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Does Cancer Care Inspire Great Writing?

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Oncologists face unique emotional challenges because of the frequency of the morbidity and mortality they see, which may be unparalleled among specialists. “We see tragedy after tragedy. And we go see the next patient,” Bill Eley, MD, of Emory University in Atlanta, Georgia, once summarized.

Last year, Riyaz Shah, MD, of the Kent Oncology Center in the United Kingdom, tweeted that this uniqueness breeds a need for communication. “Oncology is an odd one. Exposed to human distress daily (if not hourly). Very few people understand what we do, fewer would do it. There aren’t many people we can talk to.”

But oncologists not only talk, they write too — often for each other. And some oncologists believe that their unusual work life can sometimes yield transformative and even great writing, whether it is a best-selling book or a “narrative essay” published in a medical journal.

“When we wrestle with life and death on a daily basis, at some point, we need an outlet to share that struggle,” observes Jennifer Lycette, MD, of Providence Oncology and Hematology Care Clinic-Seaside in rural Oregon, who writes a blog about being a physician who cares for cancer patients.

“I think oncology definitely does [produce great writing],” says Kathryn Hitchcock, MD, PhD, a radiation oncologist and writer at the University of Florida, Gainesville. “It’s is a high-stakes game” that sheds the inessential things in life, she adds.

Of course, doctors in other specialties also face emotional challenges and also write about their experiences.

“I have no illusion that it’s only oncology [that produces great writing by healthcare professionals],” comments Lidia Schapira, MD, of Stanford University in Palo Alto, California and editor of the Art of Oncology, the essay section of the Journal of Clinical Oncology (JCO). “But I do think that oncology brings us to a very intimate space with patients and close contact because of existential worries.”

Oncology provides a notable portion of the contributions to A Piece of My Mind, the weekly medical narrative column in JAMA, says editor Preeti Malani, MD, a geriatrician who is at the University of Michigan, Ann Arbor. Now in its 41st year, the column covers all specialties and general medicine.

“Bottom line,” says Malani, is that stories from any specialty attempt to “infuse humanity into medicine, which we all try to do [in our daily work].”

One Common Theme

Schapira has edited the Art of Oncology for the past 5 years, after about 20 years as a reviewer, which nearly dates back to the column’s inception.

Shapira explains that storytelling in JCO has “evolved” from essays on emerging matters such as palliative medicine and medical education, and eventually “became more about the inner life of the oncologist and, in many cases, honoring the life of a particular patient.”

“The message is that the writers have a deep, deep respect for the people they treat,” she says.

In the mass media representation of doctors, especially on television, says Schapira, “that part is totally missed.”

In an essay published last month in JCO, entitled “Knuckles,” Florida’s Hitchcock exhibits that kind of respect with a cancer patient.

The author’s two opening sentences are arresting: “The swastikas on his knuckles kept stealing my attention. I tried not to stare but every time he gestured to emphasize his words, my gaze snapped back there.”

Roughly 1600 suspenseful words later, a surprise emerges — which dozens of JCO readers from as far away as Australia appreciated, emailing thank you notes to the radiation oncologist.

Multiple readers told Hitchcock that the essay, in which she and the patient both triumph after taking risks, breaks away from a convention in oncology writing, which is: “I was taking care of this patient and their situation made me very sad.”

At JAMA, there’s no topic for a contributed essay for a Piece of My Mind that is “too mundane,” says Malani, who reviews about 2000 stories a year for 48 publishing slots. The section is one of the journal’s most read and its writers often get “thousands of emails” in response, she observes.

The keys to great storytelling in medicine include a fresh perspective, high-quality writing, and an emotional dimension, suggests Malani, who has a master’s degree in journalism and was a newspaper reporter before medical school.

“I often pick what makes me cry,” Malani acknowledges. “Many stories are about patients — many are difficult and upsetting,” she says, echoing Schapira’s comments.

However, there is a tendency for first-time authors to submit stories that are commonplace, she says. For example, one current topic repeatedly submitted to A Piece of My Mind is “Why I Hate Virtual Med School” stories from medical students.

Writing about cancer has undergone a remarkable transformation in the past 40 to 50 years, Malani also points out. “Cancer went from being something that was stigmatized — so that no one would write about it — to being something that helps create community,” she observes.

Journals have taken notice of the appeal of community-building narratives. In addition to JCO, other cancer journals also have sections for storytelling or nontraditional (ie, not data-driven) editorial contributions, such as JAMA Oncology (Cancer Care Chronicles) and The Lancet Oncology (Perspectives).

JCO’s Art of Oncology, described last year as “well-loved” on the ASCO Post website, has also branched out into podcasting, with veteran professional Hollywood actors such as Susan Sullivan and JoBeth Williams volunteering their time and reading the essays aloud. 

Stories Can Inspire Change

Cancer has been the subject of a number of best-selling books in recent years by laypeople and physicians, including for example, When Breath Becomes Air and Radical Remission.

But perhaps the most notable, The Emperor of All Maladies, the Pulitzer Prize-winning book about the history of cancer treatment, was born out of everyday oncology practice.

In an interview with Eric Topol, MD, Medscape‘s editor-in-chief, author Sid Mukherjee, MD, DPhil, a medical oncologist at Columbia University in New York City, described how the idea for the book came to him.

“I was a fellow,” said Mukherjee. “I was asked by a cancer patient a very simple question. She said, ‘I’m willing to go on but I need to know what it is that I’m fighting.’ I was amazed by the idea that there had not been an intellectual history of one of the greatest families of illness in our history — cancer. So I looked for myself and tried to find one, and when I couldn’t find one, I decided that I would write one.”

Mukherjee has been widely credited with having a gift for merging science with storytelling.

“We ignore the importance of storytelling at our own peril,” says JCO’s Schapira. “Stories can inspire change.”

JAMA‘s Malani agrees. She highlights an essay by Jessica Colburn, MD, from Johns Hopkins University in Baltimore, Maryland. Colburn writes as a mother whose 8-year-old daughter complains of headaches, and soon after, has an MRI that reveals a brain tumor.

The article’s great lasting impression, says Malani, is the mother’s appreciation of the gentle kindness shown to her and her frightened child by the imaging technician and neuroradiologist. “When you read something like this, you say to yourself: ‘I’m going to be more kind,'” Malani comments.

She also makes a claim for first-person medical narratives in weekly journals: “The fact is that, in reading a 1000 words, I can be transformed.”

Schapira highlights “Present at Bedside at Time of Death” and other essays written by Lycette, the oncologist from Oregon, whom she describes as a “phenomenal writer.”

Lycette started writing after practicing oncology for about a decade, having settled into a life serving patients in a rural, coastal region. “A combination of personal and professional struggles culminated in my wrestling with the larger question: What is hope? I became consumed by this strong inner need to write about it,” she says. Ultimately, Lycette discovered that it was patients who taught her, culminating in her first published piece, “Practicing Hope.”

Lycette expansively explores her life and oncology practice when she writes —perhaps the polar opposite of much of medical literature, which typically is a calculated exposition in the name of stating a conclusion.

She says: “I’m always surprised at the direction the writing takes me. Where I end up is never where my conscious mind would have predicted.”

Nick Mulcahy is an award-winning senior journalist for Medscape. He previously freelanced for HealthDay, MedPageToday and had bylines in WashingtonPost.com, MSNBC, and Yahoo. Email: [email protected] and on Twitter: @MulcahyNick

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