麻豆传媒

Cutting for Stone, a 2009 novel by Abraham Verghese, MD, MACP, spent 2 years atop The New York Times Best Sellers list. As such, the door-stopper bildungsroman about physicians in the US and Ethiopia may be familiar to many surgeons鈥攏ot least of all for its evocative descriptions of surgery:

What may be less well-known to some surgeon-readers is the type of literature this novel represents. It is narrative medicine, a subset of literature focused on the lived experience of illness, healing, and clinical medicine, written from the perspective of clinicians and patients.

Larger than a genre, narrative medicine encompasses fiction, nonfiction, and poetry. The term also is applied to hospital- or university-based literary journals, writing workshops, and reading and writing clubs, all aimed at bolstering healthcare professionals鈥� lives and careers by helping them process the emotional burdens of clinical work, strengthen professional competence, and 鈥渞ehumanize medicine.鈥�²

In some ways, literature can seem like the exact opposite of surgery: the wispy ethereality of poetic language, contrasted with the weighty literality of altering an anesthetized body. Indeed, some believe narrative medicine is irrelevant to surgeons, despite evidence to the contrary.³

But like Dr. Verghese (an internal medicine specialist), some surgeons鈥攊ncluding Henry Marsh, CBE, FRCS, John (Jay) Wellons III, MD, MSPH, and Joshua Mezrich, MD, FACS鈥攈ave become full-fledged authors of narrative works. Seeking them out allows insights into what narrative medicine can offer the surgeon and how to best access its benefits.

Attention: Observing Oneself and Others

The concept of narrative medicine was popularized by internal medicine physician and English professor Rita M. Charon, MD, PhD,⁴ about 20 years ago. With colleagues at Columbia University in New York, New York, she generated a framework to clarify the characteristics that define narrative medicine: 鈥淲e early recognized attention, representation, and affiliation as the three movements of narrative medicine that emerged from our commitment to skilled listening, the power of representation to perceive the other, and the value of the partnerships that result from narrative contact.鈥�⁵

But for Dr. Marsh, a retired neurosurgeon from England, finding a reason to write has involved no careful theorizing. He just feels he must. 鈥淚 always have written to control my feelings, basically. I鈥檓 an extremely emotional person. I write compulsively,鈥� he said.

A diarist from age 13, Dr. Marsh only began writing his first book, Do No Harm: Stories of Life, Death, and Brain Surgery,⁶ after his wife, best-selling author Kate Fox, encouraged him to publish stories from his journals. To his surprise, the book hit number 1 on The New York Times Best Sellers list. Two subsequent memoirs, Admissions: A Life in Brain Surgery⁷ and And Finally: Matters of Life and Death,⁸ have shared further anecdotes, plus Dr. Marsh鈥檚 recent experience as a prostate cancer patient.

鈥淭he writing itself is cathartic,鈥� Dr. Marsh said, explaining that publishing was far less emotionally impactful. Still, 鈥淚鈥檓 rather proud of the fact that I wrote three books in a row, none of which bombed.鈥�

In fact, the cathartic approach seems essential to his success. 鈥淲hat鈥檚 unusual about my books is this brutal honesty,鈥� he said about his emotional responses to his work. Indeed, one sentence in Do No Harm is a long string of expletives directed at hospitals in general, ending in a decisive 鈥淔*** everybody.鈥�⁶

He added, 鈥淚 got a lot of comments and letters and emails over the years from doctors, saying 鈥業 found it incredibly helpful to hear a very senior famous doctor like you saying he was often incredibly anxious and depressed and fed up, and really suffered when patients came to harm,鈥欌�� a rare contrast to a perceived professional obligation for surgeons to hide their emotions and pretend to be in control.

To Dr. Marsh, reflecting the complex emotional life of a surgeon was the point: 鈥淭he dividing line between fear and excitement is very, very fine. We become surgeons because we like excitement. And what makes it exciting is our deep anxiety. There鈥檚 no contradiction between being a thrill-seeker but actually wanting your patient to do well.鈥�

There also is fine balance, he says, in feeling for patients. Dr. Marsh explained that a common motivation behind engaging with narrative medicine鈥攄eveloping empathy for patients and colleagues⁹鈥攊s slightly ill-conceived. 鈥淎s a doctor, you cannot do the work if you are truly empathic,鈥� he wrote in And Finally.⁸

In conversation, he clarified, 鈥淓mpathy in the strict sense of the word means you actually feel what other people are feeling. And of course, you cannot do that if you haven鈥檛 had the experience of being a patient yourself. So, it can become a rather artificial exercise.鈥�

What is necessary in his view is 鈥渃ompassion, understanding, and respect for patients.鈥�

鈥淔inding a balance between profound compassion and the necessary clinical, scientific detachment is very, very difficult鈥攆or the simple reason that the more you care for your patients, the more it hurts, when things go wrong or you can鈥檛 help them,鈥� he said.

Ultimately, Dr. Marsh鈥檚 writing is about observing the narrow divides between pleasure and fear or engagement and equanimity. Attending to himself and his own emotional experiences on the page facilitates attending to others in the clinic鈥攙ia what Dr. Charon described as 鈥渢he state of heightened focus and commitment that a listener can donate to a teller.鈥�⁵

鈥淲hat makes the work so interesting is the patients. I spent the whole time talking to them about their lives,鈥� Dr. Marsh noted. 鈥淚 always feel such a privilege to have access to people鈥檚 lives in the way one does as a doctor.鈥�

Representation: Writing as a Springboard to Advocacy

For Dr. Wellons, the work of writing has a very different purpose. An academic pediatric neurosurgeon at Vanderbilt University Medical Center in Nashville, Tennessee, he had dabbled in writing privately for years. But he had no intention of authoring a book until a health issue compelled him to undergo 2.5 months of bed rest. Faced with boredom (鈥渢here鈥檚 only so much Netflix you can watch鈥�), Dr. Wellons began recalling stories from his years as a surgeon.

The next step was kismet: submitting his first brief essay on a surgical case to The New York Times, he chanced upon a particularly encouraging editor. Then, he said, 鈥淚 began to think that I鈥檝e seen so much hope and so much resilience and so much joy and all kinds of human emotions. All these people have been writing about the human condition, and we live it in medicine. So, I just started writing stories down, and that鈥檚 what ultimately led to the book.鈥�

His memoir, All That Moves Us: A Pediatric Neurosurgeon, His Young Patients, and Their Stories of Grace and Resilience,¹⁰ was published in July 2023. Dr. Wellons uses its pages to tackle the intensity of life as one of roughly 250 pediatric neurosurgeons in the US, including stories of near-miraculous survival and heartbreaking loss. His prose captures surgical cases in vivid terms (鈥淭he infection was worse than I鈥檇 expected from the CT. When we opened up the dura, pus came spilling out up and over the surgical field and down the drapes onto the floor鈥�⁹) and fleshes out medical details with social and emotional aspects of patient encounters.

Like Dr. Marsh, Dr. Wellons noted that the experience has made better patient care possible: 鈥淚鈥檓 much more likely to sit down next to a family and talk to them about what鈥檚 going on and befriend them in some way. I think I鈥檝e gotten this sense that we鈥檙e all just human beings on this earth together, and we鈥檙e just doing the best we can for one another, and to show that you鈥檙e a human being and you have strengths and weaknesses is the way I want to practice medicine.鈥�

But unlike Dr. Marsh, Dr. Wellons said he is uncertain if he will ever write another book. While he continues to write essays, he is focusing on using his writing to achieve another mission: advocacy, particularly with respect to firearm-related violence affecting children in the US.

This was part of his mission from the start. He had 鈥渢he idea that I would work toward getting some credibility as a writer with the book, and once that happened, if it did happen, then I would pivot to writing and advocating on a different level.鈥�

Since then, he has published an essay about 鈥渨hat it was like to try to save a kid in the OR who had been shot in the head. I wanted people to understand just what it was like at the end, when the families had to say goodbye after all this effort to save this kid鈥檚 life. We all felt so helpless.鈥�

As a result, he accepted invitations to appear on CNN, MSNBC, and CBS in the wake of the March 2023 shooting at the Covenant School in Nashville, 鈥渢o talk about why we don鈥檛 need assault weapons in society.鈥�

For Dr. Wellons, therefore, the mission of writing is representation鈥攚hich, per Dr. Charon, 鈥渃onfers form on what is heard or perceived, thereby making it newly visible to both the listener and the teller.鈥�⁵ His writing encapsulates another reason physicians engage with narrative medicine: to make their on-the-ground experiences, including those with grave outcomes, clear to those who most need to know.

Affiliation: Connecting through the Written Word

Sharing information is also a key consideration for liver and kidney transplant surgeon Dr. Mezrich of the University of Wisconsin-Madison. Raised in a 鈥渇amily of readers,鈥� Dr. Mezrich has always connected to others through the written word: 鈥淲e loved books, and we continue to have family book clubs and are always talking about what books we鈥檙e reading.鈥�

Aware that 鈥淚 had at least one book in me, if not more,鈥� he has a standing practice of bringing the written word into the clinical encounter. 鈥淲hen I meet those patients who I find compelling or who I connect with,鈥� he explained, 鈥淚 usually say to the patient, 鈥榊ou know, I鈥檓 really interested in your story. Would you mind if I considered telling it at some point?鈥� And if they are open to that, I鈥檒l maybe write something about them in time.鈥�

His first book, When Death Becomes Life: Notes from a Transplant Surgeon (2019),¹¹ showcases many of these patients鈥� stories. It also takes an unusual approach to the medical memoir. To his retellings of cases and personal narratives, Dr. Mezrich added a researched history of the entire field of transplantation, including stories of the first patients to undergo groundbreaking procedures and the surgeons who performed those operations. 鈥淚 wanted people to know who these people were who made transplant happen,鈥� he explained. 鈥淚 wanted to meet with them and understand how they were able to do that despite all the people saying they were crazy.鈥�

This included Thomas E. Starzl, MD, FACS, the surgeon who completed the first successful liver transplant. Dr. Mezrich interviewed Dr. Starzl shortly before his 2017 death and researched his work at length. The text makes Dr. Starzl鈥檚 importance and Dr. Mezrich鈥檚 admiration clear: 鈥淰irtually every liver transplant center in this country can trace its origins to Starzl within one or two generations, and to this day, many leaders in our field are Starzl disciples.鈥�¹¹

Yet Dr. Mezrich鈥檚 path is clearly far different from that of Dr. Starzl. Although Dr. Mezrich writes about his experiences with the burdens inherent to patient care, his frank prose about Dr. Starzl鈥檚 difficulties (鈥淗e has been quoted numerous times stating how much he hated surgery鈥�¹¹) contrasts strongly with his own views (鈥淭here are so many things I love about being a surgeon鈥�¹¹). Dr. Starzl was tormented by anxiety over the patients needing his help; a near-diametric opposite, Dr. Mezrich is open-hearted, extroverted, and even joyful about his.

鈥淎 lot of my patients have ended up reading the book,鈥� he said. 鈥淚 sometimes tell them, 鈥楳aybe you should begin after the transplant or after the nephrectomy surgery,鈥� but it鈥檚 been a really fun way to connect with patients, to have them connect with me as a human being as opposed to just a physician.鈥�

Many also find the patients he depicted compelling, often asking how specific surviving individuals are doing now. Moreover, Dr. Mezrich said he routinely receives emails from strangers affected by his writing: 鈥淭he book came out in 2019, but every week to the current day, I still get an email from someone who is somehow connected to transplant who wants to reach out, whether they had a family member that donated in a sad story or someone who鈥檚 on a waiting list or someone had a bad outcome.鈥�

Noting he is careful to respond to as many as he can, he characterized these connections, even those reflecting deep grief, as 鈥渞eally gratifying and enjoyable.鈥�

In these ways, Dr. Mezrich uses writing as a means of human connection, both on the page and well beyond it. In other words, his narrative medicine reflects the principle of affiliation, which Dr. Charon writes 鈥渂inds patients and clinicians, students and teachers, self and other into relationships that support recognition and action as one stays the course with the other through whatever is to be faced.鈥�⁵

Individuation and Unity

Although Drs. Marsh, Wellons, and Mezrich all wrote books that could be classified as narrative medicine, no book or writer could be substituted for any other. Indeed, the impossibility of interchanging narratives on health and illness is central to the idea of narrative medicine. The entire field is rooted in examining the particular experience, rather than the analytic generalizations scientific thinking requires.³

Nonetheless, universalities are clear. Each surgeon succeeds at connecting to readers through honest disclosures鈥攑articularly when a situation and the emotions it evokes are difficult鈥攁nd benefits from the emotional equilibrium and increased closeness to others that this creates.

All three also were clear that there is no need to publish a book to benefit from narrative medicine. Citing busy schedules, the authors noted that brief periods of reading and writing, even if kept entirely private, are still worthwhile.

In fact, Dr. Mezrich shared his enthusiasm about reading, another core narrative medicine practice: 鈥淚 can鈥檛 see a better way to learn about the world around you, to learn about fascinating people, to learn how to balance your own emotions. There鈥檚 nothing better than reading, in my opinion.鈥�

Asked if others should consider keeping journals, as he has, Dr. Marsh鈥攚ith a rather drier wit than his American counterparts鈥攏oted, 鈥淚t wouldn鈥檛 do them any harm,鈥� adding that a focus on communication was essential to a medical career.

In his book, Dr. Wellons included a chapter on a one-time narrative medicine gathering he led for his neurosurgical residents, 鈥渙n the theory that telling stories about the things that most affect us is a redemptive act and will help us all鈥攑atient and practitioner鈥攊n the push to heal.鈥�¹⁰

The robustly attended meeting yielded an outpouring of emotion. About the event, Dr. Wellons offered a comment that might sum up all narrative medicine: 鈥淧eople want to be able to share their stories of joy and grief.鈥�

Sophia Newman is the Medical Writer and Speechwriter in the 麻豆传媒Division of Integrated Communications in Chicago, IL.

References

1. Verghese A. Cutting for Stone. Vintage Books, 2010.
2. Johna S, Rahman S. Humanity before science: Narrative medicine, clinical practice, and medical education. Permanente J. 2011;15(4):92-94.
3. Fox DA, Hauser JM. Exploring perception and usage of narrative medicine by physician specialty: A qualitative analysis. Philos Ethics Humanit Med. 2021;16(7):1-9.
4. Charon R. Narrative medicine: A model for empathy, reflection, profession, and trust. JAMA. 2001;286(15):1897-1902.
5. Charon R. 鈥淚ntroduction.鈥� In: Charon R, DasGupta S, Hermann N, et al, Eds. The Principles and Practice of Narrative Medicine. Oxford University Press, 2017.
6. Marsh H. Do No Harm: Stories of Life, Death, and Brain Surgery. Weidenfeld & Nicolson, 2014.
7. Marsh H. Admissions: A Life in Brain Surgery. Weidenfeld & Nicolson, 2017.
8. Marsh H. And Finally: Matters of Life and Death. Jonathan Cape/MacMillan, 2023.
9. Cao EL, Blinderman CD, Cross I. Reconsidering empathy: An interpersonal approach and participatory arts in the medical humanities. J Medical Humanit. 2021;42:627-640.
10. Wellons J. All That Moves Us: A Pediatric Neurosurgeon, His Young Patients, and Their Stories of Grace and Resilience. Random House, 2022.
11. Mezrich JD. When Death Becomes Life: Notes from a Transplant Surgeon. Harper Collins, 2019.