One of my elderly patients, Valeria, has been coming to see me twice a week for the past 10 years. She is always full of complaints I can recite by heart: Her legs are swollen; her back hurts; she didn’t sleep a wink last night; she hardly eats but can’t lose weight; her daughter doesn’t visit enough; her head feels as though a lead weight is pressing on it.
“I asked my husband for diamonds, but all he gave me were gallstones” is her favorite kvetch.
She’s a right, royal pain in the arse. Nothing I ever do is good enough for her, but she keeps coming back to me every Monday and Friday, without fail. She has done the rounds of all the specialists, had every investigation known to man, and no one can find much physically wrong with her. No one has been able to come up with a diagnosis. Although I tear my hair out every time I see her seated in the waiting room, I am secretly very fond of her.
Last month, she surprised me. While I was away on vacation, she went to see an 85-year-old general practitioner at another clinic about her headaches. She told me he spent an hour with her and took a lengthy history, asking about her life in Russia during the war, her current social circumstances, how her husband’s death 10 years ago affected her. She also reported he did a thorough physical exam. He looked at her bunions and the insides of her shoes, and much to my surprise, he didn’t order any tests to add to the pile of investigations Valeria has already been through. He even took the trouble to write me a long letter, concluding that there is nothing much physically wrong with Valeria and suggesting she take up bridge at the local community center.
“He was the best doctor I’ve ever been to,” Valeria told me when she came in to see me as soon as I was back at work.
“How’s that?” I asked, incredulous of the huge red lipstick smile plastered across her normally sour-as-lemons face.
“He checked me out thoroughly, then told me I was terrific for a woman of my age.”
This doctor didn’t say anything different from all the others, but he said it differently. All of Valeria’s specialists had focused on particular symptoms they had in-depth knowledge of, trying to reach a diagnosis. The elderly family physician, on the other hand, had looked at her from a generalist’s point of view, placing her multitude of complaints in the vital context of her age, and concluded that her complaints were all part and parcel of her body slowly wearing out. It took this old Marcus Welby look-alike to see the truth and tell Valeria, reframing the news in the nicest of ways, that she is simply getting old.
In medicine, over recent decades, there has been a drive for specialization, partly because expertise is currency that buys professional status and an assured career path. Specialization has also flourished in response to the demands of patient dollars for “experts” in various fields. Yet, studies by Barbara Starfield, a late American academic, show that the more medical specialists we have (beyond a fixed point), the greater the correlation with more deaths. Dr. Abraham Verghese, once an orderly and now a highly esteemed physician and author, points out that, nowadays, the average physician interrupts his patient within 14 seconds. Patient narratives have been relegated to the periphery, overshadowed by MRI scan results and biopsy reports. But, as my experience with Valeria shows, none of this necessarily results in better patient care.
In literature, too, where the parallel to an assured career path—think John Grisham and Stephen King—may be predictable shelf space, there is intense specialization. I wonder whether there are any studies relating to literary specialization and the death of books?
I used to feel that by not specializing as a doctor—having no in-depth knowledge about the interaction between cellular mitochondria and microtubules in a ﬁlamentous fungus, for example, or not knowing off the top of my head the approximate molecular weight of pegylated interferon alpha-2a—meant I had dumbed myself down. My brilliant colleagues, many of whom became professors at a young age, were making cutting-edge discoveries in cancer research while, as a family physician, I was busy pulling out small marbles from children’s ears or freezing yet another wart off Mrs. McRae’s foot.
Creative nonfiction may be the literary equivalent of medical general practice. It is just as broad-based and difficult to define, having no strict boundaries. As a form, it zooms in on micro-details but also zooms out to deal with broader issues, which are of equal importance and worthy of wider consideration. And it listens to story truths, serving as a kind of meeting point for various genres, various specialties. That seems a pretty good definition of a family physician to me.
Scientific and literary creativity intersect. Creativity has nothing to do with specialization or genre. What may help promote creativity more is the ability to see things from a different angle—being an outsider. Perhaps this is why family physicians and creative nonfiction writers, who see things through the perspective of a broad lens, are often considered mavericks in their professions. According to Cormac McCarthy, the link between great science and great writing is “being willing to say something nine-tenths of people will say is wrong.” How often have I received a letter from a specialist telling me the best cure for my patient is to send them to a psychiatrist? More often than not, my intuitive “inner chicken” is proven right as we eventually uncover some rare disease as the cause of the patient’s bizarre constellation of symptoms. General practice in medicine and creative nonfiction in the literary arena are both journeys of exploration, often taking paths that seem to meander, wandering around the subject while observing and trying to figure out the truth.
Maybe the reason I love family medicine and creative nonfiction is that both are about taking your time to listen to the story as it unravels during the telling. As I analyze a medical history in order to make a diagnosis, or struggle to craft an essay, it is often those little intuitive sidetracks and dirt roads that lead me to the answer I have been searching for—that “Eureka!” or “Aha!” moment that Lehrer and others describe as an integral part of the creative process. Of course, these moments don’t always come to you in an instant of sudden realization; more often, they develop over time. Jerome Groopman, Professor of Internal Medicine at Harvard University, a staff writer at The New Yorker and the author of several books including “How Doctors Think,” describes his creative thought processes as evolving, rather than arriving as a distinctive and sudden revelation. When I spoke to him about my hypothesis of taking a macro approach in order to reach this “Aha!” moment of understanding, he reflected on his own writing process: “Alas, I don’t really have such a moment to recount. Thoughts seem to drift into my mind in multiples, meaning not a single epiphany but rather groups of ideas, which then get winnowed. As it happens, this often occurs when I’m swimming, perhaps because of the sensory isolation and the repetitive turns while counting laps.”
Writers of creative nonfiction often say things in a fresh and enlightening way; they synthesize others’ research and communicate it effectively to a wider audience. Creative nonfiction writers examine subjects through a broad lens that reflects the truth: Anne Lamott does this on the process of writing, Malcolm Gladwell on the art of decision making and George Orwell on our prejudice against beggars.
General practice and creative nonfiction share common ground when they zoom out from their subjects and take a broad overview. I specialize in being a generalist; knowing a little bit about a lot is the gig for me as a family physician. It’s how many creative nonfiction writers roll, too. Both professions are built on expecting the unexpected; as a matter of fact, the best actively search it out. In the end, it’s not the genre or the specialty that counts: It’s the truth of the story and the journey that matter most.