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.

What does a report on cancer survival rates in the United States have in common with civil unrest in Syria? The withering of fear.

Fear of cancer in the national psyche began to wither in July of 1985, with an essay entitled “Seasons of Survival: Reflections of a Physician with Cancer.” [Mullan, Fitzhugh, M.D. New England Journal of Medicine 313, No. 4 (July 25, 1985): 270-273.] Fear of tyranny in the Middle East—in Syria no less than in occupied Iraq—began to wither on April 9, 2003, when a U. S. Marine armored vehicle toppled the imposing statue of Saddam Hussein in Baghdad’s Firdos Square.

From each of these seemingly unrelated historical inflection points have come a flowering of human potential.

The CDC reported in the March 11 issue of the Morbidity and Mortality Weekly Reporthttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm6009a1.htm?s_cid=mm6009a1_w—that the five year cancer survival rate in America is now up to 66%, the highest in the world, confirming empirically what Dr. Mullan passionately asserted two decades before: that it was time to begin speaking of cancer survivors rather than cancer victims. By believing it could be so, the tenacious striving of medical science eventually made it so.

The eidetic image of Saddam Hussein’s massive totem falling in central Baghdad is an equally powerful symbol of the dynamism of human belief, indelibly burning into the brains of millions of oppressed people throughout the Middle East the notion that if Iraq could be free of Saddam, they could all be free. In Tunisia and Egypt and maybe Libya and even in the police state of Syria—and yes, one day Iran, too. Like cancer survival rates—climbing slowly but inexorably, decade by decade—so will the number of countries in the Middle East no longer under the yoke of authoritarian regimes rise too, painfully but relentlessly.

Yet neither of these vital struggles—the quest to overcome cancer and the quest to overcome tyranny—would ever have been joined without the necessary withering of fear. For fear suffocates hope, and it is hope that gives rise to noble deed. Only when fear withers can hope and nobility of deed germinate and take root, to finally grow into the stout trees of human health and liberty.

Remarkably, a single work of literature anticipated—as great art often does anticipate—each of these still-chrysalid human triumphs, the (partial) cure of cancer and the incipient bloom of liberty amongst the darkest of tyrannies: The Cancer Ward, by Aleksandr Solzhenitsyn. First published in 1967, the book was banned in the former Soviet Union for its symbolic contumely of Soviet totalitarianism. Though famous as a metaphor for the ravages of tyranny, it is also—all 616 pages of it—a poignant and courageous narrative on the ravages of cancer in the mid-twentieth century.

The action occurs in a hospital ward—Ward 13— dedicated to the care of cancer victims in Central Asia in 1955. The patients, who come from all strata of Soviet society, have one thing in common: cancer.

The main character is Oleg Kostoglotov, a political exile who is transferred to Ward 13 from a gulag for treatment of a nebulous tumor. (The author had a similar real-life experience: Solzhenitsyn was transferred to a hospital in Tashkent for treatment of testicular cancer after having spent eight years in exile as a political prisoner.) Kostoglotov’s foil in the story is Pavel Rusanov, a Communist Party minion who has an enlarging neck mass and boundless contempt for the other patients—whom Solzhenitsyn democratically introduces chapter-by-chapter—of Ward 13.

But Pavel Nikolayevich was tormented, no less than by the disease itself, by having to enter the clinic as an ordinary patient, just like everyone else.

Rusanov is as much in denial of his neck cancer as he is of the “cancer” of Soviet tyranny.

“We mustn’t talk about death! We mustn’t even remind anyone of it.”

To which Kostoglotov responds, “If we can’t talk about death HERE, where on earth can we?”

Prominent in the story, too, are Zoya, a nurse/medical student to whom Kostoglotov is attracted—“The strongest memory he had…was of her neatly supported breasts which formed, as it were, a little shelf, almost horizontal”—and Vera Gangart, a female physician (all the physicians at Ward 13 are female) whose romance with Kostoglotov is never consummated.

…he began thinking about Vera Gangart…Her smile was kind, not so much her smile as the lips themselves. They were vital, separate lips…made, as all lips are, for kissing, yet they had other more important work to do: to sing of brightness and beauty.

But mostly the patients of Ward 13 think about their cancers. It is everywhere, all around them, in plain sight day after day, week after week, moment after excruciating moment.

There was a stabbing pain under his neck—his tumor, deaf and indifferent, had moved in to shut off the whole world.

But the real cancer in the novel is tyranny. Again, it is Kostoglotov who frames the matter.

“A man dies from a tumor, so how can a country survive with growths like labor camps and exiles?”

The corrosive effect of totalitarianism oozes from the pores of every patient of Ward 13 like the shameful ichor it is. The librarian Shulubin (afflicted with rectal cancer), one of the “good Russians” who cooperated with Stalin’s purges, gives voice to it while speaking to Kostoglotov.

“At least you haven’t had to stoop so low…You people were arrested, but we were herded into meetings to ‘expose’ you. They executed people like you, but they made us stand up and applaud the verdicts…they made us demand the firing squad, demand it!”

A 1968 New York Times book review of The Cancer Ward, entitled “A Diseased Body Politic,” correctly identified the true subject matter of Solzhenitsyn’s story.

http://www.nytimes.com/books/98/03/01/home/solz-cancer.html

But the review couldn’t have been more mistaken in its opinion of the impact the novel would have.

“Clearly Solzhenitsyn believes in the power of literature to exorcise Stalinism. Vain as this hope may be, it has inextricably bound a great writer to his great, and perhaps his only subject.”

Pace New York Times, it was precisely the power of Aleksandr Solzhenitsyn’s literature—One Day in the Life of Ivan Denisovich; The First Circle; The Gulag Archipelago; and The Cancer Ward—that began the decades-long exorcism of Leninism and Stalinism from Russia. The Cancer Ward challenged tyranny in the same way Dr. Fitzhugh Mullan challenged cancer and in the same way that America challenged the brutal authoritarianism of Saddam Hussein’s Iraq: by replacing fear with hope.

May hope thrive, and may health and liberty follow.

What makes a young man or woman want to become a doctor? Ego? Intellectual challenge? The prospect of financial success? Scientific fascination?

The answer for most of us—none of the above—can be found in the 2009 debut novel Cutting for Stone, by fellow physician Abraham Verghese.

It is a novel that is widely loved by readers, if not all critics. The New York Times Sunday Book Review, for instance, concluded its critique of Cutting for Stone on a decided downer: “In Verghese’s second profession, a great surgeon is called an editor. Here’s hoping that in the future the author finds stronger medicine in that line.”http://www.nytimes.com/2009/02/08/books/review/Wagner-t.html?_r=1And the Boston Globe’s traducing review was no kinder: “…not a great work of fiction but an interesting one…Despite its somewhat labored plot and alternately flat and overwrought characterizations, Cutting for Stone is worth  reading…”

http://www.boston.com/ae/books/articles/2009/03/19/a_familys_odyssey_of_love_and_healing/

Most other reviews, however, were glowing, and readers have decisively overruled the above outliers. Many reasons for the book’s appeal have been suggested: Verghese’s engrossing description of Ethiopia, where much of the action occurs; the detailed descriptions of all things medical and of the taxing life of a surgeon (which Verghese is not, by the way—he is an infectious disease expert and professor of medicine at Stanford); the obvious love the author has for medicine; the compassion he holds for his characters.

There is no denying, though, that Verghese qua author found it difficult to detach from being a doctor, and consequently let the physician in him rule the novelist. The price paid is that the book is laden with long, jargon-filled passages that bring its narrative flow to a screeching halt. Yet despite this, it is clear that both Abraham Verghese and his physician-characters in Cutting for Stone became doctors to help people. Which is why the public continues to hold physicians in such high esteem, repeatedly naming “doctor” as the most respected career choice, reserving their deepest contumely for lawyers and politicians. In my opinion, it is on account of its manifestation of human altruism that Cutting for Stone has enjoyed such stunning commercial, if not always critical, success.

Altruism has fascinated mankind for centuries. Altruistic behavior is at first blush inconsistent with Darwinian natural selection, in that it is behavior by an organism that benefits another at its own expense. The great religions of the world use the fact of human altruism as evidence of God’s existence, by equating love of others with love of God: “…thou shalt love thy neighbor as thyself: I am the LORD.” (Leviticus 19:18.)

For unbelievers, the existence of altruistic behavior is a glaring contradiction, an inconvenient conundrum that challenges the very foundation of secular rationalism: evolution. For how could behavior benefitting another to one’s own detriment possibly be explained by evolution theory? But recently, the scientific community—mostly, though not exclusively, atheist—has produced a multitude of studies purporting to show that altruism is purely a neurobiological phenomenon. One of the earliest came out of Duke, and showed that sophisticated MRI scans of the brain revealed relatively greater activation of the brain’s posterior superior temporal sulcus when experimental subjects were watching as compared to playing a computer game. This heightened activity strongly predicted a given subject’s propensity for altruistic behavior. (Nat Neurosci. 2007 Feb;10(2):150-1. Epub 2007 Jan 21.Altruism is associated with an increased neural response to agency. Tankersley D, Stowe CJ, Huettel SA.
Brain Imaging and Analysis Center, Box 3918, Duke University Medical Center, Durham, North Carolina 27710, USA.)

Other researchers found that areas of the brain stimulated by food or sex—fronto-mesolimbic networks—became relatively more active when subjects were asked to think about donating a large sum of money as compared to keeping it for their own use. That is, it made them feel good to be altruistic, thereby explaining Saint Francis of Assisi’s famous observation: “For it is in giving that we receive.”

http://www.pnas.org/content/103/42/15623.full

Predictably, it was only a matter of time before a study appeared to advance the notion that altruism was selected out over the course of human evolution in order to confer a survival advantage. Last October, Dr. Tim Phillips and colleagues studied the responses of identical and non-identical female twin pairs to questions about their own altruism and how desirable they found altruism to be in potential husbands. Results showed a link between human altruism and sexual selection, supporting the theory that altruistic behavior evolved as it became necessary for the earliest human beings to choose mates who would be willing to make the sacrifices required for successful child-rearing. (Tim Phillips, Eamonn Ferguson and Fruhling Rijsdijk. A link between altruism and sexual selection: Genetic influence on altruistic behaviour and mate preference towards it. British Journal of Psychology, 2010; DOI: 10.1348/000712610X493494)

So, is altruism a conscious, moral act of free will, or is it a complex neuronal circuit? I have covered this ground before in a discussion on Cartesian dualism and the mind-body problem: Does human consciousness—the mind—exist separately from the human body? This is the larger issue under which any debate about the origins of altruism must be subsumed.

http://richardbarager.com/near-death-experiences/watching-yourself-die/

Whatever the answer, the attraction of medicine as a calling is born in large part from the altruistic urge to help other human beings. What the proximate cause of this desire is depends on where one believes consciousness resides: in the soul or in the neurochemistry of the brain. It is my personal belief that the mind and soul are not discoverable by scientific method, as they are infinitely intangible and not part of the observable, accessible universe. Serious works of fiction like Cutting for Stone, however—with complex meanings embedded in narrative in a manner beyond the capacity of ratiocination to convey—are capable of accessing the infinitely intangible.

And of revealing why doctors become doctors.

How would you like to lower your blood pressure by listening to a story? As improbable as it may sound, that is exactly what happened in a study reported in the January 18, 2011 issue of Annals of Internal Medicine (Houston TK, et al. Culturally appropriate storytelling to improve blood pressure. A randomized trial. Ann Intern Med. 2011; 154:77-84).

I have previously written of a category of medical instruction known as narrative medicine. Integral to the field of narrative medicine is the idea that while a disease can be understood through the process of empiric research and publication (left brain activity), illness—defined as the fully expressed human response to disease, as manifested by its emotional, spiritual, financial, and physical aspects—is best understood in story form, i.e. the narrative (a right brain activity).

Stories have a multi-layered, intuitive meaning that purely rational expression does not. Literary fiction, for instance, has the capacity to present characters so completely rendered we begin to understand ourselves—and others—more profoundly simply by identifying with such characters. Fully drawn fictional characters have much in common with patients. Identifying deeply with a fictional character—shivering when a character is cold, feeling sorrow when a character is sad, or becoming angry when a character is wronged—stimulates the same neuronal connections that allow physicians to feel empathy for patients#mce_temp_url#. Experiencing the world from a fictional character’s point of view is not so very different than experiencing the world from a patient’s point of view—a critical skill for doctors to have.

But what about our patients? Might they benefit from the unique virtues of storytelling too?

The authors of the Annals article sought the answer to this question by performing a randomized, controlled study to determine if viewing culturally appropriate videos had a beneficial effect on blood pressure control. 147 patients watched a series of 3 hypertension DVDs given at baseline, three months, and six months; a control group of 152 patients witnessed DVDs unrelated to hypertension control. The hypertension DVDs involved personal stories of blood pressure control as related by patients drawn from the same African American population in Birmingham, Alabama as the control patients.

Results of the trial showed that patients with uncontrolled blood pressure who viewed hypertension-treatment stories of cultural peers experienced an 11-point greater fall in systolic blood pressure than did similar patients in the control group. The authors speculate that such video storytelling changes behavior—in this case compliance with diet and medication—by breaking down cognitive resistance, perhaps by identifying with and mimicking the behavior of a particular story character.

This study is unique in that it applied left brain scientific method in an effort to document benefits of a right brain, intuitive form of treatment. The authors’ conclusion?

Storytelling not only changes lives, it can help save them, too.

I want to welcome all my followers from The Literary Doctor—and all new visitors—to richardbarager.com. All of the posts from The Literary Doctor are archived here. It is my hope that the transition to the new site will be a smooth one for you. I apologize for any inconvenience the change in URLs may have caused you, and I thank you for your loyalty. I invite you all to have a thorough look around.

I have over these past months at theliterarydoctor.com written often of the natural connections between medicine and literature. Stories, both listening to and telling them, are an integral part of medicine. To be effective healers, doctors must be expert at eliciting and critically analyzing stories of illness from their patients, and equally as adept at relating the story of a given patient’s illness back to them, in a succinct and meaningful way.

I have always made it a priority to learn not just my patients’ medical stories, but their life stories as well: where they were born, what they do, how many children they have, how they spend their free time. Unearthing the military histories of the many veterans I have cared for over the years has been a special interest of mine. Practicing medicine in San Diego County—home to large numbers of both active duty and retired military personnel—has afforded me the privilege of hearing some remarkable oral histories.

I have counted among my patients a Pearl Harbor survivor, a sailor who fought at the Battle of Midway, and a marine who was in the first assault wave at Tarawa Atoll. I even had in my practice an RAF pilot who flew a Spitfire in the Battle of Britain, and a Luftwaffe pilot who flew a Messerschmitt against him, each having settled in San Diego, each for a while a patient of mine. There were others who fought at Chosin Reservoir and Inchon in Korea, and many more who fought in Vietnam—one of them at a place called Khe Sanh. His name was Earnest Ross. Gene, he told me to call him.

Around the time Gene was first referred to me, I was in the midst of researching and writing a novel about the 1960s, with a number of scenes set in Vietnam at a legendary battleground: Khe Sanh. When I learned from eliciting Gene’s story—the story of his life, not his medical story—that he had fought at Khe Sanh, I told him about the book I was writing. He graciously consented to a series of interviews to educate me about the rigors of boot camp—where he had been a drill instructor during the sixties—and the brutal siege of Khe Sanh.

The novel—Altamont Augie—is finished now and heading toward publication. Gene is mentioned in my acknowledgment section, though I’m sure not the way he would have preferred. Here’s how his shout-out reads:

“The author’s heartfelt thanks to Earnest “Gene” Ross, who passed away 12/4/09. Though I never went through boot camp, you made me feel as if I had.”

There is sometimes little difference, I have learned, between a physician-writer’s fictional characters and his patients; either can make him sad. It has become an easy thing for me to move back and forth between medicine and literature, from doctor to writer, the bridges barely even perceptible any more. My patients inform my writing and my writing makes me more humane.

I have promised Gene’s widow one of the first copies of Altamont Augie—a promise I am anxious to keep.

Thank you, Gene Ross. And may God rest your valiant soul.

Most often, this space is devoted to the nexus of literature and medicine, but on occasion, it is about only one or the other. This is one of those occasions.

Two recent events have captured my attention: the awarding of the Nobel Peace Prize to Chinese dissident Liu Xiaobo, and this year’s National Book Awards.

First, Liu Xiaobo.

The Chinese government’s response to Liu’s Nobel made it abundantly clear that the greatest threat to the world’s rising superpower, China, is not the world’s reigning superpower, the United States, but rather a fifty-five-year-old professor of literature who is currently serving an eleven-year prison sentence (for signing a manifesto of democratic values called Charter 08). How can this be? American complaints about Chinese currency manipulation and intellectual piracy barely elicit a fillip from Beijing, yet a Chinese citizen winning the Noble Peace Prize results in one of the greatest governmental overreactions since the Gulf oil spill. (Where did all that all oil go to, anyway? Apocalypse Not.)

By preventing Liu or his wife from journeying to Oslo to accept the award (the first time in 74 years the prize winner went unrepresented), the ChiComs have fatefully ushered their bête noir—public doubts about their legitimacy—onto a brightly lit international stage. The empty chair in Oslo is a lasting and damaging image, imprinted not only onto the minds of hundreds of millions of Chinese, but onto the minds of the rest of the world, as well. Even President Obama—no great champion of democracy and human rights when it comes to the Chinese, not with all those devalued dollars he wants them to sop up—seems bolstered by the incident, calling for Liu’s release “as soon as possible.”

It is no coincidence that Liu is a professor of literature. For literature—and in particular, literary fiction—has always challenged tyranny. Consider One Day in the Life of Ivan Denisovich, the landmark 1962 novel of Stalinist repression by Nobel Prize winner—in Literature, of course—Aleksandr Solzhenitsyn. His 158-page indictment of the Soviet Gulag is credited with fundamentally and forever changing the West’s perception of the U.S.S.R. And then there’s the book recently released by Charles Hill, entitled Grand Strategies: Literature, Statecraft, and World Order, which explores literature’s influence through the ages on politics and government through the works of 70 poets and novelists.

“Statecraft cannot be practiced in the absence of literature,” Hill writes. “Literature lives in the realm grand strategy requires, beyond rational calculation, in acts of the imagination.” (Precisely the argument for studying the nexus of medicine and literature: to wit, literary fiction accesses the meaning of illness in ways scientific method—logic and reason—cannot.)

Hill argues, as do I, that only fiction can reveal the truth. “Literature’s freedom to explore endless or exquisite details, portray the thoughts of imaginary characters, and dramatize large themes through intricate plots brings it closest to the reality of ‘how the world really works.’”

Which brings me to this year’s National Book Awards, held November 17 in New York. The winner in Fiction—Lord of Misrule—however, is not the novel that interests me: one of the other finalists, Parrot and Olivier in America, is the one I was rooting for. Not because it was the best novel—though imaginative and forceful and beautiful in style and prose, it loses focus and lacks unity at times—but because of what it is about: Democracy in America, the French aristocrat Alexis de Tocqueville’s brilliant chronicle of the American experiment. Written by an expatriate Australian, Peter Carey, Parrot and Olivier in America is a re-imagining of the life of de Tocqueville and his study of the phenomenon of American democracy, this time as seen through the eyes of a disaffected, voluble French lawyer and his spunky English factotum. Any novel attempting to plow the hallowed ground of de Tocqueville’s classic treatise—in many ways the most profound analysis of American democracy I have ever read—is thumbs up with me. That it was written by a foreigner—as was the original—only adds to its appeal.

So there you have it, an Australian novelist re-discovering the treasure of American democracy, and a Chinese professor of literature with the courage to speak truth to power about democracy, as he did in the December 1988 Hong Kong Liberty Monthly, and has done ever since: “Westernization is not a choice of a nation, but a choice for the human race.” No wonder they’re afraid of him.

All in all, a very good month for literature and democracy.

I evoke a variety of expressions—ranging from quizzical to dubious to why-are-you- wasting-my-time?—from my colleagues when I tell them I have started a literature and medicine blog. Their eyes become filmy if I mention the phrase “narrative medicine”—a sure sign I have thirty seconds tops to win them over.

I usually succeed in under twenty. How? By pointing out to them that storytelling is integral to what we do.

Every time we gather a medical history from a patient, we listen to a story; every time we dictate a consultation and formulate a treatment plan, we tell a story. But the manner in which we elicit our patients’ stories is critical. We will have a hard time arriving at a correct diagnosis if we are not skillful enough in extracting a complete and accurate narrative from a patient. Similarly, if we fail to construct a persuasive enough narrative to explain to a patient what we think she has, she will be less inclined to think our diagnosis credible, and less willing to comply with our treatment plan. And since we spend so much time listening to, analyzing, constructing, and telling stories, it can only be helpful to develop and hone this type of critical thinking. What better way to achieve this than by reading and reflecting upon the fiction of master storytellers?

After making these arguments, my skeptical colleagues’ eyes spark with comprehension, as if to say, “Yes, that is what we do.” (Except the dermatologists among us, who do not do any of these things, and who are not awakened at night to come to the ER, and who make more money than…Sorry. I know. I could have done a Derm residency. I’ll behave. I promise.)

Stories—narratives—are no less critical in the legal world, where the plaintiff goes head-to-head with a defendant’s competing version of the dispute in question. More often than not, the attorney that tells the most persuasive, credible story—that weaves the best narrative for the jury—is the attorney that wins the case.

But perhaps nowhere is the power of a compelling narrative more evident than on the hustings during a political campaign. I would even suggest that nearly all the heat and noise of American politics is generated by a single pair of competing narratives: those in support of the values of equality and liberty.

What matters most to Democrats is equality—even, sometimes, at the expense of liberty. Case in point? Healthcare for all, even if their fellow citizens, under penalty of law, have to be forced to buy something—health insurance—they may not want. And what matters most to Republicans is liberty—even, sometimes, at the expense of equality. Case in point? The same issue, healthcare: by their willingness to tolerate unequal access to healthcare in favor of protecting each individual citizen’s freedom—liberty—to decide for themselves whether or not to purchase health insurance. The tension inherent between the values of liberty and equality has given rise to two overarching national narratives that define the two political parties organized around these values. Depending on which narrative resonates most with voters at a particular time, that of equality or liberty, one party or the other carries the day. In our current mid-term elections, for example, the narrative of liberty prevailed; but in the Democrat landslide year of 1964, at the height of the Civil Rights Movement, a narrative of equality triumphed. In two years there will be a presidential election, and I am quite confident that the dueling narratives of equality and liberty will again shape the conflict. And to the side that tells the best story—the best narrative—go the spoils.

At all levels of interaction between human beings, stories matter: whether in our personal lives, in forming the national debate over equality and liberty, or when it comes to doctors caring for their patients. It is in our best interest as a nation and, more narrowly, as physicians to be proficient in evaluating the various narratives in our lives. Many medical schools agree with this and now require courses within the field of narrative medicine (the study of literature applied to medicine).

But the benefits of narrative medicine should not be limited to medical students. We can all read and reflect upon great works of literature, even in the absence of specialized instruction. By reading literary fiction, we naturally and unconsciously examine narrative structure, become more familiar with narrative process, and hone our skills of narrative criticism. The critical thinking and sifting of ideas we do while reading and reflecting on a novel is the same type of critical thinking and consideration we do in caring for patients—and in deciding elections.

In all of us, there lies a voice within that utters but one command: Tell me a story. Wise are those who heed it.

One of my colleagues recently told me he doesn’t read fiction because he doesn’t see the point in wasting time on something that isn’t real and doesn’t matter. He learns more from non-fiction, he said.

Oh my.

The awarding of the 2010 Nobel Prize in literature yesterday to Mario Vargas Llosa of Peru for ten million Swedish Kronors—or, in our increasingly worthless American currency, 1.5 million dollars—is a powerful reminder that fiction, for society in general and for our little niche of narrative medicine in particular, does indeed matter.

To those who believe the reading of fiction to be of no practical value, like viewing an action movie or a cops-and-robbers TV show, we need look no further than Mr. Vargas Llosa’s oeuvre for rebuttal. In his youth a prototypical Latin American leftist, Vargas Llosa later became a powerful advocate of free-market capitalism and liberal democracy. His fiction concerns itself with the dehumanizing effects of autocracy and the virtues of individual empowerment. Born in 1936, he came of age in the 1950s, a period during which Peru suffered greatly from a corrupt dictatorship. His personal experience with tyranny and his enormous compassion for victims of statist oppression led him to become a controversial and vocal supporter of the American-led liberation of Iraq and the effort to depose Saddam Hussein. He was awarded the Nobel, in the words of the Swedish Academy, “for his cartography of the structures of power and his trenchant images of the individual’s resistance, revolt and defeat.”

So what does the literary success of an apostate Marxist have to do with a blog on literature and medicine?

Well, everything. Because, in the words of Vargas Llosa himself, as reported today by Emily Parker in the Opinion section of The Wall Street Journal, “Through writing, one can change history…Nothing better protects a human being against the stupidity of prejudice, racism, religious or political sectarianism, and exclusivist nationalism than this truth that invariably appears in great literature: that men and women of all nations and places are essentially equal.”

And so it is with literary fiction and medicine. Through stories, one can change lives. The meaning of illness is revealed and the suffering of others deeply and personally experienced. Reading, reflecting on, and discussing great fiction increases the empathy of caregivers (Anyone out there whose doctor seems cold and unemotional?) and helps patients understand the universal question: Why? Why me? What does my illness mean?

The answer is different for each that asks, but the journey (of understanding illness) is not—just as citizens in a free society share in common their quest for liberty, though their expression of it is individually unique.

For those who take the time to enjoy it, literary fiction, whether dealing with matters of tyranny and liberty, as do the novels of Nobel Prize winner Mario Varga Llosa, or in dealing with human illness, as does this blog and the field of narrative medicine, is transformative.

Sorry, my doctor’s lounge companion, but fiction matters.