The Writing Doctor
As a doctor who has spent many years stringing sentences together for the fun of it, I have often wondered: How does my lifelong interest in creative writing affect my day job? Doctors, especially internists like me, spend a lot of time writing patient notes — often more time than seeing patients, unfortunately. All those thousands of patients over 20 years of clinical practice have yielded a concordant collection of many thousands of patient notes. Add to that my home habit, which includes the more than 900 entries in this blog and much else, and you have a volume of words that must have made a return impression on the writer. And I have arrived at a theory about it. I have to have something new to write about, after all.
In my estimation, there is a meaningful difference between doctors who are writers and those who are not. Non-writing doctors write patient notes to record their ideas. Writing doctors write to find out what they think. For non-writers, a patient note is a record, a means to document, detail, and describe. For the writer, it is a dynamic tool, a way to outline, evaluate, and expand.
In my practice, the patient note is the way I work out ideas. It is thinking on paper. Writing patient notes is a process, each daily chart entry a development of the previous one. When I start a new note for a patient visit, I review my last note and bring forward most of the previous text. This carryover becomes the bones — the rough draft — for the next note. Then I revise, delete, addend, expand. If I do it well, a series of patient notes isn’t just a medical record; it is a chain of ideas developing over days, weeks, and sometimes over multiple hospital visits. It is a story.
I practiced medicine for many years before I understood how rare it is for me to formulate a medical opinion about a patient until I have written a note. This is why I sometimes freeze when a patient abruptly asks me at the end of an examination, “What is your prognosis?” The truth is, I have no prognosis — not then. I have no definite diagnosis. Those don’t come until I set pen to paper (figuratively — my typical note is written on the computer). Once I have gone through the paces of setting my ideas down, organizing, and revising a note, then I know the prognosis, but not before. This does not seem to be common. Most of my colleagues know what they think and what they will do before they begin writing. They change medications, order labs, and consult specialists first, leaving the note writing for last. Some devise a plan before they have seen the patient, much less written a note.
This difference in approach is rooted in how the doctor regards the patient. Many see the patient as a to-do list, and once all the boxes are checked off, the patient leaves the clinic or the hospital. Medical administrators, who in today’s hospitals do not see patients (and perhaps never have), definitely see cases this way. It can work. Sometimes it works well. But writers see patients as a mystery waiting to be answered, or better yet a character in a story, developing each day, some of the plot twists expected, some not. For writers, writing is a process, not an end. The end comes not when you have filled up the page or checked off all the boxes, but when you give up revising. When you have answered all the questions and allowed all the plot twists to play out. This is a different way of seeking truth, not by compiling data and arriving at a solution, but as a journey that seeks a conclusion, as much moral as scientific.
Words are marks on a page, rough ideas to be edited and revisited, each revision bringing the writer closer to the truth. Serious writers consciously put off conclusions before starting a writing process, because writing is a thought process all in itself, one in which the constant refining of ideas on the page leads to new discoveries. The end doesn’t matter as much as integrity of process. This is why some fiction writers say that when they write a story, the ending will sometimes surprise them. They are not joking. Writing is the process, and if you carry out the process faithfully, the conclusion emerges on its own, without prodding. Or to put it more scientifically, the answer will appear almost on its own when the question is properly posed.
I, like many writers, have had the experience of starting an essay with the intention of arguing one point of view, only to discover during the revision process that the idea was all wrong. At that point, I had to either abandon the project or rewrite everything to argue the opposite conclusion. My computer files are bursting with abandoned essays and stories in which the answer I got was not the one I was looking for. People who aren’t committed writers seldom have this experience. The difference is the approach. A writer begins a piece as a painter begins a landscape — with sketches. After a few sketches, one approach emerges as better than the others, and at that point the painter is ready to begin. For a writer, the experience is the same, except that it occurs through revision. It could be that way for doctors.
This isn’t to say that I do multiple drafts of patient notes. I don’t have that kind of time. But what I can do is set a few of my ideas down and then add and subtract from my analysis each day as a coherent plan emerges. Each day, when I see the patient again, I make revisions. Add new ideas. Remove old ones.
Not every diagnosis or treatment I pursue is the right one. The goal isn’t perfection the first time, it’s finding the right answer in the end. And no, this isn’t experimenting on patients. It is trying your best and not continuing to do the wrong thing out of ego. A good writer has no ego, at least not while he writes. He searches for the right words, the best words, and is unafraid to admit he is wrong when he has to make a change. In writing classes, instructors use a phrase for abandoning writing that doesn’t work: “Cutting your darlings.”
For me, a series of hospital notes is like a dialogue that proceeds to an agreement, rather than a list of unchanging conclusions. Think of it as a discourse on ethics instead of the Ten Commandments. Or a chef tasting the dish and adjusting the seasonings depending on the quality of the ingredients at hand, instead of strictly adhering to a recipe.
This is not to say that one approach is always better than the other, but pronouncements tend to be, by necessity, more spare and inflexible than dialogues. And dialogues are more interesting. A reader can follow a long discussion without tiring, but a set of commandments wears him out very quickly. Try reading a Shakespeare play or watching a political debate for awhile, and then tackle the Constitution, and this becomes abundantly clear. The Constitution may be a great document, but it is still dull bedtime reading.
Interest isn’t the most important thing in a medical record, but interest in a patient is. Patients do better when their doctors are curious and interested. A dynamic, thinking-out-loud medical note keeps my mind engaged with the patient, her problems, and her story. For me to maintain interest in a patient, it helps to write a story first, rather than a collection of cold facts.
