My Best Idea: Why I Write

As a medical student, I remember having to examine an ER patient and then, with little sleep, present the case to a roomful of other trainees and a chief of services who delighted in grilling us. He wanted the whole story and he wanted it with multiple possible endings.

I presented in the time-honored way: “Mr. Jones is a 42-year-old never-married Caucasian man who presents with three days of sub-sternal chest pain that he describes as, ‘crushing, like something is sitting on me.’ It’s worse with exertion, is relieved with rest, and radiates to his jaw, but not down his arm.”

Now that I’m pursuing the dual careers of novelist and psychiatrist, I’ve come to realize that learning to obtain a history and present a case - in both written and oral fashion - is excellent training for both doctors and writers. Obviously, there’s a difference between what and how we write in a medical record and what’s likely to become a blockbuster novel, but similar skills are required for both.

It’s no accident that so many physicians have become successful authors, from Somerset Maugham and Arthur Conan Doyle to modern best-selling writers such as Robin Cook, Tess Gerritson, and Michael Crichton. Doctors often make natural writers because our profession relies on stories: hearing them, using them, and telling them.

In training, we learn to take a history: “So, what brings you in today?” It’s the simplicity of an open-ended question that invites any response: “I’ve had a cough that won’t go away.” “I got this rash after I came back from Vegas.” “Every time I walk up a flight of stairs I feel heaviness in my chest.”

The answers come with emotion and body language. We observe it all: the pain, the fear, the embarrassment. Our attitude and willingness to listen have a strong bearing on whether our patient will trust us enough to give us the whole truth.

The more interested, relaxed, and nonjudgmental we are, the greater the chance of getting the information we need. We generate hypotheses about the cough, the rash, and the heaviness. We ask more questions: “How long have you had the cough?” “What happened in Vegas?” “Tell me about the feeling in your chest.”

We’re careful not to jump too quickly to a diagnosis, as missteps in the gathering of a history lead to wasted time and bad treatment. A cough could be the common cold, or the only symptom of a malignancy. The rash could be from the detergent used on the hotel’s sheets or a psychosomatic reaction to an extramarital liaison. Is the chest pain indigestion, angina, panic?

Our most important tool is our skill in taking and interpreting a history. Our jobs are all about gathering data, interpreting it, and putting together a story that makes sense.

Basic truths

As I think back through medical school and residency, I can see that I was taught basic truths about the nature of storytelling that have helped me both clinically and as a writer:

• Common things are common; when you hear hooves, don’t think zebras.

• Consider all angles: who, what, when, where, why?

• Don’t jump to conclusions; generate a differential.

• Consider your reader.

Once we’ve fleshed out the story, it’s time to write it down. As medical students and trainees, we learned how to present and write up a case.

I’ve come to view these different approaches to storytelling as points on a continuum. On one end we have the most objective clinical reporting, and on the other, personal narrative and, finally, fiction.

Similar to popular nonfiction and fiction, the medical record is a story that serves multiple purposes and has multiple readers. All must be considered when leaving a note in a medical record. The histories we write lay out the clinical data upon which we arrive at our diagnostic impressions and conclusions. Our notes reflect why we’re prescribing various treatments and whether they’re working. Our charts must meet criteria for “medical necessity” as defined by various payers. We need to remember the Joint Commission reviewer who will scrutinize what we’ve written. We must write clearly so that a colleague covering in the middle of the night will know what’s going on. Should there be a bad clinical outcome, the chart is a legal record where the written story is all that matters.

Just as when writing a novel or nonfiction book, I need to consider my readers whenever I document something in a chart. As someone who teaches clinical documentation, I stress to my students the importance of imagining everyone who could one day read your note standing over your shoulder as you write it: the insurance reviewer, the attorney for a patient wishing to sue you, the hospital risk manager, the patient, the patient’s mother, and your colleagues.

The medical record requires a particular type of storytelling. It must be factual and free from editorializing. Judgment-laden words and phrases to describe patients, such as manipulative, noncompliant, or difficult, should be eliminated. Just stick to what happened. Or as they say in writer’s lingo, “Show, don’t tell.”

Yet even with meticulous attention to the facts, the medical record is highly subjective. When teaching, I’ll give a class of students the data from a single patient and instruct them to write up their formulation and present the case aloud. I’ll hear as many stories as there are students.

From the case presentation or case study we come to the jumping-off point that separates clinical writing from narrative and fiction. For physician-authors, this leap is not far or difficult. Take the following example (from my upcoming nonfiction work, “The Bipolar Disorder Answer Book”) of a standard history of present illness, which is then rewritten as a personal narrative.

Case Presentation:

“Patient is a 48-year-old Caucasian man brought by ambulance to the ER following a near-fatal suicide attempt by carbon monoxide poisoning in the context of multiple recent stresses: job loss, separation from family, and severe financial difficulties. For the past four weeks, patient has experienced worsening symptoms of depression, including diminished sleep with difficulty falling asleep, early-morning awakening and midnight arousal, feelings of worthlessness and hopelessness, and increased thoughts of suicide with a plan to kill himself, which he attempted earlier today. Client was discovered by a neighbor who was concerned by the sound of the car engine in the closed garage.”

Personal Narrative:

It’s so hard to find words. Everything inside me feels dead. I don’t want to write this, or even think. I’d like to go away and be done with everything. I’m so sorry. I’ve screwed up everything. Peg and the kids will be better off without me. I should be looking for a job. John told me the layoff had nothing to do with my performance. Others got laid off, too. I know this, but how do I not take it personally? I feel like a total failure. Like everything I’ve worked for all of these years didn’t matter. You’re with a company for 20 years, and they tell you it’s not personal when you have two weeks to say goodbye and clean out your desk. I can’t sleep. I lay there thinking the same thoughts over and over.

My whole life is unraveling and there’s nothing I can do to stop it. I get up and even the television is too much. I can’t focus. I hear Leno tell a joke, I used to think he was hysterical; it’s not funny, even though I hear the audience laugh. I used to laugh all the time. People would come up to me and tell me what a happy person I must be because I’m always smiling. Every day, every hour I think about the car and how easy it would be to do this. The weird part is that thinking about killing myself doesn’t feel bad, more like a relief. Just be done with it. I think that’s what I’ll do. I’ll do it in the morning.

As physician-writers, once we bridge the gap between clinical presentation and personal narrative, only talent and imagination limit our storytelling ability. My interest as a novelist has been to take psychiatric and forensic topics and explore them in fiction. I picked the mainstream genre of the psychological thriller because I like to read them, they’re commercially viable, and because, as a psychiatrist, I know something about human nature and why we do the things we do - even bad things. A novel is an ideal medium for in-depth exploration of a complex subject.

If you want to write

For the would-be doctor-writer, there aren’t a lot of absolute rules, but there are some helpful hints. Go with your expertise, write what you know, think of your reader, and pay attention to the conventions of your chosen genre. Beyond that, most of the principles of clinical writing continue to apply. Just as you consider the Medicare, managed care and Joint Commission reviewers when writing in a chart, think about who’s going to read your work and give them what they want.

In novels, the first goal is to entertain. My thrillers need to generate tension, suspense, and fear; they must snag the reader at the first page and not let up. After that, I want to educate both the reader and myself about topics I find interesting, confusing, and important. This is where clinical skill and experience can inform fiction.

For instance, my first novel, “The Portrait,” was a thriller that had a hero with a serious mental illness. I wanted to create an insider’s view of what it’s like to have a serious mental illness, to become psychotic, paranoid, and even suicidal. I chose a first-person narrative so that the readers could have this voice inside their heads.

During the time that I was writing my second book, I was also working with troubled teen-agers. “Risk Factor” allowed me to demonstrate in fiction the process by which a child grows up to become a sociopath. More recently, in the wake of the September 11 attacks, Hurricane Katrina, and some personal tragedies, I wove the topics of trauma and post-traumatic stress disorder into “The Cadaver’s Ball.” I wanted to demonstrate through multiple characters how life-threatening events change us, and how some people recover and others are destroyed by the experience.

While my characters are products of my imagination, their experiences are drawn from reality. This is what I find most exciting about fiction: We can get to truths about mental illness and human nature and present them in ways the reader can easily understand.

As physicians, when we span this continuum of clinical storytelling - from the medical record and case presentations to narrative and fiction - we come full circle by taking what we learn in training and in our clinical practices and giving it life. It’s a practical fusion of science and art.

Beyond that, pushing clinical material into the realm of fiction offers endless opportunities to gather insight into the wonderful complexity of being human. For physicians, this is a path that’s worth the trip. Our training as doctors starts us on the road; should we choose to follow, it brings us to the whole story, the whole person, and the bigger truth.

Charles Atkins is a psychiatrist at Waterbury Hospital in Connecticut, a member of the Yale University clinical faculty, and the author of three novels: “The Portrait,” “Risk Factor,” and “The Cadaver’s Ball.” His next novel, “The Prodigy,” will be released this winter and his first nonfiction work, “The Bipolar Disorder Answer Book,” will be out this fall. He can be reached through his Web site, www.charlesatkins.com, or via editor@physicianspractice.com.

This article originally appeared in the July/August 2007 issue of Physicians Practice.