ASSAY: A JOURNAL OF NONFICTION STUDIES
As the Covid-19 pandemic spread in 2020, the literary world responded by providing, crowdsourcing, and aggregating writings about experience of pandemic and quarantine. These include LitHub’s dedicated pandemic page, Suleika Jaouad’s Isolation Journal project, COVID-19-inspired Calls for Submissions and even a Humanities Coronavirus Syllabus developed essentially overnight by English professors functioning at a much high level than myself.
Literature and illness are inextricably linked, and I’m not just simply talking about cultural theorists (Sontag, Foucault) writing about illness, or illness narratives by sick individuals (Acker, Kalanithi, Wurtzel). More emphatically, I’m talking about about creative writing as both a therapeutic and reflective outlet for our #HealthHeroes: doctors, nurses, triage support, EMT’s and the entire constellation of allied health care workers, including residents and interns fulfilling their clinical hours as apotheosized by Grey’s Anatomy and Scrubs.
While the sheer 24/7 scale of the pandemic now precludes most if not all health workers from having the time to belletristically reflect on these times (I have scoured the Internet and found nothing; if you find something please Tweet at me), professors who, like me, have introduced creative writing assignments into the medical classroom can leverage this period to encourage professional healthcare reflection on sickness and disease. As of this writing, the scope of the pandemic remains too large to reflect on in any meaningful way. In an essay published on Pulse Voices, Ibrahim Sablaban, a fourth-year psychiatric resident at Wayne State University and Henry Ford Hospital, describes one of his first identified patients with COVID-19. He writes about her promising response to treatment and the elation that he and the staff experiences as her vital signs returned to normal. However, she quickly relapsed, Ibrahim laments,
But our relief was premature. Within forty-eight hours, the woman suffered a rapid deterioration, then passed away in the hospital ICU. She was one of Michigan’s first fatalities. Throughout the month of March, as COVID-19 cases mounted, the daily routines at the hospital changed. Entrances to the emergency department and parking buildings were locked and monitored. Employees stationed at the hospital entrance screened arriving caregivers and staff for fever and other symptoms. Certain areas were off-limits to all but the primary teams. An atmosphere of fear took root and spread among patients and employees alike. (Pulse Voices)
When this pandemic is over, an entire generation of healthcare workers will have stories to tell, and it’s our job as writers, professors, editors, and proofreaders to help them. One of the best ways to do this is by demonstrating that doctors writing about illness is more common than we may think.
Since the 1980s, the “narrative turn in medicine,” promoted by such scholars as Rita Charon, Arthur Kleinmann, and Jerome Bruner, has become increasingly prominent in medical schools and hospitals. This movement emphasizes that doctors adopt a more person-centered approach that prioritizes collaboration between doctor and patient, as well as a realization that disease is always part of an individual’s life story, and thus has a necessary narrative component.
A narrative perspective, proponents argue, necessarily requires empathy, and for this reason medical schools throughout the country have begun to include literature classes in the early years of training. Creative writing teaches doctor-readers how to see things from different perspectives, and to realize that this act of imaginative empathy is transferable to the examination room, where they learn to treat the patient as a unique person with a particular life story, and not a scanned body with a discrete set of symptoms.
While the integration of literary studies and its ancillary set of techniques—close reading, textual analysis, imagery—with medical programs and courses in both pre-med and medical schools has become de rigeur, to this date the pedagogical model seems stuck on this idea that doctors should simply read, and not write, literature. However, if the foundational argument for this teaching innovation is that reading literature engenders empathy and thus improves doctor-patient communication, why would the same not be true for residents, interns, and pre-med students writing, and not just reading. Can’t we at least presume that writing would have an equivalent, if not perhaps superior, empathy-generation function as reading?
My answer to these questions is a resounding yes. Two years ago, I taught an “Illness Narratives: Creative Writing and the Medical Humanities” class at Lehigh University in Bethlehem, Pennsylvania, also known winningly as “Christmas City.” The class consisted of 27 students: 6 English majors and 21 pre-med or HMS (History of Medicine and Society) majors. Unsure of whether the non-English students would embrace the “creative writing” element in the course title, I created two versions of the syllabus. The former, more conservative one, required readings of medical humanities texts, memoirs, films, and assigned traditional reflective or argumentative papers about the subjects dredged up by these texts and discussed in class, vast and complex issues such as public health, vaccinations, and pharmaceutical regulations. The other syllabus, more attuned to the English students, cut the readings in half in favor of a vast expansion of creative writing assignments and weekly workshops. In other words, Syllabus 1 covered traditional academic terrain with readings and reflective/ argumentative/ position papers, while Syllabus 2 was in essence a creative writing workshop, with the caveat that the subject matter must, at least tangentially, touch on medicine, stigma, disease, dying, grief, mental health, or related issues in the field of HMS.
We spent the first week of the semester discussing which syllabus to follow, in addition to private correspondence between students and myself to ensure that all voices were heard and all opinions considered. The results were, to put it mildly, surprising. One after another, residents, interns, neuroscience majors, bio/chemistry majors, and others devoted to medical careers wrote the same thing: “I want to try my hand at creative writing.” They justified this decision for two main reasons, one being that “I’m sick of writing lab reports and clinical consultation entries,” and the other being “I would love to be able to find a way to reflect on the experiences I’m having instead of just getting through [the medical program] as fast as possible.”
In other words, Syllabus 2 won. (While not having a medical background myself, as in all other creative writing classes I felt it would be beneficial for me to be writing along with the students.) We read canonical texts by Rita Charon, Arthur Frank, and Ann Jurecic to establish a “base” in the theory and practice of narrative medicine, and applied these in our first class discussions and response posts to movies like Wit, Dallas Buyers Club, and Manic, and short stories and poems by canonical authors ranging from Chekhov to Toni Cade Bambara; and, what turned out to be the classes favorite, “illness narratives” such as Paul Kalanithi’s just-then released When Breath Becomes Air, Susannah Cahalan’s Brain on Fire, and Marya Hornbacher’s criminally neglected account of anorexia-bulimia, Wasted.
With this structure and theory in place, the students were enthused and encouraged to try their hands and composing creative writing of their own. Many of these were short stories or creative essay-diaries paired with reflections where they would note 1) if there was a non-fiction analogue to the story (for instance, was it a fictional elaboration of something they witness as a resident or patient?); and 2) also what creative writing techniques, such as dialogue, characterization, symbolism, they had used to fully convey the emotionality of the story. In the next part of this essay, I will employ three case studies, as it were, analyzing stories written by students and the reflections they paired with them. I will then return with final thoughts and conclusions as to how this practice demonstrates the utility of creative writing in the medical and pre-medical classroom.
“In the short story, there is an interaction between the doctors and the patient where it shows the dialogue of a generic conversation between the doctors and patient. It is meant to show the relationship that doctors have with their patients. It also shows how the doctor must be able to put on a smile even though they know that the patient may not even be alive in a few days. This must be very emotionally taxing and it possibly gives an explanation for why doctors do not use the narrative approach when practicing medicine.”
On April 28, 2020, Maya Alexandri, a third-year medical student and EMT, published the first of numerous pieces entitled “A Night on the Frontlines During a Pandemic.” In bewildering, almost sci-fi detail, she describes the almost paradoxical phenomenon of being an EMT, offering frontline support for people in every kind of crisis, during a period of social distancing where the primary default intervention of touch is ruled out as unsafe. However, the author soon begins to value compassion, physical proximity, and engagement without masks (which she says scared patients) over her own safety. Of this decision, which would later result in her becoming exposed to the virus, she reflects:
I had shared a significant exchange with her. I valued that moment of rapport, and I also felt the poignancy of being a stranger in possession of an experience that her loved ones would have treasured. I felt the obligation of vicarious valuation: the duty to treasure that moment of connection with Eugenia, differently than I otherwise would have, out of consideration for people who did not have the opportunity to have it themselves.
In the three examples that follow, I want to show how my students completed similar projects. Writing about experiences from the standpoint of healthcare providers, using the writing process to articulate, if even just to themselves, their grief, fear, confusion, and all-too-often sense of inadequacy over treating the sick and dying. Sometimes they changed the narrative to focus more or patients or families, but ultimately the genesis of these stories came from their training and experience as students or resident interns in the healthcare system. And ultimately, the writing proved cathartic, in Aristotle’s sense, the writing of the words creating a sense of distance and objectivity, a therapeutic stance against feeling overwhelmed and helpless.
In the following section, I do my best to provide a sense of a student’s identity and career ambition while retaining their anonymity. I’ve tried to find a fine balance between summary, paraphrasis, in-line or block quotations to convey the story’s sense and meaning as easily as possible. Finally, I’ve attached what seem to me to be the most apposite and relevant comments by students about their students to provide a sense of the kinds of issues we considered in class discussion and writing workshops.
Tabitha S. was a senior pre-med major with a minor in HMS. Her ambition was to be a surgeon, and in August she will commence her medical school studies at Columbia University. Her father was a doctor himself, an internist, until degenerative arthritis caused him to retire. She plans, therefore, to focus on “small bone surgery” of the toes and hands. In the following piece, she fictionalizes the personal journal she had to keep for her Summer 2016 Internship at Princeton University Hospital.
Taking the form of three “Pre-Health Professional” journal entries documenting the three events that changed the protagonist’s views on medicine and public health, Tabitha’s short story reads like a contemporary epistolary novel or memoir. The first journal entry concerns a surgical intervention in the operating room, which she describes “as a war-room.” The second entry concerns the protagonist’s first confrontation with death, assisting in ER she foreshadows as “so empty and slow it usually means something bad is coming”—and indeed soon a patient from a car accident arrives from the Helipad and is pronounced dead almost immediately. The protagonist writes in her journal, “It was the most horrifying thing I’ve ever seen.” The final entry relates the protagonist’s encounter between two different doctors: an older, brusque one who screams at his assistants and only reads images, and a younger, female doctor who talks to the family and patient, explaining what their options are, and later, over coffee, relating to the protagonist her belief in the power of empathy over simple evidence-based medicine in the operating room.
In her reflection, Tabitha notes a number of changes she made from the real-life events upon which these sequences are based, and in many cases attaches these changes to techniques we had discussed in class about the stories we studies. For instance, regarding the first entry, she explains why she portrayed the OR as she did:
Symbols/Images: The Operating Room. The OR was depicted as a warzone to show how vicious and cut-throat the medical field can be. Often times doctors will compete against each other for personal satisfaction rather than provide great care to the patient. Stuffing the patient full of gauze also shows the reader how patients are often viewed as objects that can be put together without delicate care.
Overall, her reflection focused on using techniques of narrative medicine that increased the understanding of the patient as a person in context, and not simply an array of images and diagnoses, and ways of using dialogue and characterization to portray the priority of empathy that she would need to cultivate as a successful surgeon.
Another student, Grace W., was in the pre-med program with a focus on neuroscience and an ambition to study oncology in medical school. She is currently studying at the University of California-Sacramento. In her very first story, she wrote about a children’s oncology ward similar to one she had interned at in Oakland, CA for many of her undergraduate years. This astounding story, “Pierre’s Birthday Fund,” is told from the point-of-view of a “15 year-old girl who was born with a rare heart condition that forces her to have multiple surgeries at a young age.” The focal incident occurs when she returns as a teenager and meets Pierre, a fellow teenager with terminal cancer. Pierre, whom she stated she based off a fellow student she knew from high school, is eternally optimistic, and is depicted as doing anything he can to do special things at the hospital to make things easier for younger children. Through his persistence, he made the nurses and doctors provide more lavish celebrations for the patients, especially on birthdays, managing to get them Amazon gift cards and video games through the Kickstarter-like fund he’d devised. Ultimately, as the narrator reflects upon her own birthday there, where she was too sick to go out or eat anything special, and was depressed and listless until she heard Pierre shout,
“Hey Emily,” from the hallway. I turned my head to see Pierre and two nurses enter my room. Pierre was holding a tray and the nurses were holding balloons and a small stuffed bear. “Happy Birthday!” he said as he smiled and put the tray on my bedside table. On the tray was a huge block of red Jello. I was going to have some more tests done so I had mentioned to Pierre that I wasn’t allowed to eat cake on my birthday. Apparently, he had asked the nurses what else I could eat and they thought of Jello. It had been a long, disappointing day, but in that moment all I could do was smile. For one hour of my day, Pierre helped me forget about everything else going on so I could celebrate being one year older.
The story ends on a sad/happy note, with Pierre ultimately passing away but the hospital retaining the innovations he had developed. The title then, “Pierre’s Birthday Fund,” becomes a campaign that they continued to use for other patients, including Emily, after his death, both in tribute to him and in realization that the children especially needed to have things to look forward to when spending months in a hospital with cancer or cancer-associated illnesses.
In her reflection, Grace notes that, while Pierre was real, she used a variety of fictional techniques to transpose the student she had known from high school to the character in the hospital ward. Emily, she wrote, was a completely fictional character whose function was to provide an account of Pierre’s doing, which would have been difficult using Pierre’s 1st-person, point-of-view. Further, she wanted Pierre to show how much power the ill have to improve others lives, contra the common conception of them as helpless and solipsistic about their illness. Writing astutely about what she’d accomplished by writing the story in this way, she noted:
In the end, I wanted this narrative to show how one person could make an impact on someone’s life and how a little bit of persistence can change people’s lives. Pierre was diagnosed when he was 16 years-old and passed away when he was 18 years-old, but in that time he impacted hundreds of children’s and family’s lives. His impact on the hospital and the pediatric community was astounding and helped the main character in the narrative gain a new perspective on giving back to the community. So the one place [Emily] hated the hospital because it made her feel weak and vulnerable, turned into a place where she could help others and honor Pierre.
In private conversation, Grace noted how Pierre was among the influences that made her want to be a surgeon, specifically in the field of oncology, and how in writing this story she was reminding herself to always remember the person behind, and before, the disease that doctors would be treating. Like Tabitha, she used the theories of Narrative Medicine and the fictional stratagems of our reading assignments to become better prepared as a medical student and ultimately a surgeon.
Finally, the third story I’d like to annotate for review was written by a student named Gary R. Gary’s father is a surgeon at Mt. Sinai Hospital, and Gary, both as a younger son and later as an intern, came to know the strictures of the hospital exceedingly well. This untitled story relates a fictionalized version of Gary having to tell his mother that scans had revealed that she was suffering from stage 4 peritoneal primary cancer. Gary’s major move here, as we will see, takes a lot from a book we read together that semester, Paul Kalanithi’s best-selling memoir When Breath Becomes Air. This memoir, which recounts (with the help of his widowed wife) the narrative of his death of lung cancer at the age of 37, was incredibly popular in class, and something that Gary had in mind when writing this story.
Following Kalanithi’s decision to foreground family, domestic scenes, over the traditional medical lore where we follow characters through various hospital wards, tests, ICU’s, and hospice units, the story starts with the protagonist in his living room with his family: his wife, his kids, and his sick mother. While they all talk before a fireplace, the doctor silently reviews scans of various patients on his laptop, ultimately coming upon his own mother’s blotted peritoneal scan and diagnosis.
Ensuring the story avoids the traditional medical intervention model, we first see through the doctor’s mind that “looking back at the charts, he knew the conversation that awaited would not be an easy one. Growing up, he had always viewed his mother as tiny, but strong. Determined and unyielding, she effortlessly raised a family of ten kids and maintained close relationships with every single one of them, to this day.” Despite her diagnosis, Gary portrays the mother as remaining vital, preparing her famous Christmas pot roast and playing games with her grandchildren.
Gary writes that the doctor, John, deciding how to approach this as he watches his happy family prepare for the holidays,
was never one for romanticizing disease. He loathed the idea of bending the truth with any of his patients, telling them that their survival chances were higher even the classic anthem of any cancer-awareness group, “We can beat this!” John preferred the facts; his patients knew and respected that. Yet somehow, he could not maintain this type of composure when the patient at hand was the woman who had taught him everything about life. This was the woman whom he adored and respected more than anyone else. He couldn’t bear to think of a world without her.
The story ends beautifully, with John helping his mom and his wife serve dinner, glancing at his lidded laptop on the recliner by the fire, and beginning to say grace for them all.
Gary wrote stridently in his reflection that “ultimately, I wanted to write a piece that detailed the close relationship and love a son felt for his mother. I did not want this to be another cancer story; there are enough of those, as it is.” Instead, the piece explored the family complications and relationships that undergird all illness, situations that are often neglected in clinical lab reports and medical transcriptions that treat patients like objects, and assume doctors to be robots or machines operating in a purely rational world of Science, devoid of human attachment. By moving the story from the OR to the fireside dining room table, Gary achieved what is very difficult: to use cancer not as a focal point of an illness narrative, but rather as a catalyst to think with more passion about family.
As these three pieces show (and I could have selected many more), medical programs are currently neglecting a potentially viable part of their students training. While it is true that over the last decade the tenets of narrative medicine and the introduction of literary classes and book reading groups have been introduced to increase empathy in medical-track students, we have not gone far enough in serving their needs. Self-expression, creativity, re-imagination of a stressful encounter as a piece of fictional writing—all of these modalities of creative writing diversify the range of experiences, perspectives, and situations students can draw from to increase empathy and patient-doctor collaboration in operating rooms, ICU’s, mental hospital wards, and triage units. To finish on a high, this paper has not just demonstrated that creative writing is beneficial for medical students, but that, given the right environment and support system, many of them possess transcendent writing talents, writing that humanizes, engages, and even works to translate the obscurities of medical practice to everyday language and life—like Paul Kalanithi, M.D., Lauren Slater, M.D., Atul Gawande, M.D., and my hero Abraham Vergehese, M.D., they are capable of enriching both our literary discourse as well as the quality of our lives. At the same time, even if these writings are never published they hold value for the writers themselves, as statements of who they are, where they’ve been, and what they stand for. This was true before COVID-19, and will be more true after.
James McAdams’ debut short story collection, Ambushing the Void, was published in May 2020 by Frayed Edge Press. He teaches literature at the University of South Florida, Ringling College of Art+Design, and Keep St. Pete Lit. He is Flash Fiction editor of Barren Magazine. Currently, he’s working on a novel WIP about rehab scams entitled The Florida Shuffle; Or My Summer in Rat Park II. You can find him at jamesmcadams.org and follow him @jamestmcadams on Twitter/Insta.