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.

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.

Pity me as I wish to be pitied. That is the plea of the tortured protagonist in Leo Tolstoy’s brilliant 1886 novella, The Death of Ivan Ilyich.

Tolstoy was born in 1828 into Czarist Russia’s landed gentry. Though orphaned at a young age, he enjoyed the typical privileges wealth and title afforded—passive income, summers in the country, and enrollment at Kazan University. But it was later, after dropping out of school and joining the army, that Count Tolstoy would launch his career as a writer from the Crimean front.

There is perhaps no other literary character who gives voice to the agony of the afflicted more profoundly than Ivan Ilyich, a forty-five-year-old parvenu who assiduously wends his way through Czarist Russia’s bureaucracy to become a respected judge, only to develop an insidious illness that announces its presence while he is hanging curtains in a stylish home beyond his means to afford.

…he made a false step and slipped…but only knocked his side against the knob of the window frame. The bruised place was painful but the pain soon passed…

But not for long.

…Ivan Ilyich…had a queer taste in his mouth and felt some discomfort in his left side.

His symptoms begin to disrupt his carefully ordered and superficially fulfilling life. He grows irritable from discomfort and more quarrelsome with his wife, with whom his relationship is abysmal to begin with, a thing to be endured to keep up appearances. Her patience with him is soon exhausted.

She began to wish he would die; yet she did not want him to die because then his salary would cease.

Tolstoy passes judgment on the spiritual emptiness of social striving with one of the most famous and devastating sentences in Russian literature.

Ivan Ilyich’s life had been most simple and most ordinary and therefore most terrible.

Ivan’s symptoms intensify, mystifying a bevy of doctors who attribute it one day to a “floating kidney,” and the next to appendicitis.

The pain in his side oppressed him and seemed to grow worse and more incessant, while the taste in his mouth grew stranger and stranger…It seemed to him that his breath had a disgusting smell, and he was conscious of a loss of appetite and strength.

The nephrologist in me cannot resist pointing out that with the exception of his pain, all of Ivan Ilyich’s symptoms can be explained by uremia, an advanced stage of kidney failure. But whatever the cause, he becomes angry and bitter over his doctors’ failure to cure him. He realizes he is dying.

And he had to live thus all alone on the brink of an abyss, with no one who understood or pitied him…

He becomes resentful, especially of his still-healthy wife.

While she was kissing him he hated her from the bottom of his soul and with difficulty refrained from pushing her away.

Why is he so resentful? Because no one gives him what he wants. We come, now, to the heart of things, to what patients want and need and crave with all their being.

…what most tormented Ivan Ilyich was that no one pitied him as he wished to be pitied. At certain moments after prolonged suffering he wished most of all (though he would have been ashamed to confess it) for someone to pity him as a sick child is pitied. He longed to be petted and comforted.

He finally gets the succor he seeks from the peasant Gerasim, who holds him the way he wants to be held—and talks to him about death openly and honestly. The authenticity of Gerasim, in contrast to the hypocrisy of the aristocrats Ivan Ilyich has lived his life to please, has a powerful effect on him.

“Maybe I did not live as I ought to have done,” it suddenly occurred to him…“What if my whole life has been wrong?”

He softens and allows a priest to hear his confession, then endures an agonizing three days, during which…he struggled in that black sack into which he was being thrust by an invisible, resistless force.

In the end, Ivan Ilyich rejects the lie of his life and embraces the truth of his death; in so doing, he is at peace.

He sought his former accustomed fear of death and did not find it. “Where is it? What death?” There was no fear because there was no death.

In place of death there was light.

“So that’s what it is!” he suddenly exclaimed aloud. “What joy!”

Ivan Ilyich wanted nothing more than to be stroked like a child. Tolstoy’s insight into the enormous frustration patients feel at the end of life, the agony they endure, at not being touched in a compassionate way is a call to physicians—to all caregivers—to lay hands on our patients not only in a clinical way, as part of an examination, but also in an emotionally meaningful, loving way. Embrace them. Pity them. And patients: express your need. No pathos, no pity. Let people know you want to be held like a baby.

For from this will come a relief no surgery or medication can bring.

Doctors are often asked to treat disagreeable patients. Sometimes really disagreeable patients: loathsome, repugnant, nasty, hateful human beings. But it is not often that a doctor is asked to treat a patient who has invaded his home, threatened his life, and forced his daughter to strip naked in front of him. Such are the circumstances confronting London neurosurgeon Henry Perowne in the hugely successful novel Saturday, by Ian McEwan.

Ian McEwan is one of the most acclaimed and popular British novelists of our time. He has won the Somerset Maugham Award for his collection of short stories, First Love, Last Rites, and the Booker Prize for Fiction—England’s National Book Award—for his 1998 novel Amsterdam. He is perhaps best known to American readers for the lush period piece Atonement, made into an Oscar-nominated film starring Keira Knightley.

Saturday is written in present tense, with the entire story occurring on a single day: February 15, 2003, the date of the largest anti-war demonstration—against the war in Iraq—in English history. It is a day in which the forty-eight-year-old Perowne awakens and makes love to his still-fetching attorney wife; has a trivial car accident on the way to his weekly squash game that leads to a discomfiting scrape with a thug named Baxter (whom Perowne perceptively realizes is suffering from Huntington’s Disease, a degenerative neurological condition with no known cure); visits his demented, nursing home-bound mother; attends his talented, blues guitarist son’s jam session; and then makes his way back home to cook dinner for a family gathering that includes his poet daughter and literary lion father-in-law.

In the middle of dinner, this affluent, refined, accomplished—if rather self-conscious and guilt-ridden—English family is surprised by knife-wielding lowlifes, led by the impoverished, unaccomplished, uncouth Baxter, who has stalked Perowne to his home out of anger at all he represents—and out of a sense of desperation that Perowne might somehow conjure a cure for his incurable disease.

At the darkest moment of the intrusion, Perowne’s daugter Daisy—stripped naked and quivering, her gravid belly swollen with child— recites the poem Dover Beach, temporarily calming Baxter.

Perowne sees a glimmer of hope.

It’s of the essence of a degenerating mind, periodically to lose all sense of a continuous self, and therefore any regard for what others think of your lack of continuity. Baxter has forgotten that he forced Daisy to undress, or threatened Rosalind. Powerful feelings have obliterated the memory. In the sudden emotional rush of his mood swing, he inhabits the confining bright spotlight of the present. This is the moment to rush him.

He seduces Baxter into fantasizing about a cure for his Huntington’s long enough for Perowne and his musician son Theo to tackle him and knock him down a staircase onto a stone landing below, where he lies unconscious, a threat no more. Police and paramedics are called. The traumatized family begins to recover, leaning on one another for comfort.

Until Perowne receives a call from the hospital informing him of a case of head trauma in need of surgery. Intracranial hemorrhage of a life-threatening nature, it seems. Baxter.

Is Perowne obligated to treat Baxter? Or, given the circumstances of what Baxter has just put him through, is it acceptable for Perowne to tell the hospital to find another neurosurgeon—even though Perowne is the one on call that night? And if he does refuse, what if no other neurosurgeon can be located in time to operate on Baxter? What is Perowne’s duty—if any—to Baxter then? And what about Baxter’s terminal illness of Huntington’s? Even if Perowne were inclined to save him, wouldn’t it be more compassionate to refuse to operate on Baxter in order to spare him the undignified death of relentless neurological degeneration? Or perhaps Perowne should save Baxter to guarantee that he suffers a grinding, debilitating decline, poetic justice meted out by Perowne’s own scalpel.

So what does Henry Perowne do? He responds with hardly a bump in pulse rate and leaves for the hospital, where he saves the hapless Baxter—for what, he wonders: prison and an excruciating death from Huntington’s?—with his considerable surgical skill.

I suspect the overwhelming majority of physicians, myself included, would have reacted in exactly the same manner. There would be no more doubt about how a well-trained physician would respond in a situation like this than there would be over how an Alaskan sled dog would respond to being asked to race on a very cold day: it’s what we do. The average physician will treat anyone, anywhere, anytime, under the most trying of circumstances. Like sled dogs bred to run, we are bred to deliver care to patients. There was no agonizing by Perowne over whether or not to treat Baxter, because his sense of professional duty overwhelmed all other considerations—hate, fear, and revenge included.

But Perowne’s dilemma does raise an important medical ethics issue. When is a physician justified in refusing to treat a patient who has threatened him or her in some way, either explicitly or implicitly? At what point on the continuum does a physician’s safety become more important than a physician’s duty? Where—and when—to draw the line with dangerous patients?

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.

Douglas MacArdle looked at Tuisamoa Fauatea’s empty dialysis chair and bowed his head in shame.

“Just keep me alive ‘til my grandson graduates from USC, Doc,” Tui had told him a week before. “That’s all I ask. One more year. Then, if the Lord wants me, I’ll be ready.”

“I will, Tui,” MacArdle had reassured him. “I promise.”

Tui had collapsed and died while brushing his teeth that morning, one of the nurses had informed MacArdle. The visual was sickening, two hundred and seventy pounds of Pacific Islander goodness and joy toppling to the cold tile with a disbelieving rictus on his face. One of the stents propping open his diseased coronaries, probably.

He lifted his head and gazed again at Tui’s empty chair. It was located in the middle of a row of chairs strung along the northern end of the clinic, adjacent to the elaborate water purification system that was so vital in preparing the ultrapure water they needed to perform safe dialysis treatments. But what good had their impressive technology been? Tui had still died like everyone dies, in the humbling repose of death, legs splayed at an unnatural angle, his cheek smeared with Crest. Death with dignity? No such thing. A soporific trope to ease the angst of the living was all that was.

“Tofa soifua,” MacArdle said sotto voce, in the Samoan words Tui had taught him. Fare thee well my friend. He sighed and scanned the clinic he had been medical director of for the past fifteen years, seeing it as if for the first time.

Twenty dialysis stations and a glass-partitioned isolation stall (for patients with hepatitis) lined the walls of a commodious rectangular room, with a nursing desk in the center. Each station consisted of an aqua-colored chair resembling a La-Z-Boy recliner, and a futuristic silver dialysis machine, standing five feet high and about two feet in width. A display screen with an array of orange LEDs flashing real-time treatment data occupied the upper third of each machine; a roller-pump propelling blood through hollow fibers encased in a plastic cartridge—an artificial kidney—took up the middle third. An assortment of inlets and outlets bearing a tangle of blood tubing and water hoses marked the bottom third.

Patients reclined in their chairs, staring at televisions suspended in front of them by c-arms. Nurses and dialysis technicians in blue scrubs flitted amongst them, taking blood pressures, responding to machine alarms, entering vital signs into electronic charts. The patients appeared oblivious to the large-bore needles impaled in their arms like harpoons—and to the blood-sucking machines stationed next to them like metallic sentries. Given that each patient’s entire blood volume passed through their artificial kidney every twelve minutes, it never ceased to amaze MacArdle that they weren’t all bolt upright squeezing finger marks into their armrests. But like pilgrims to Epidaurus, they came in profound trust, asking only to be kept alive.

In the coming year alone, one out every seven of them would not be kept alive; by some measures, having end stage renal disease was as bad as having cancer. And with each new death—each new empty chair—MacArdle would feel shame. Shame for having failed to keep his sacred covenant. For having failed to stay a step ahead of their disease, despite his top-drawer training and considerable ken, the marvelous technology at his fingertips. Shame for failing them the way he failed Tuisamoa Fauatea.

Yet despite the sorrow his clinic was sure to endure, the sheer vastation of it, knowing, like all nephrologists knew, that death draped his every day like moist cheesecloth, MacArdle had yet to become cynical, had yet to succumb to “compassion fatigue”—a feeble euphemism for being too exhausted to care anymore. More language dilution to avoid offending anyone.

He was, he supposed, like a hopelessly addicted gambler, always believing the next hand would deal him a winner, that third ace so long overdue. In the dialysis world, winning meant keeping a patient alive long enough to get a transplant—or, for those patients who were, for whatever reason, unfit to receive transplants, keeping them healthy enough to make the rigors of dialysis worthwhile. And he had won, plenty of times. Scores of his patients had received transplants over the years, and more and more of them were surviving—thriving, even—for ten and fifteen and even twenty years on dialysis. Winning kept him fresh, vital, enthused to still be doing what he had wanted to do ever since he was twelve years old: save lives. If only for awhile.

Soon a new patient would fill Tui’s chair. Someone recently told they would die without dialysis. Someone with a spouse who still needed them, children who still loved them: grandchildren to send to college. Someone who would come in profound trust. Maybe even another Samoan with diabetes—it was always diabetes with Samoans. High-density, urban living had proved lethal to their island constitutions.

MacArdle would go over to her with his sympathetic smile and warm, welcoming handshake, say hello to her the Samoan way. “Talofa lava.” He would touch her shoulder, reassure her that everything would be okay. And the rills in her frightened brown face would disappear and her fists would unclench when he told her, this thick-set Samoan queen in her red and white sarong, with her black, braided hair and emotive eyes, that he and the nurses and techs would do everything in their power to keep her alive and well.

“I promise,” he would say. And with that it would start all over, their cage match against death.

Only then would MacArdle feel whole again.

(This story is a work of fiction, and as such is entirely the product of the author’s imagination. Any resemblance to real events, organizations, locales, or persons is unintended and entirely coincidental.)

Much is required of physicians: an unstinting devotion to others, a mountain of psychic energy. The punishing effect of these demands on doctors’ personal lives has long been recognized. Medicine is indeed a jealous mistress.

But what of the women and men who are married to doctors? What of the impact this grueling profession has on them, the non-physician spouses of doctors? (Two-physician marriages are another matter; doctors who are married to other doctors enjoy a considerably lower divorce rate than marriages where one spouse is a physician and the other not.) The phone rings all night long, emergencies constantly disrupt family functions, and their physician-mates, immersed from dawn to dusk in the drama of human illness, are often emotionally unavailable. Yet how to compete with matters of life and death?

One of the unhappiest medical marriages of all time is the subject of Gustave Flaubert’s Madame Bovary, a literary masterpiece about the dreamy wife of a kind, but inferior small-town doctor. Flaubert’s father was the resident physician of a hospital in Rouen, France, but Flaubert the younger chose to study law in Paris before turning to writing. He published Madame Bovary in 1857, following the acquittal of charges of immorality brought against him because of the book’s frank treatment of adultery.

The doctor in the story is Charles Bovary, an amiable dullard smitten by young Emma Rouault, the beautiful and—compared to Charles—refined daughter of a patient of his. After the death of his first wife, Charles pursues Emma and convinces her to marry him. But their torpid, ordinary marriage leaves Emma yearning for the excitement, opulence, and romance she has read about in certain novels of the day.

…it was at meal-times that life seemed especially unbearable, down there in that little ground-floor dining-room with its smoking stove, its creaking door, its sweating walls, and its damp floors. It seemed as though all the bitterness of life was served up to her on her plate…

Was this hopeless existence going to last forever? Was there to be no escape?

…She would lean her head against the wall and weep, longing for a life of excitement, masked balls and tumultuous pleasures…

She enters into a lengthy affair—which her adoring husband Charles remains oblivious to—with a local rake, who seduces her and then casts her aside, plunging her into a state of depression made worse by the financial burden of her many impulsive purchases.

Emma’s opinion of Charles during this time suffers even more on account of his disastrous attempt to repair the clubfoot of a villager named Hippolyte. An under-qualified, second-rate doctor with an appealing bedside manner and gentle disposition, Charles’s motivation for trying such (then) experimental surgery is professional vanity. Unfortunately, he is nowhere near skilled enough to perform the procedure, which he bungles horribly, resulting in the amputation of poor Hippolyte’s leg.

…Bovary kept indoors, not daring to stir from the house…If Hippolyte were to die, everyone would say he had killed him. And then what was he to answer when he went his rounds and people asked him about it? Perhaps he had made a mistake somewhere…Of course the best surgeons make mistakes. But that’s just what people will never understand. They would laugh at him. Everyone would be talking…There would be controversy in the papers and he would have to reply. Hippolyte might bring an action against him. He saw dishonor, ruin, irretrievable disaster staring him in the face…

Emma emerges from her grief no more satisfied with Charles than before; she takes another lover, and is even more indiscreet than the first time.

It little mattered that she felt herself humiliated by such degrading pleasures. Habit, or vice, demoralization, compelled her to cling to them; and every day saw her calling ‘for madder music and for stronger wine’, drying up pleasure at the source by asking too much of it.

Her contempt for Charles and her ruinous spending intensify, even as she grows tired of her new lover. When a creditor calls in her debt, which has been secured by her husband’s modest estate, she turns in desperation to her first lover, offering herself in prostitution to secure the money she needs. His refusal drives her to suicide; she poisons herself with arsenic, a torturous, anguished death.

A minute or two later she was bringing up blood. Her lips were drawn, her limbs contracted, her body covered all over with brown patches, and her pulse flickered away beneath the fingers like a taut wire, or like a harp-string, stretched to breaking point. Then she began to scream.

Only after Emma’s death, upon finding her love letters, does the loyal but fatuous Charles learn of his wife’s adulteries. He dies penniless and alone, leaving their daughter Berthe an orphan who is forced to work in a cotton mill.

This remarkable piece of writing is best known for its explicit treatment of adultery and for Flaubert’s complex rendering of Emma Bovary. His brilliant characterization of her is so vivid and original it even gave name to a new kind of psychological malady: bovarism, from the French bovaryisme, romantic fantasy run amok, until the dreamer becomes detached from reality and pursues her dreams with wanton self-destruction.

So, the question is, was this new malady of bovarism cause or effect? That is, did Emma Bovary destroy herself? Or did the peculiar oppression of being a doctor’s wife drive her crazy?

Tell us your thoughts about medicine, marriage, and Madame Bovary.