Clicked back in…Holiday reading and thoughts on medical writing

Hey everyone…

Welcome to 2014. I’m back from holiday. I like to say ‘holiday’ rather than ‘vacation.’ It sounds more Euro. Plus, if one truly seeks word precision, saying holiday when describing time in Key West works. Everything about that place is celebratory and festive.

Let’s talk about reading and writing.

First, I’m not going to do a top-ten DrJohnM posts of 2013. WordPress sends you a tidy email of your most popular posts. I didn’t look at it. I do enough self-promotion as it is. It feels funny re-posting stuff that is already out there.

Second, I have to tell you about my holiday reading. At my age, and with my slow start in all things literary, holiday offers a great chance to push forward in acquiring wisdom. Five years ago, when I decided to get smart (for real smart, not doctor smart), I spent an entire Christmas holiday reading Walden. Actually liking Henry David was a tipping point. Now, I see holiday periods the same way a crit rider sees a downwind leg of the course: a time to make hay.

You have to understand, doctors–especially heart doctors–don’t get much time off the science campus. The shock collar keeps us learning about ion-channels, murmurs, doppler flows, and now, appropriate use criteria and managing Commodore-64-like EMR systems. There’s not much time to learn about real human life.

Oops. Sorry. That wandered a bit. Back to the books and writing.

I’ve been looking forward to reading David Epstein’s The Sports Gene for some time. As a lifelong athlete and fan of all things sport, I wanted to learn more about the science of extraordinary athletic performance. The Sports Gene works. In fact, the more curious you are, the better the book works. Why do some athletes respond to training so quickly, and others, like me, perform about the same at the beginning of the season as they do at the end? Why do many of the world’s best sprinters hail from a small area of Jamaica? What about those Eastern African distance runners? And my fav: Perhaps the finest endurance athletes of all species live in Alaska and run on four legs? The Sports Gene gets my highest non-fiction recommendation–5/5 stars. You will not be disappointed. Trust me.

Next up was Hemingway. He hadn’t caught a fish in 84 days. He had lost his mojo. Damn it; he was going for it. Out far. Oh Santiago. The Old Man of the Sea: 120 pages, a couple of hours on a sun-lit porch in Key West, a cold beer…just beautiful. You get the sense Mr. Hemingway wrote that story in a single afternoon before going out for cocktails. Those sentences. That flow.

Non-fiction and a short novel were the warm-ups for the marathon–John Updike’s Rabbit Angstrom tetraology. At 400+ pages per, there were times when I was worried about blood clots. “John…are you going to move?”

But the story of Harry Angstrom had me hooked. Here’s the thing: people who win Pulitzer prizes do so for a reason. What’s not to like? You get a story of a high school athlete; you get American history, beautiful prose, vivid descriptions of life’s treasures and anxieties, consideration of the meaning of life and death, and, for the win, cardiology figures as a central theme. How did Updike know so much about Medicine–even inappropriate coronary interventions? How did he know so much of everything?

One of my themes in writing about Medicine is that doctors (and patients) struggle with the notion that treating disease is not the same as treating people. We too often deny that death is part of normal life. Stories like Rabbit Angstrom help us see past the white screens and checklists. They help us see people. Am I wrong to think that the little wisdom I have acquired in two decades of practice could have been accelerated if I had spent more time reading literature rather than ion-channels?

Dr. Richard Gunderman is an Indiana University Professor of Radiology. He is also an author and famous writer. He writes in The Atlantic that “first-rate physicians need to be knowledgeable and skillful, but they also need to be curious, insightful, and compassionate.” And, “such abilities are not developed by reading typical medical school textbook chapters and journal articles about diseases and their treatments. If they can be cultivated by study at all, it must be through the encounter with another kind of book, a work of literature.” He then goes on to offer seven classics that doctors should read. It would be hard to disagree.

On writing:

Finally, I’ve been wondering about the act of writing–or in my case blogging. My friend Doctor Wes, a leader in the realm of medical social media, wrote yesterday that medical blogging may be suffering a slow death. He cites the increasing pressure of medical practice:

I feel the pressure to produce like never before – bogus MGMA benchmarks and dwindling RVUs have a way of doing that to you.  So it is harder to be a cheerleader for social media when I see the mounting challenges real care-taking doctors and nurses are asked to face. After all,  not only are we tasked with the responsibility of being care givers, we are also being tasked with negotiating minefields of codes, becoming typists, consulting as business efficiency experts, and serving as social psychologists, too. If we could just add another eight hours to every day…

So blogs go untended.  Writing shortens. Or withers away.

He has a valid point. Medicine takes more from you now. Those of us in this generation knew what it felt like to be productive. But it’s not possible to click and check and comply and still see the same number of patients. But they are there to see. “This patient needs to be seen this week but your first opening is in March.”

Yet I have two other problems with being productive as a writer. It’s sort of paradox: the more I write, the harder it gets. In the beginning, I would sit down at the computer full of enthusiasm and just go. Type. Hyperbolize. Screw up verb tense and not even know I was doing it. Now it’s hard to go back and read those early posts. I cringe. As you write more, and people begin to read your words, standards rise. And that slows things down. I’ve often thought about having a free-range/first draft/flight of ideas blog. One where you just type little zingers of thoughts, maybe bullet style, on lots of topics. Wait…isn’t that Twitter?

Developing higher standards is only part of my current problem. Another is fear. Again, in the beginning, I would shoot from the hip about what was going on in Medicine. I would speak frankly. I could tell patient stories more easily. (I went to four hospitals and now go to one.). Times are changed. I am now an employed doctor working in a system that is awfully sensitive to criticism.

I have to be careful about how much I say. One must tread lightly with words. Be careful when describing how duct-tapped EMR systems are destroying the patient-doctor relationship. Or how misplaced incentives contribute to wasteful over-treatment. Or how some quality measures actually impede quality care–and everyone knows it and just keeps doing it. These are narratives that need to be told. But doing so can be a challenge when still practicing in a competitive marketplace. Thoughtfulness and candor about health policy isn’t really useful to hospital administrators/employers these days.

These problems aside, I will continue to press on. Learning to write makes me happy. Making Medicine better is worth the trouble.

JMM