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.

Practicing Medicine Turns One

As I look back on the first year of this blog and reflect on my four years of medical school, I am amazed at how much I have learned and how much
I have seen. All of it has informed what I have written about here on Practicing Medicine. And many of the issues I have raised remain vital to my experience within the hospital.
Medicine forces physicians to ask questions; questions beyond which IV fluids to give or which antibiotic to use. Medicine demands that we ask the same
questions that any student of human history might ask: What makes us human? What is so humorous about human suffering and pain? Why
do we become numb to human forms of sufferingWhat is the process by which we die? And is it dignified?

How should we view the place of the mentally ill in our society
?

I have also made other, perhaps less broad and less grand, attempts at explicating the practice of medicine. My first post explained why I decided to blog and the awkward place
of medical students within the medical field. This piece
discussed the potent smells of the hospital — they are unavoidable and yet we adjust to them. Stepping into the ED for the very first time, I
explained how a trauma code works and the horrors that
trauma patients face. The kidney-failure patient also faces difficulties,
but they are of a chronic nature due to dialysis, a miracle of modern science with its own drawbacks.

I compared
George Orwell’s experiences in a French hospital in the early twentieth century to my own experiences in a hospital in the early twenty-first; yes, there are major differences, but there are also similarities. This is a pragmatic post on how we ought to think about
scientific studies and evidence-based medicine. I have written about depression and schizophrenia. And, in a more recent post that would have
pleased me greatly as a younger reader, I wrote about Sir Arthur Conan Doyle’s eponymous detective, Sherlock Holmes — it turns out his methods are relevant to physicians today.

Over the next year I hope to continue to write about the big questions and bring up others in relation to what I see and do. I also have a few bigger writing projects in the works, which I will mention here on the blog. If you have suggestions or
comments, please feel free to send them my way. My e-mail address and Twitter handle can be found at the right.

What Doctors Can Learn from Sherlock Holmes

I remember reading Sir Arthur Conan Doyle’s Sherlock Holmes detective stories as a child. I tore through each page of each book, relishing Holmes’s crime-fighting abilities and dreaming that I could replicate them. I even would have settled for the opportunity to work alongside Holmes like his loyal ally Dr. Watson, sharing in adventures and assisting the great investigator. Today, when I return to stories like The Sign of the Four, I am just as enthralled and entertained as I was then.

Sherlock Holmes sculpture by John Doubleday,
at Meiringen, Switzerland, near the Reichenbach waterfalls,
where Holmes faces his nemesis Professor Moriarty
in “The Final Problem.”
Image via Shutterstock

Holmes’s power of observation is his most impressive trait. He observes his surroundings more carefully than any of the professionals at Scotland Yard. He
notices the way a man dresses, the way someone walks, different types of ash from pipes, and unique types of handwriting. Holmes succeeds as a detective
using this unmatched faculty. As a budding physician, I am beginning to realize how relevant this ability is to the practice of medicine.

Indeed, Conan Doyle based Holmes off of his teacher in medical school: Dr. Joseph Bell, a professor
of medicine at the University of Edinburgh. The author wrote to Dr. Bell in 1892: “It is most certainly to you that I owe Sherlock Holmes.” Though Conan Doyle never pursued medicine as a
career, he assimilated much from his mentor. He describes his encounter with Dr. Bell in the book Memories and Adventures (1924):

For some reason which I have never understood he singled me out from the drove of students who frequented his wards and made me his outpatient clerk, which
meant that I had to array his outpatients, make simple notes of their cases, and then show them in, one by one, to the large room in which Bell sat in
state surrounded by his dressers and students. Then I had ample chance of studying his methods and of noticing that he often learned more of the patient by
a few quick glances than I had done by my questions.

From Dr. Bell’s perspective, teaching students to use their eyes as well as their textbook knowledge was of paramount importance. Deflecting his former student’s praise, Dr. Bell explained in the Strand Magazine

Dr. Conan Doyle has, by his imaginative genius, made a great deal out of very little, and his warm remembrance of one of his old teachers has coloured the picture. In teaching the treatment of disease and accident, all careful teachers have first to show the student how to recognize accurately the case. The
recognition depends in great measure on the accurate and rapid appreciation of small points in which the diseased differs from the healthy state.
In fact, the student must be taught to observe. To interest him in this kind of work we teachers find it useful to show the student how much a trained use
of the observation can discover in ordinary matters such as the previous history, nationality, and occupation of a patient.

An example of Bell’s acumen tells us much about his prowess as a physician. Conan Doyle recounts the following conversation between Bell and a patient:

“Well, my man, you’ve served in the army.”
“Aye, sir.”
“Not long discharged?”
“No, sir.”
“A Highland regiment?”
“Aye, sir.”
“A non-com. officer?”
“Aye, sir.”
“Stationed at Barbados?”
“Aye, sir.”
“You see, gentlemen,” he would explain, “the man was a respectful man but did not remove his hat. They do not in the army, but he would have learned
civilian ways had he been long discharged. He has an air of authority and he is obviously Scottish. As to Barbados, his complaint is elephantiasis, which
is West Indian and not British.” To his audience of Watsons it all seemed very miraculous until it was explained, and then it became simple enough. It is
no wonder that after the study of such a character I used and amplified his methods when in later life I tried to build up a scientific detective who
solved cases on his own merits and not through the folly of the criminal.

Dr. Bell

further explained his methods in the Strand Magazine:

And the whole trick is much easier than it appears at first. For instance, physiognomy helps you to nationality, accent to district, and, to an educated
ear, almost to county. Nearly every handicraft writes its sign manual on the hands. The scars of the miner differ from those of the quarryman. The
carpenter’s callosities are not those of the mason. The shoemaker and the tailor are quite different.

It is tempting to think of Dr. Bell’s and Sherlock Holmes’s skill as the stuff of history. How many of us handcraft shoes these days? Also, these methods seem useless
in the age of labs and imaging. We can track liver enzymes, look at cells from biopsies, get blood counts, and perform full body scans showing us much of what
we need to see. Nevertheless, to rely on labs and imaging and other recent techniques to dismiss Dr. Bell’s method would be a mistake.

* * *

During an outpatient clinic week, one woman came in complaining of a “racing heartbeat.” The resident and I interviewed her together and asked a series of
questions that most physicians ask a patient during a visit: When did this start? What does it feel like? Do you have any shortness of breath with it? Does
it happen while you’re active or at rest? Does anything make it better or worse? Is there any pain associated with it? Is it constant or does it wax and
wane? Do you have any other symptoms with it? Have you had any sick contacts recently?

From what we gathered, she, her two children, and her husband all had pertussis, or whooping cough (That a whole
family has a disease for which we have a vaccine is distressing — see my post on vaccines here.) She had been coughing hard for months
and was taking Robitussin to mitigate her symptoms. But at random times during the day, she felt
like her heart was racing. She denied an association between the cough and any activity and claimed that she wasn’t taking any medicine other than
Robitussin. None of us could figure out why she was having these symptoms. We ordered an Electrocardiogram (EKG), which demonstrated a fast heart rate but no abnormal rhythms.

As we walked out of the room we noticed an inhaler of albuterol hanging out of the patient’s purse. An inhaler is used by asthmatics
to control wheezing. It is one of the first-line treatments for asthma and it allows patients to breathe in medication, thus making sure the medicine gets
into the lungs. We asked if she was using it. She admitted to taking it seven to eight times per day. Her son had asthma and she used his inhaler to help
with her cough.

Albuterol acts on beta-2 receptors in the lungs. These receptors, when stimulated,
cause relaxation of the muscles that control the airways. In asthmatics, the airways clamp down and cause shortness of breath and wheezing. Albuterol
reverses this effect. Unfortunately, there is minor cross-reactivity between beta-2 receptors and beta-1 receptors. Beta-1 receptors can increase the heart rate and cause cardiac arrhythmias. This particular patient was using the inhaler so often that she was
getting a lot of cross-reactivity and consequently felt like her heart was going to jump out of her chest.

We explained this to her and told her to stop using the inhaler. She left without any prescriptions — an unusual outcome for a clinic visit. In this case,
even though we had taken a thorough history by asking the patient careful questions and getting an EKG, we were flummoxed. Only by observing not just
the patient but her belongings were we able to figure out what was going on.

A doctor’s success depends both on the ability to elicit information from the patient and to watch carefully for signs of unusual behavior or circumstances. Observation is and remains, as it was for Dr. Joseph Bell, integral to the accurate
recognition of a patient’s illness. It requires levels of attentiveness that only the expert observer could describe as “much easier than it appears at first”; while being foundational, it is by no means elementary.