Special to LitSite Alaska

For almost twenty years, I have practiced medicine in a small rural community in Virginia. And I won't apologize for saying that I practice, as many aspects of my life require practice, such as taking a photograph of a sunrise or an early spring wildflower, working on personal and professional relationships, and paying attention to what is present in each moment. My writing, too, requires practice, as it does not often just happen. William Carlos Williams wrote in his essay "The Practice" that "it's the humdrum, day-in, day-out, everyday work that is the real satisfaction of the practice of medicine."(1). And I agree with him. For all of us, doctors included, the real aspects of our lives are in our everyday existence.

Julie Connelly, M. D.

During these years, I have seen over fifty thousand patients. Doctors have the most incredible view of life, and it is extraordinary to share such a glimpse of humanity. Physicians know the personal stories of many individuals. From the elderly man with a congenital deformity, we know how is it to walk with a limp for an entire life; from the young woman with ovarian cancer, we learn how a positive attitude and direct connections with family and friends help provide strength to face a life threatening illness; from the man with severe headaches, we know how it feels to be "worried to death" that, perhaps, you are dying from a brain tumor; and, from the woman with chronic mental illness, we listen to the trials of living without privacy, sharing a bedroom with three other women in a home for adults. Every day we have the privilege and opportunity to interact with patients and their family members in the most intimate and individual ways. People have amazing stories and many of them need to tell these stories in order to move on with their lives. They want an objective, but compassionate listener whom they trust.

Not everyone is born to become a writer, but everyone can learn to write. Doctors are in an ideal position to be writers (2). The stories that are shared, the physician's personal responses, the interpersonal connections provide an opportunity for physicians to reflect on their lives by writing short stories and poems. Many physicians have been writers. For instance, Mikhail Bulgakov in A Country Doctor's Notebook describes his first experiences as a fearful, young physician working alone in rural Russia (3). The writings of pediatrician William Carlos Williams, especially those collected by Robert Coles in The Doctor Stories, chronicle dilemmas -- both his and those of society -- that he faced while caring for poor immigrants in Rutherford, N.J., during the Depression (4). In the anthology of contemporary poems, Blood and Bones, editors Angela Belli and Jack Coulehan demonstrate how physicians through their writing attempt to bring order to disordered situations (5).

During grade school my classmates wrote wonderful stories of fantastical worlds, but my stories did not begin to take shape until 1980 during my fellowship in General Medicine and Medical Psychiatry at the University of Rochester when I met Kathryn Montgomery, head of the Humanities Program. One day I told her about a patient that I was struggling to understand, and she suggested I write a story. "No way! I can't write." I responded, horrified by the suggestion. But that evening I wrote about this troublesome interaction --what I said, what I felt, what I heard the patient say, what I observed to happen between the patient and me. Soon I had written a story, and I had explored the situation from a refreshing, open, and surprising point of view. Why did I feel as I did about this patient? What made me respond to her as I did? I began to understand more, and slowly I realized how my personal history was interfering with my ability to care for her.

Some days I take a break from the office to run an errand, and I am always amazed in the bank, the grocery store, the post office, or the hardware store about how many people I really know. I don't just know that they played on the winning softball team, I know the details and very personal ones. You might wonder, what is my relationship with these individuals? And that is where things get more complex. I, too, have a personal story that influences how I react in various situations, my degree of compassion, and most everything else. Between the patient and the physician, two stories are present and out of these stories arises a relationship. Physicians experience a diversity of relationships -- some functional and others not. As I said, relationships between patients and physicians get complex really fast.

Feelings, emotions, reactions arise in this relationship from both the doctor and the patient. One challenge for me is to develop an understanding of my personal experience with patients. This is not necessary with each patient at every visit, but there are times when knowing what and why I feel a particular way is extremely important. To clarify my point of view, I sometimes write in my journal and other times I go straight to my computer. I write stories for a variety of reasons: to process an upsetting experience, as I did after making a mistake and becoming fearful about being sued for malpractice (6); to look into the anger and frustration that occurs occasionally while I work in the office, as when patients don't take medications to prevent strokes or change behaviors known to cause problems; to record touching or meaningful interactions, as when patients teach me some important lesson (7) or give me a gift of their love and kindness. Recently, I have written to review the process -- the steps of an interaction -- to understand why the situation unfolded as it did: What choices did I, as the physician, make? What was the impact on the patient? Recently, I was sitting with a dying patient who was in pain and short of breath. I said, "I can see you are suffering." He replied, "Yes, I'm no longer a person -- I can't walk around, I can't play the piano, or do any of the things I've enjoyed." Writing the story helped me assess how my exploration of his suffering allowed me to have a profound understanding of his experience (8). Most of my stories are never published, but if I decide to use one in an article, now I ask the patient or family for permission.

So what happens during the process of writing? At times the surface of the situation is explored as the specific details of a particular situation, the context including the "characters," and the point-of-view of the observer are all taken into account. This writing often clarifies a situation for the physician. At other times, writing may expose the depths of a situation. The physician's awareness may expand, interpersonal connections may be realized, and the truth of the situation understood. Such writing can help physicians process the intense and stressful aspects of their work because writing brings a sense of relief and renewal (9). A personal unfolding is possible, too, as patterns of emotional responses or habitual styles of interacting are explored. Much of a physician's work is confidential; it cannot be easily shared with others. Writing for the purpose of self-reflection and to gain self-knowledge is a way to bring more satisfaction to one's professional life, continue steps in personal growth, and decompress what others cannot know. Writing is a creative process and many physicians will be surprised where their writing takes them, and they may be shocked at the lively sense that creativity brings (10). Sometimes I share my writing with other physicians and students, and I am always surprised when they understand immediately the conflicts and dilemmas that I describe. In this sharing, there is a feeling of connection to the larger world of medicine and an understanding that many experiences are universal, even if the details are different.