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.

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.

Middlemarch is the magnum opus of George Eliot, the masculine nom de plume of Mary Ann Evans, one of the foremost English novelists of all time. She was born in 1819 at Arbury Farm, England, to an Evangelical Protestant father whose religious beliefs she soundly rejected. Like Tolstoy and Flaubert, George Eliot was part of the nineteenth century realist movement in literature, taking great pains to create life-like characters representing ordinary people in stories of remarkable verisimilitude. Eliot believed female novelists were held in low regard by the English literati, thus the pen name.

At 838 pages and 86 chapters, Middlemarch is no light read; entire semesters have been consumed by it. Suffice it to say that a broad cast of characters—none dominant, all astonishingly real—drive three wide-ranging but interwoven story lines revolving around a number of themes: love and marriage; the station of women in Victorian society; class and social mobility; and the clash between idealism and self-interest, all set in the (fictitious) rural English town of Middlemarch. The book’s complete title— Middlemarch: A Study of Provincial Life—suggests as much.

Among the principal characters is Tertius Lydgate, an ambitious young doctor who comes to Middlemarch intent on starting a new fever hospital for the poor. Lydgate vows to establish new ways of practicing medicine, based on observation and the recording of data and scientific method, in place of the rampant charlatanism of the day.

“A fine fever hospital in addition to the old infirmary might be the nucleus of a medical school here, when once we get our medical reforms; and what would do more for medical education than the spread of such schools over the country?”

…there was a general impression that Lydgate was something rather more uncommon than any general practitioner in Middlemarch.

But Lydgate, like many visionaries, is arrogant, to colleagues and patients alike.

“I have not yet been pained by finding any excessive talent in Middlemarch,” said Lydgate bluntly.

Lydgate’s conceit was…never simpering, never impertinent, but massive in its claims and benevolently contemptuous.

He winds up marrying the town beauty, Rosamond Vincy, but it is an unhappy match. Rosamond is shallow and materialistic, and her pretentious spending quickly plunges Lydgate into severe indebtedness. His financial desperation leads him to accept a loan under dubious circumstances, and the ensuing public humiliation he suffers causes him to surrender his dream of revolutionizing the way medicine is practiced. To appease his wife, he becomes the kind of doctor he once held in contempt, catering to the wealthy until he becomes wealthy himself. Lydgate dies at fifty, disillusioned and unfulfilled, arrogant no more.

But arrogance is not the brilliant and perceptive Lydgate’s worst flaw; a lack of empathy is. He seeks to understand human behavior in a cold, dispassionate way, without emotionally connecting to the human beings he studies. Both his métier and marriage suffer for it.

“I was early bitten with an interest in structure, and it is what lies most directly in my profession. I have no hobby besides.”

The tragedy of Lydgate is the tragedy of any doctor who fails to become proficient in the art of medicine as well as the science. The science of medicine involves knowing what treatment to apply; the art of medicine requires the persuasion of other human beings to suffer it.

All medical schools produce their share of Lydgates, brilliant classroom students who excel at mastering the basic sciences, but founder at the bedside. It just isn’t there, that natural camaraderie that causes a patient to turn to his wife and say, within minutes of meeting a surgeon, “I like her. I’m going to let her do whatever she needs to.”

Consent to undergo the often invasive and sometimes hazardous treatments we ask patients to endure depends upon an irrational trust—irrational in that an emotional connection forged between doctor and patient gives rise to it. Such trust is the coin of the medical realm, and the path to gaining it begins with authentic recognition of—and genuine sympathy for—the plight of the afflicted. These skills are not acquired in cellular biology class, but rather are developed with the aid of paintings and plays and poems and novels.

Like Middlemarch.

One of the most challenging aspects of medical school is to drink from the torrent—the fire hose—of scientific knowledge pumped down your throat while still remaining a sentient human being. And to remember that it was a desire to help other human beings that attracted you to medicine in the first place. The amount of information medical students are asked to assimilate is so enormous—so pantagruelian, to steal from the French doctor-turned-humanist Francois Rabelais—that it almost unavoidably turns idealistic young men and women into cold-purposed cyborgs, whose entire reason for being becomes the digestion of data.

Medical educators have for decades struggled to produce physicians who can not only process this ever-growing fund of knowledge, but who are also capable of evincing genuine compassion and empathy for the patients they apply it to. Many approaches have been tried to achieve this delicate balance. As readers of this blog are aware, courses in the field of narrative medicine help medical students maintain a humanistic perspective by requiring close reading of specific works of literature that stimulate the brain’s empathy centers, putatively located in the anterior cingulate cortex and amygdala.

Another possible way of assuring that medical trainees leave medical school with an ability to forge empathic connections with their patients is to select a limited number of students who already have this quality, in hopes that their humanistic impulses will be less prone to withering than those of hard-core science types. One medical school that has gone all in on this theory is the Mount Sinai School of Medicine in New York, with their Humanities and Medicine Early Acceptance Program, which “provides a path to medical school that offers maximum flexibility in the undergraduate years for students to explore their interests in humanities and social sciences at top liberal arts colleges and research universities.”

Thirty to thirty-five college sophomores are accepted annually into the program. To qualify, they are required to major in a humanities subject in exchange for not having to take physics or calculus, and for taking a reduced course load of organic chemistry. One year of undergraduate general chemistry and biology and one semester of organic chemistry remain mandatory for matriculation. Students admitted through this program are not permitted to take the Medical College Admission Test (MCAT). In 2009, there were 300 or so applicants to the program, with 34 students accepted.

Medical students entering Mount Sinai via the Humanities and Medicine Program performed in line with students accepted in traditional fashion, as assessed by class ranking, medical clerkship grades, standardized test scores, and the quality of residency positions obtained for post-graduate training. As described in a letter in the British medical journal The Lancet this month (Medoff, S. Correspondence. Lancet. 2010; 376: 1542), “Students in the programme this year have worked as professional actors, lived with shaman healers in Peru, taught English in Indonesia as Fulbright scholars, and pursued advanced degrees in classical music performance.” Mount Sinai’s web site states that they seek candidates who “have personal attributes that show promise for becoming a compassionate and humanistic physician.”

In other words, despite the explosion in basic science knowledge all medical students are expected to master, educators have become gun-shy about taking too many science nerds. The message of programs such as Mount Sinai’s is clear: Be first a human, then a doctor.

Yes, that’s right, the title of a song played at Woodstock by The Who—at sunrise of the third day, no less—is the title of my post. The song begins with those very words sung in dramatic refrain, followed by four more: Touch Me/Heal Me.

The same four imperatives succinctly describe the essence of what patients want from their doctors. But in the age of the EHR (electronic health record), they may have to stand on top the exam table and ululate these lyrics at the top of their lungs just to get their doctors to look up from their laptops. And smash a guitar, too.

An article in this week’s issue of The Journal of the American Medical Association—which hit my desk today, prompting this effusion—reviews the Department of Health and Human Service’s ambitious plan for converting the nation’s paper-based medical record system to an electronic one.

“Meaningful use provisions will help improve legibility of clinical records, reduce prescription errors, improve adherence to guidelines, improve patients’ access to their records, and ensure that clinicians and hospitals are capable of exchanging clinical data.” (Ashish, KJ. Meaningful Use of Electronic Health Records. JAMA. 2010;304(15):1709-1710.)

Laudable intentions, all. And in an effort to fast track this massive undertaking, a $44,000 bribe—er, incentive—has been allocated for each physician who purchases and implements (for about the same cost as the incentive) an electronic health record in his or her office by 2014. The article goes on to warn, like a surgeon obtaining informed consent, of the risks associated with this nationwide conversion.

“Many of these transitions will be poorly executed, some with serious consequences. Poorly designed or poorly implemented EHR systems can cause as much harm as good. Reports of failed adoption and patient harm are likely to emerge.”

And so on and so on, the author’s disclaimer mainly a congeries of tech snafus likely to plague this feverish, government-mandated rollout. I appreciate the heads-up on potential adverse effects, but he left a biggie off the list of unintended consequences: the decided propensity of digital health care records to emotionally disengage physicians from their patients.

Doctors ask patients to submit to unspeakable things: the carving of viscera, the infusion of poisons, the ghoulish machines we attach them to. Their consent to undergo such unnatural acts depends upon an irrational trust—irrational in that an emotional, rather than logical, connection between doctor and patient gives rise to it. Such trust is the coin of the medical realm, and the first step in gaining it is the authentic recognition of the basic humanity of the patients seated in front of us.

Experienced physicians establish patient-rapport in three main ways: eye contact, empathic listening, and touch. Note that verbal communication is not on the list; it’s not that easy to talk someone into trusting you. But the more we stare at our computer screens, the less eye contact we make. See me. And the more time we spend scrolling for lab results, the less time we spend in empathic listening mode, vicariously experiencing our patients. Feel me. The more our hands are on the keyboard, the less they reach out in a reassuring, comforting way. Touch me. And the less successful we are in establishing these empathic connections, the less likely we are to cure the conditions that caused our patients to come to us, like pilgrims to Epidaurus, in the first place. Heal me.

Don’t get me wrong; I’m not some churlish medical reactionary yearning for the halcyon days of Marcus Welby. We’ve had an EHR in our office for nearly four years, and I like it well enough. It got rid of our transcriptionist, freed up an entire room full of paper charts waiting to be shredded, and improved the flow of information to our referring physicians. I encourage all doctors to go digital.

Just remember to look up from the keyboard once in awhile and smile.