I have been asked a lot lately, owing to the release of my novel Altamont Augie, what writing fiction and being a doctor could possibly have in common? Patients and colleagues seem shocked that the rational, left-brain doctor they have come to know and depend on to deliver technologically complex medical care to patients with kidney failure could produce such a right-brain thing as a novel. Where did this come from? they ask. What does writing a novel have to do with giving medical care?

Well, everything.

Writing fiction and the practice of medicine are paired callings that require remarkably similar skill sets. And the act of performing these two seemingly disparate activities affects me in exactly the same manner.

When I return from a vacation or long weekend and begin making rounds in the dialysis clinic at 7:00 a.m. on a Monday morning, there is a restlessness inside me that is hard to understand, an anxiousness verging on a state of unease—or dis-ease, if you will. Yet nothing has happened to cause such unease—no personal crisis, no professional calamity. Nothing.

This mysterious, discomfiting anxiety reliably and predictably dissolves shortly after greeting the first patient I see. Simply by asking them how they are doing. And I realize my anxiousness is a withdrawal symptom—withdrawal from attending to the needs of another human being. Like an alcoholic needing a drink or an addict needing a fix, I am addicted to patient care, because the act of placing myself in the service of another human being makes me blissful.

Attending to the needs of others gets me outside myself and leaves me feeling selfless—a good thing, as the Marine Corps drill instructor Westbrook tells his young recruits in my novel: “For to be selfless is to be free of one’s self. And dwellin’ on one’s self is the root of the problem, thinkin’ you deserve this or that…Only selflessness will protect you…”

Medicine allows me to achieve a virtuous state of selflessness through the active process of empathy—vicariously experiencing the lives of others, and in so doing, transcending my own selfishness. And better yet, since I have the technical skills to do so, medicine allows me to help preserve the lives of others. Feeding my addiction to selflessness by saving lives—heady stuff, this ministering to the human condition.

And so it is with writing fiction.

It is not possible to limn a complex literary character without becoming, if only for a while, that character. The same neuronal connections that allow me to empathize with patients—the same empathic connections, putatively located in the anterior cingulate cortex and amygdala—are required to create characters in a novel. And if these characters are believable and seem real, readers will experience a stimulation of their empathic connections, and be moved and profoundly affected by the story the characters participate in. This all-important sense of verisimilitude is the lifeblood of fiction, and when achieved, has the potential to influence the lives of others in a positive and lasting way by illuminating the human condition rather than by ministering to it, as the practice of medicine does.

But the intent is no less profound: to alter and improve a human life. And that is why writing fiction places me in the same blissful state that practicing medicine does, making me redivivus and new by achieving selflessness through empathy—in this case for my characters rather than for my patients. Empathy leads to selflessness, a virtue that feels good—a feeling to which I am addicted.

Medicine and fiction, feeding my addiction.

It has been reported that up to 60% of doctors suffer from symptoms of psychological job-exhaustion, or physician burnout, leading to diminished career satisfaction, substance abuse, divorce, quitting the profession, and suicide.

An article in this week’s Journal of the American Medical Association attributes much of this psychosocial carnage to the loss of an “empathic connection” between doctors and their patients (Riess, Helen. Empathy in Medicine—A Neurobiological Perspective. JAMA. 2010; 304(14): 1604-1605).

The author summarizes a number of studies positing that empathy resides in specific areas and structures of the brain, such as the anterior cingulate cortex and amygdala. In one report, 17 experimental subjects viewed images of patients experiencing intense pain; simultaneous magnetic resonance imaging (MRI) of the study subjects’ brains revealed heightened neuronal activity in the purported empathy centers.

It also appears that the amount of empathy one is capable of mustering from these locations—which can be measured by psychotherapy tools like the Empathic Understanding Scale—is not static, and can be modulated up or down by external circumstances. The article describes the phenomenon of “empathy erosion” documented in third-year medical students—caused, perhaps, by a reflexive, self-protecting down-regulation of empathic neural circuits in order to keep the students from being overwhelmed by their exposure to so much pain and suffering.

But too much of this self-protective down-regulation by physicians can give rise to a permanent empathy deficit. They become hardened to human misery, and rupture the vital empathic connection between doctor and patient that is the cornerstone of all medical care. Patients who bond emotionally with their physicians have better outcomes, and physicians who are emotionally engaged with their patients are happier and more satisfied with their jobs—and less likely to suffer from the destructive malady of physician burnout. Dr. Riess, a Harvard psychiatrist, advocates education and the use of certain acquired behavioral skills to help prevent the erosion of physician empathy.

So what does the crippling syndrome of physician burnout have to do with Quasimodo? Regular readers of this blog know the answer lies at the nexus of literature and medical science, in the realm of the discipline known as narrative medicine.

Victor Hugo’s hunch-backed bell-ringer of Notre-Dame Cathedral is one of the most sympathetic characters in all of Western literature. Only someone possessing the heart of one of the gargoyles crouched atop the roof of the Cathedral could remain unmoved by this deformed, grotesque foundling who, at the same time, is the very soul of innocence and purity. We pity him for his deafness—caused by the loudness of the bells that are his greatest love—even as we share the bewitching Esmeralda’s disgust at his desire for her.

The act of identifying deeply with a complex literary character such as Quasimodo cannot help but result in the beneficial stimulation of the brain’s empathy centers that Dr. Riess advocates. Her failure to mention the reading of literary fiction as a time-tested means of increasing empathy is my one criticism of her article.

It is an effortless, natural way of healing hearts and souls one book at a time.