January 10, 2024
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—not least of all for its evocative descriptions of surgery:
“He cut the peritoneum along the length of the incision. At once, the colon bullied its way out like a zeppelin escaping its hangar. He covered the sides of the wound with wet packs, inserted a large Balfour retractor to hold the edges open, and delivered the twisted loop out of the wound…Ghosh flexed his gloved fingers. They looked competent and powerful—a surgeon’s hands. You can’t feel this way, he thought, unless you have the ultimate responsibility.”1
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’ lives and careers by helping them process the emotional burdens of clinical work, strengthen professional competence, and “rehumanize medicine.”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—including Henry Marsh, CBE, FRCS, John (Jay) Wellons III, MD, MSPH, and Joshua Mezrich, MD, FACS—have 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.
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: “We 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.”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. “I always have written to control my feelings, basically. I’m an extremely emotional person. I write compulsively,” 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’s recent experience as a prostate cancer patient.
“The writing itself is cathartic,” Dr. Marsh said, explaining that publishing was far less emotionally impactful. Still, “I’m rather proud of the fact that I wrote three books in a row, none of which bombed.”
In fact, the cathartic approach seems essential to his success. “What’s unusual about my books is this brutal honesty,” 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 “F*** everybody.”6
He added, “I got a lot of comments and letters and emails over the years from doctors, saying ‘I 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,’” a rare contrast to a perceived professional obligation for surgeons to hide their emotions and pretend to be in control.
“Finding a balance between profound compassion and the necessary clinical, scientific detachment is very, very difficult.”
To Dr. Marsh, reflecting the complex emotional life of a surgeon was the point: “The 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’s no contradiction between being a thrill-seeker but actually wanting your patient to do well.”
There also is fine balance, he says, in feeling for patients. Dr. Marsh explained that a common motivation behind engaging with narrative medicine—developing empathy for patients and colleagues9—is slightly ill-conceived. “As a doctor, you cannot do the work if you are truly empathic,” he wrote in And Finally.8
In conversation, he clarified, “Empathy 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’t had the experience of being a patient yourself. So, it can become a rather artificial exercise.”
What is necessary in his view is “compassion, understanding, and respect for patients.”
“Finding a balance between profound compassion and the necessary clinical, scientific detachment is very, very difficult—for the simple reason that the more you care for your patients, the more it hurts, when things go wrong or you can’t help them,” he said.
Ultimately, Dr. Marsh’s 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—via what Dr. Charon described as “the state of heightened focus and commitment that a listener can donate to a teller.”5
“What makes the work so interesting is the patients. I spent the whole time talking to them about their lives,” Dr. Marsh noted. “I always feel such a privilege to have access to people’s lives in the way one does as a doctor.”
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 (“there’s only so much Netflix you can watch”), 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, “I began to think that I’ve 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’s what ultimately led to the book.”
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 (“The infection was worse than I’d 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”9) and fleshes out medical details with social and emotional aspects of patient encounters.
“I would work toward getting some credibility as a writer with the book, then I would pivot to writing and advocating on a different level.”
Like Dr. Marsh, Dr. Wellons noted that the experience has made better patient care possible: “I’m much more likely to sit down next to a family and talk to them about what’s going on and befriend them in some way. I think I’ve gotten this sense that we’re all just human beings on this earth together, and we’re just doing the best we can for one another, and to show that you’re a human being and you have strengths and weaknesses is the way I want to practice medicine.”
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 “the 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.”
Since then, he has published an essay about “what 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’s life. We all felt so helpless.”
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, “to talk about why we don’t need assault weapons in society.”
For Dr. Wellons, therefore, the mission of writing is representation—which, per Dr. Charon, “confers form on what is heard or perceived, thereby making it newly visible to both the listener and the teller.”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.
Sharing information is also a key consideration for liver and kidney transplant surgeon Dr. Mezrich of the University of Wisconsin-Madison. Raised in a “family of readers,” Dr. Mezrich has always connected to others through the written word: “We loved books, and we continue to have family book clubs and are always talking about what books we’re reading.”
Aware that “I had at least one book in me, if not more,” he has a standing practice of bringing the written word into the clinical encounter. “When I meet those patients who I find compelling or who I connect with,” he explained, “I usually say to the patient, ‘You know, I’m really interested in your story. Would you mind if I considered telling it at some point?’ And if they are open to that, I’ll maybe write something about them in time.”
“It’s 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.”
His first book, When Death Becomes Life: Notes from a Transplant Surgeon (2019),11 showcases many of these patients’ 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. “I wanted people to know who these people were who made transplant happen,” he explained. “I wanted to meet with them and understand how they were able to do that despite all the people saying they were crazy.”
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’s importance and Dr. Mezrich’s admiration clear: “Virtually 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.”11
Yet Dr. Mezrich’s 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’s difficulties (“He has been quoted numerous times stating how much he hated surgery”11) contrasts strongly with his own views (“There are so many things I love about being a surgeon”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.
“A lot of my patients have ended up reading the book,” he said. “I sometimes tell them, ‘Maybe you should begin after the transplant or after the nephrectomy surgery,’ but it’s 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.”
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: “The 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’s on a waiting list or someone had a bad outcome.”
Noting he is careful to respond to as many as he can, he characterized these connections, even those reflecting deep grief, as “really gratifying and enjoyable.”
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 “binds 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.”5
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—particularly when a situation and the emotions it evokes are difficult—and 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: “I can’t 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’s nothing better than reading, in my opinion.”
Asked if others should consider keeping journals, as he has, Dr. Marsh—with a rather drier wit than his American counterparts—noted, “It wouldn’t do them any harm,” 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, “on the theory that telling stories about the things that most affect us is a redemptive act and will help us all—patient and practitioner—in the push to heal.”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: “People want to be able to share their stories of joy and grief.”
Sophia Newman is the Medical Writer and Speechwriter in the ACS Division of Integrated Communications in Chicago, IL.