Doctors as Writers: Overshare, Be Real

Portrayals of medical issues in HBO's Girls are on point. Patients understand that medicine is messy. Doctors should let that show.


Medical training has a way of scrubbing any interesting human pain from the written record. You learn to talk in case vignettes. In a case vignette, the goal is to communicate the salient parts of a patient's story in order to argue for the most likely medical diagnosis by her subjective level of distress. Consider the following patient:

A 24 year old female with a past medical history of recurrent UTIs and anxiety presented complaining of burning pain with urination. The patient was in her usual state of health when she had a sudden urge to urinate. As she was waiting on an outdoor train platform, her friend directed her to squat in the woods next to a power generator, which she was able to do with some maneuvering. When she tried to void, she grunted and shrieked and was unable to do so completely. The patient also reports suprapubic tenderness. Lives alone, social drinker, non-smoker, experimentation with coke. Sex with men, sometimes with contraception. Menstrual history unknown. Of note, she recently had unprotected intercourse without vaginal penetration, near miss in a cemetery. Meds: PPI, anxiolytic, past SSRI prescription (needs refill). She refused physical exam. No costovertebral angle tenderness observed during hugs from friend. Assessment: Cystitis vs. UTI. Boring. Plan: Most recent antibiotic course unknown. Bactrim, or whatever. However many days. Look that up again.

You could break down the medical jargon -- PPIs are acid reflux drugs, cystitis is a bladder infection, costovertebral tenderness the doctor pounding on your back to get at your kidneys -- but this case is already available in the general record. It is yet another recap of a recent episode of Girls.

I don't even like Girls that much, but I like the way it defamiliarizes "the patient encounter" (i.e. the patient visiting clinic): On Girls, medicine is gross, which it is and should be on screen. It shows public hospitals and private hospitals in what feels like a new light -- with bad lighting. I like that the doctors on the show are portrayed as empathic to, yet walled off from, Hannah's obvious neediness. (It appears that many of the experiences of medicine depicted on the show are drawn from Lena Dunham's own life: Brian Hiatt described Dunham's medical history with obsessive-compulsive disorder and various somatic complaints in a Rolling Stone profile out this month.) The more I watch it, the more I wonder why doctors don't characterize their own work that way, too.

The navel-gazing doesn't bother me, but the pat endings do.

Over the last two decades some likeminded internists working in different American teaching hospitals developed a writing workshop network they call "narrative medicine," which teaches health care workers how to process what they see on the job. The idea, as I understand it, is to encourage doctors to read and write about suffering so they learn to celebrate and grieve together. Unfortunately, many of the personal essays the movement has produced remind me of how writers write about MFA graduate programs as psychotherapy. The navel-gazing doesn't bother me -- that's how we heal! -- but the pat endings do. In too many of these stories the doctor decides to suck it up after 800 words of genuine alienation or anger. She moves on the next day, no longer rattled or mad or scared, just happy to be doing what she does. If the story is about grief, there must be some hope for an out from the grief at the end even if it's not resolved. By no means is the exercise useless, but I am worried the workshopping label encourages doctors to produce a very specific narrative style: hermetic work that does not so much resemble the real experience of practice as stock rhythms for real psychosomatic distress.

I remember much of my time in medical school in New York as a bad Girls setpiece, filled with unflattering, if honest, behavior I fear would come off as "unprofessional" in a published piece. The sanitized version: The first two years of med school required too much memorizing, and so I took lots of breaks avoiding work at various movie theaters, including the IFC in the West Village where I saw Lena Dunham's Tiny Furniture one early afternoon. It was okay. I didn't relate to it, but my friends related me to her. Sometimes when I wasn't at movies I would do uncouth stuff I was careful never to discuss with classmates, who I am sure did their own uncouth things on their own time. Some of us do avoidant things for a reason. For me, it was because I had trouble dealing with the emotions aroused by medical training. Yet I can't quite bring myself to cop up to how my work with patients triggered my figurative screwing around. I can't produce one of those pieces of art about the masochistic joys and fueling toil of the vocation like our professors keep urging us to.

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Maureen Miller studies medicine and public health. She is based in New York and Boston.

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