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.
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.
As it happens, my own best experience with narrative medicine also might as well have been a Girls setpiece. On my OB-GYN clerkship, a resident asked two other students and I if we wouldn't mind piloting a writing workshop research project with an abortion doula we worked with in clinic. Not knowing what an abortion doula was (they are emotional counselors and spiritual companions to women during medical and surgical terminations) we said whatever, because we had to, because we wanted to, because we were on shift at the time. The girl seemed pleasant enough and had the affect you would want in a doula, even and earthy and San Fernando Valley girly and something to which none of the three of us could relate (though the other two were male). Despite my initial skepticism, it was actually a pretty exciting exercise: Our doula friend was well-trained in leading writing workshops, and given the privacy of the small group, she let us share whatever we wanted. It was all very intimate.
Both of those guys are great storytellers outside of that room, and in that room they shined, transcribing the histronics that made them so entertaining to work with on shift into prose. I won't divulge what they wrote, as I didn't tell either of them I was writing this piece. My hope is that they write on their own, but I doubt it. Let's just say that I liked how dark their stuff was, not at all the types of things you see published by medical students in op-eds and magazines. I worry there's an air of secrecy making this so. In most publications, transgression is not allowed, even the transgression of telling somebody you think the idea of writing about medical practice is silly and self-absorbed.
For physicians, particularly those in training, gratuitous displays of flesh can feel crass, like us advertising our lack of control. Lena Dunham and her writing staff are well aware they are parroting this sense of proportion among the coming-of-age in their show. It is hard to expose oneself to ridicule, but maybe those who like helping others out with their most private lives, meaning doctors, have some desire to do it deep down.
So by far the most affecting piece I've read on medicine in some time is an essay in the political journal Dissent -- not my usual reading, granted -- by a nursing home worker. The essay is about abuse of female labor in the health care market, but, like Girls, it is also about a bunch of young women (there, multiracial) in solidarity about how low they feel. United by disgust with their work and their love for the patients they sometimes hate, it makes geriatrics sound both disgusting and exhilarating. It was originally published on an anonymous blog, which I think is important: The best medical trainee writing appears on unpublished anonymous blogs. It shouldn't. It's not even a violation of HIPAA, as the one you are exposing is you. That's narcissism, yes, but the kind of sublimated narcissism that makes great art or produces social change. It is not safe to be a standard-bearer, but it will save American practice.
This cathartic self-examination is more like one might see in an Alcoholics Anonymous meeting, now also portrayed on Girls. When I attended an AA meeting for a medical school assignment, I sat in a chair that felt like the time-out section. I was asked to join the circle and integrate. They asked if my visit was an assignment for class. I leveled: Yes. I wanted to lie to them, desperately. I will not divulge anything else out of respect for the participants, but that is the one difference between narrative medicine and group therapy: If we are public figures, we need to show honest portraits of ourselves as caretakers so patients feel like we will take them in. It's tempting to say "unflinching," but I mean the product should make the reader flinch, serve as a non-tin ear. Our patients come to us and tell us their stories without shame, and whether we like it our not they will tell ours elsewhere, nice or ugly. We should drop ours more often so they know we're with them.
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