckle Story” featuring Leonardo di Caprio, and a dramatization of Mikhail Baryshnikov's life starring Anthony Hopkins. (“Would you look at this. Ol' Hannibal dancin up a storm here.”) But books, whether fictional or nonfictional, highbrow or lowbrow, are almost impossible to find, because they have played no role in shaping the hearts and minds of these characters.Even Heidi, Maxine's academic friend who uses words like “mimesis” and “alexithymic,” is never seen reading and makes no references to books. (It's probably significant also that she studies popular culture: she visits ComicCon—more formally, Comic-Con International, held annually in San Diego since 1970—and observes trends in Halloween costumes.) I can think of only one book mentioned in Bleeding Edge, and not by name: a computer programmer is said to have on his desk a copy of “the camel book"—that is, Larry Wall's Programming Perl (probably the 2nd or 3rd edition). In 2001, when the book's events take place, Perl was still the most widely used scripting language, especially by those who coded the internet, though Python and a brand-new language called Ruby were on the rise. It says something about Pynchon's attention to detail that he gets this right. It says something about his book's themes that the only book referred to is a programming manual.Pynchon writes long, complex, demanding, learned books about people who don't read long, complex, demanding, learned books, and while this could be said of many other writers as well, in Pynchon it has, I think, a particular significance. Most of Pynchon's characters in these recent books—and, I think it is fair to say, in all of his books in one way or another—are caught up in immensely complex semiotic fields. All around them events are happening that seem not just to be but to mean, but the characters lack the key to unlock those mysteries, and as they try to make their way are constantly buffeted by the sounds and images from movies, tv shows, tv commercials, popular songs, brands of clothing, architectural styles, particular makes of automobile … all combining to weave an almost impossibly intricate web of signification. Rare indeed is the Pynchonian character who is not entangled to some degree in this web.By doing what he does in book after book, Pynchon clearly indicates not just that he finds this entanglement problematic in multiple ways—psychologically, socially, politically—but also that the primary means by which the entanglement may be described and diagnosed is that of books—large books comprised of dense and complicated sentences. In Pynchon's fiction we see an immensely bookish mind representing an unbooked world, and its great unspoken message is: Let the non-reader beware.

I have sometimes wondered whether, centuries from now, when the large hand of History has smoothed over differences that seem vitally important to us, readers might see Pynchon and Dickens as pretty much the same kind of writer: makers of big rambling eventful tragicomic books featuring outlandish characters with comical names. The Pynchonian and the Dickensian projects have a great deal in common, and as timegoes on I think it will become more and more clear that there is something truly old-fashioned about Pynchon's career.

Oprah’s Dickens

Hillary Kelly at The New Republic is experiencing considerable agitá about Oprah’s selection of two Dickens novels for her book club:

But what can Oprah really bring to the table with these books? Oprah has said that, together, the novels will “double your reading pleasure.” But is that even true? And do the novels even complement each other? Can you connect Miss Havisham’s treatment of time to Carton’s misuse of his “youthful promise”? Well, don’t ask Oprah herself, as she “shamefully” admits she has “never read Dickens.” . . .

Even more confusingly, Oprah’s comments about Dickens making for cozy reading in front of a winter fire misinterprets the large-scale social realism of his work. It stands to reason that her sentimentalized view of Dickens might stem from A Christmas Carol — probably his most family-friendly read and one of his most frequently recounted tales. But her quaint view of Victoriana, as she’s expressed it, belies an ignorance of Dickens’s authorial intentions. Indeed, both A Tale of Two Cities and Great Expectations are dark and disturbing, with elaborate ventures into the seedy underbelly of London and the bloody streets of Paris. How can we trust a literary guide who, ignorant of the terrain ahead, promises us it will be light and easy? . . .

Indeed, Oprah’s readers have been left in the dark. They must now scramble about to decipher Dickens’s obscure dialectical styling and his long-lost euphemisms. . . .

And so on — at considerable length. Yes, we certainly can’t countenance such a thing — masterpieces of literature being read by naïve people lacking certified professional instruction! Oh, the humanity! What if someone got caught up in Pip’s love for Estella, or Sydney Carton’s noble self-sacrifice, but failed to parse Dickens’s incisive critique of the Victorian social order? Can you imagine the consequences?

Kelly’s core concern is summed up here: “the sad truth is that, with no real guidance, readers cannot grow into lovers of the canon.” Cannot? Actually, that isn’t a sad truth — it’s not a truth at all — though it is quite sad that someone thinks the world’s greatest works of art are so powerless to reach an audience without academic assistance. As a corrective to such dark thoughts she should read another Dickens novel, David Copperfield, especially this passage:

My father had left a small collection of books in a little room upstairs, to which I had access (for it adjoined my own) and which nobody else in our house ever troubled. From that blessed little room, Roderick Random, Peregrine Pickle, Humphrey Clinker, Tom Jones, the Vicar of Wakefield, Don Quixote, Gil Blas, and Robinson Crusoe, came out, a glorious host, to keep me company. They kept alive my fancy, and my hope of something beyond that place and time, — they, and the Arabian Nights, and the Tales of the Genii, — and did me no harm; for whatever harm was in some of them was not there for me; I knew nothing of it. . . . It is curious to me how I could ever have consoled myself under my small troubles (which were great troubles to me), by impersonating my favourite characters in them — as I did — and by putting Mr. and Miss Murdstone into all the bad ones — which I did too. I have been Tom Jones (a child’s Tom Jones, a harmless creature) for a week together. I have sustained my own idea of Roderick Random for a month at a stretch, I verily believe.

“This was my only and my constant comfort,” David concludes. “When I think of it, the picture always rises in my mind, of a summer evening, the boys at play in the churchyard, and I sitting on my bed, reading as if for life.”

Reading as if for life. And with no teachers in sight. A miracle indeed; but one repeated every day. Oprah is giving many, many people an incentive to have experiences like David Copperfield’s, and by my lights that’s not a bad thing.

picture books

David Abrams, new Kindle owner and speculator about the future of reading:

While I might initially object to the distraction of video clips in the middle of fiction narrative, I have to remind myself of how many times I’ve been pulled out of “Bleak House” or “Nicholas Nickleby” by the marvelous illustrations of Hablot Browne (aka “Phiz”). Perhaps video is the new engraving. Given my newfound enjoyment of e-books on the Kindle, I’m more than open to the possibility of reading e-only books. As the world (according to Thomas L. Friedman) continues to flatten, this will inevitably mean staying open to the occasional self-published book. But I’m okay with that. I’ll just continue to apply the same standard I do to those “old-fashioned” books that smell like Grandma’s kitchen: it’s the content that matters, not the means of delivery.

Well, as we have seen in previous posts, the “means of delivery” does matter — more for some books than for others, and not absolutely, but nevertheless: the form of the book counts. Still, I’m interested in this comparison to illustrated Victorian novels. Phiz’s illustrations of Dickens were for many Victorian readers (and are for some modern ones) co-extensive with the novels themselves. Similarly the Pauline Baynes illustrations of the Narnia books, and Quentin Blake’s of Roald Dahl’s stories. I can imagine future readers for whom embedded videos in novels have similar associative power. I wonder if some filmmakers will attach themselves to particular novelists, creating future versions of the Boz/Phiz collaboration.

Dickens’s keen vision

Simon Callow on Michael Slater’s new biography of Dickens:

The book is an incomparable portrait of the writing life of Dickens. Cumulatively, it is profoundly moving, chronicling the constant restless interaction between the life and the work. Slater quotes to immensely touching effect the account by Forster, Dickens’s best friend and first biographer, of a day trip up river, undertaken to furnish him with material for a chapter he needed to write for Great Expectations: “he seemed to have no care, all of that summer day, except to enjoy [his friends’ and family’s] enjoyment and entertain them with his own in the shape of a thousand whims and fancies; but his sleepless observation was at work all the time, and nothing had escaped his keen vision on either side of the river.”
I am enamored of Peter Ackroyd’s account of the novelist’s life — all thousand pages of it — and am grieved to see that it is out of print. But I’m tempted by this new one.