As a medical student, I remember having to examine an ER patient and then, with little sleep, present the case to a roomful of other trainees and a chief of services who delighted in grilling us. He wanted the whole story and he wanted it with multiple possible endings.
I presented in the time-honored way: “Mr. Jones is a 42-year-old never-married Caucasian man who presents with three days of sub-sternal chest pain that he describes as, ‘crushing, like something is sitting on me.’ It’s worse with exertion, is relieved with rest, and radiates to his jaw, but not down his arm.”
Now that I’m pursuing the dual careers of novelist and psychiatrist, I’ve come to realize that learning to obtain a history and present a case — in both written and oral fashion — is excellent training for both doctors and writers. Obviously, there’s a difference between what and how we write in a medical record and what’s likely to become a blockbuster novel, but similar skills are required for both.
It’s no accident that so many physicians have become successful authors, from Somerset Maugham and Arthur Conan Doyle to modern best-selling writers such as Robin Cook, Tess Gerritson, and Michael Crichton. Doctors often make natural writers because our profession relies on stories: hearing them, using them, and telling them.
In training, we learn to take a history: “So, what brings you in today?” It’s the simplicity of an open-ended question that invites any response: “I’ve had a cough that won’t go away.” “I got this rash after I came back from Vegas.” “Every time I walk up a flight of stairs I feel heaviness in my chest.”
The answers come with emotion and body language. We observe it all: the pain, the fear, the embarrassment. Our attitude and willingness to listen have a strong bearing on whether our patient will trust us enough to give us the whole truth.
The more interested, relaxed, and nonjudgmental we are, the greater the chance of getting the information we need. We generate hypotheses about the cough, the rash, and the heaviness. We ask more questions: “How long have you had the cough?” “What happened in Vegas?” “Tell me about the feeling in your chest.”
We’re careful not to jump too quickly to a diagnosis, as missteps in the gathering of a history lead to wasted time and bad treatment. A cough could be the common cold, or the only symptom of a malignancy. The rash could be from the detergent used on the hotel’s sheets or a psychosomatic reaction to an extramarital liaison. Is the chest pain indigestion, angina, panic?
Our most important tool is our skill in taking and interpreting a history. Our jobs are all about gathering data, interpreting it, and putting together a story that makes sense.
Basic truths
As I think back through medical school and residency, I can see that I was taught basic truths about the nature of storytelling that have helped me both clinically and as a writer:
- Common things are common; when you hear hooves, don’t think zebras.
- Consider all angles: who, what, when, where, why?
- Don’t jump to conclusions; generate a differential.
- Consider your reader.
I’ve come to view these different approaches to storytelling as points on a continuum. On one end we have the most objective clinical reporting, and on the other, personal narrative and, finally, fiction.
Similar to popular nonfiction and fiction, the medical record is a story that serves multiple purposes and has multiple readers. All must be considered when leaving a note in a medical record. The histories we write lay out the clinical data upon which we arrive at our diagnostic impressions and conclusions. Our notes reflect why we’re prescribing various treatments and whether they’re working. Our charts must meet criteria for “medical necessity” as defined by various payers. We need to remember the Joint Commission reviewer who will scrutinize what we’ve written. We must write clearly so that a colleague covering in the middle of the night will know what’s going on. Should there be a bad clinical outcome, the chart is a legal record where the written story is all that matters.
