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Physician, reveal thyself: why do doctors write about their lives?

2005; Elsevier BV; Volume: 365; Issue: 9453 Linguagem: Inglês

10.1016/s0140-6736(04)17646-0

1474-547X

Faith McLellan,

Empathy and Medical Education

It was Kathryn Montgomery (Hunter) who first drew back the curtain on a phenomenon in medicine long tacitly accepted but little examined. Doctors' Stories: The Narrative Structure of Medical Knowledge, her 1991 book, was the culmination of a painstaking analysis of the differences between the way medicine is thought to be practised and what actually happens. She concluded that doctors ground their clinical reasoning not in evidence or meta-analyses or large epidemiological studies, but in cases, in a story—a personal, particular, specific story, one that almost invariably begins, “There was this one guy …”. As a fundamental framework of medical epistemology, then, the compulsion of doctors to tell stories about their patients is neither new nor particularly unusual. The three books discussed here are part of a tradition that includes such practitioners as Freud, Chekhov, and William Carlos Williams. They are related to traditional literary forms, like the Bildungsroman (literally, a novel of education; one that shows, for example, a doctor's training and development), and the memoir, a genre that has exploded in the past few years. But these three books don't fall neatly into any one category. And thereby hangs a tale. Bryson City Seasons is the second in a series of books, issued by a Christian publishing house, about a family practitioner's life in a rural mountain town in North Carolina, USA. The physician-author, Walt Larimore, says he intended it to be a record of a vanishing way of practice, rather than a “partial autobiography”. Woven throughout his encounters with patients and against a backdrop of small-town life are other stories: a young, bewildered newcomer trying to fit into a tightly knit community, and strong religious ideas about how God works in human affairs. But that didactic religious purpose is achieved through an enormous amount of telling, not showing. The patients depicted thus become mere vehicles for conveying moral messages and theological explanations, in effect, one-dimensional sermon illustrations. Larimore's goals are unfortunately further obscured by number of stylistic tics. The most annoying, which could have been eliminated by a heavy editorial hand, is the attempt at dialect. For even the most skilled authors, writing convincing dialect is a formidable challenge. Many have felt called to try, but few have been chosen to succeed. As a writer, I say this with some sympathy. But as a native of rural North Carolina, Larimore's setting, I say it with something between bemusement and anger. It is not necessary to depict the residents of the real Bryson City, however colourful their language and strong their accents, as simpletons from the backwoods who wouldn't know syntax from a hole in the ground. Some of them might not be educated, most might be poor, and many might not have seen a great deal beyond the Great Smoky mountains, but I doubt whether they all just fell off the turnip truck, so to speak. One would think so, though, from the repeated employment of such phrases as “git on down here”, “I done told you”, and “shore ‘nuff”. Besides its inescapable air of condescension, the dialogue suffers from inconsistency and invites disbelief. Does the same person who says, “He was purty tore up” also say, “The men had been lumbering together the best part of four decades”? Has anyone ever really said in conversation, “Both his reputation and his physique are enormous”? Furthermore, why can't these characters just “say” anything—why must they always “add”, “comment”, “exclaim”, “mutter”, “answer”, “remark”, and, indeed, “growl”? Larimore has some promising raw materials in the quest to become part of a community and the pleasures of rural life, including fishing, exploring the mountains, Rotary club luncheons, and discussions of the finer points of barbeque. Most of these opportunities are lost here, but the not-quite-convincing cliffhanger ending makes it clear that he will have more opportunities to hone his technique. Like Larimore, Michael Barrie has written a memoir. And, again like Larimore, he has more on his mind than merely describing his encounters with patients. In The Surgeon's Rhyme, Barrie's purpose is to expose the exasperations and frustrations of working in the UK's National Health Service and to describe the challenges and humiliations inherent in medical education. So far, so good. But his slew of referents and ideas turns into an eclectic pile-up: why doctors commit suicide, a 3-paragraph gloss on Sept 11 that culminates in Barrie's desire to be first to visit a proposed Islamic culture centre in London, a letter from TGI Friday's restaurant in reply to a complaint he made about its “wicked chicken” advertisement, and a 13-page exchange of letters about hospital parking regulations. With such a quirky mix, making a cohesive narrative is ultimately an insurmountable challenge. Cecil Helman's Suburban Shaman is also deeply rooted in its location. The agenda-driven air of the other two books is missing here, though there are plenty of messages to ponder. Helman's discursive thoughtfulness is one of the work's many strengths. In fact, place, and what it means to be connected to a community, tradition, and history, provide a solid foundation for this meditative work. Helman is explicit about the fundamental importance of these connections: “beyond the disease is the person, but beyond the person are always the time and place and particular circumstances in which they live and die.” And, he acutely observes that the only route by which doctors can come to understand the patient as a whole person is “prolonged and detailed contact with a particular community”. It is clear that he has taken these imperatives seriously. Take, for example, this miniature portrait of a lonely, elderly woman: “Gladys is superstitious. She's a worshipper of the little gods, the gods of lotteries and luck, the gods of traffic jams and parking places, the ones to whom you pray for nice weather, for a particular picnic, or for finding just the right sort of dress for that Christmas party, at just the right sort of price. Gladys relies on these small, personal gods to help her with the small, personal problems of her daily life.” Helman's career—family practice, social anthropology, ship's doctor, research, and writing—and interests in shamans and traditional healers have taken him from his birthplace in South Africa to London, the Mediterranean, New Mexico, and Brazil. Thus, his frame of reference is wide. His touchstones—Susan Sontag, Roy Porter, Arthur Kleinman, Howard Brody, and Somerset Maugham to Mircea Eliade—underpin the narrative and form part of an illuminating bibliography. All three of these books raise important questions. Are they helpful to other doctors? To patients? Is their main function catharsis or therapy for the writer? Are they meant to educate, to influence policy, to warn? Most crucially, whose stories are these? (Each author says something different about the degree to which he has taken liberties with the stories of real people, and space does not permit me to examine all the issues relevant to the special problems of doctors telling patients' stories.) Each of these doctor-writers starts from that great clinical prologue: “there was this one guy”. But the real subject of these tales is the one guy the author may or may not explicitly acknowledge—himself.