 Thank you for joining us this evening for One Community, One Book. I'm Ruth Bergrin, the Director of the Center for Medical Humanities and Ethics, and I am delighted to once again partner with our Health Science Center Libraries to bring you this program. And I'd like to take a moment to especially thank two people, Rajya Tobaya, who's our Executive Director of Libraries, who's over here in red, and very importantly and somewhat sadly tonight, we're saying goodbye to our friend Susan Honeycutt, who has been a key mover and inspirer of the One Community, One Book program. I don't know where are you, Susan? Okay, thank you, Susan. I will miss you as you go off to your new life. Thank you for this legacy. I'd like to also acknowledge the financial support of this event from Humanities, Texas. That's the state affiliate of the National Endowment for the Humanities. We also have an endowment called the Gerald Winnaker Endowment for Humanities and Ethics, and Dr. Jerry Winnaker and his wife, Lee Robinson, are the professors who teach our medicine through literature course, and they are responsible for introducing us to this evening's presenter. So we're very grateful to Jerry and Lee and to that endowment as well. You also need to know that we have live streaming onto the web, and tonight's live stream was underwritten by Methodist healthcare ministries and is being provided by nowcast San Antonio. We also have live streaming to the Regional Academic Health Center in Harlingen, our Laredo extension campus, and we welcome all of those folks as well as everyone who's tuning in now via live stream. If you want to participate in an online discussion, during the event, we have a hashtag, which is present illness, all one word. I don't know how to use that, but we have it, and maybe it will foster some more discussion. After the presentation, Dr. Aronson will be available to sign books, and we have our campus bookstore here, and they are selling copies of the book in the auditorium foyer. So this is a culmination this evening of a community-wide effort where we try to get people to read and read the same book and talk about it. As a result, there have been a number of formal as well as informal book discussions both on our campus and in the city, and of course, many impromptu conversations. If you didn't have a chance to participate in the book discussion yet, there's going to be one this evening immediately following the presentation. Hanitio, if I could get you to stand up and wave. Hanitio Guzman, who's a medical student and a nursing student, will be co-leading a book discussion on the fourth floor of the Briscoe Library. So anyone who is going to be hanging around and going to study might want to join that book discussion after the event. So Dr. Aronson's stories have inspired all of us to reflect on our patient's experience of illness. That's a theme at the Center for Humanities and Ethics, and has been for over a decade. And the non-medical community has been able to look rather deeply into the personal lives of doctors as well as medical students. And these kinds of moments where we can all connect around a shared experience, thereby becoming more insightful about the challenges of our calling as healers, this is what our Center for Humanities and Ethics is really all about. We say that we can teach ethics and professionalism, but that we must nurture empathy and humanitarian values. And we do that through activities like this one. Before Dr. Aronson shares her book, A History of the Present Illness, here, I will briefly introduce her background. She attended Harvard Medical School and holds a master of fine arts from the Warren Wilson College. She is an associate professor of geriatrics at University of California, San Francisco, where she also directs a geriatrics education center and the medical humanities program there. Her clinical practice is through something called the House Calls Program, providing care to homebound elders in underserved San Francisco neighborhoods. She also serves as associate editor for the JAMA Care of the Aging Patient Series. She has earned an MFA in fiction from the Warren Wilson program, as I mentioned, and has won a number of literary prizes and a short fiction award, among others. Her passion is blending medicine and writing to produce works that simultaneously entertain and educate and to create compassionate, inquisitive physicians committed to improving health and health care. Please help me welcome Dr. Louise Aronson. Thank you, Ruth, and thank you all for coming. It's a real pleasure to be here. I've heard some of the other speakers you've had in past years for this tremendous series, and it's absolutely an honor to be among them. So this book really should never have happened for any number of reasons. I started writing when I finished training, mostly because I felt that certain parts of me that I'd really valued had kind of atrophied during training. And so I did three things. I adopted a dog, and I took a graphic design course, and I took a mystery novel writing course. And I really thought I would just do this for a few months, and then I would fully recover. Well, the dog thing went fairly well, although he was crazy. The graphic design less well. People were taking that quite seriously. And what I found from the mystery writing class was that I loved writing. And although my intention was not to write about medicine, I also realized that that didn't make any sense, because medicine, like literature, really puts us at the crux of what has meaning in life. And so it's a fabulous marriage. I'm going to do a few things tonight. I'm going to read stories from the book or parts of stories, and then also talk a little bit about how I think narrative can enrich medicine and can enrich patients' lives and health professionals' lives. So the first story, and I should say for those who aren't aware, that this is a book of fiction. It's 16 stories that are loosely linked, because whenever I read the title of the story, I'm about to read people laugh. So just remember it's fiction. It's called 25 Things I Know About My Husband's Mother. Every time? OK. One, she was born in the Ahmedabad District of Bombay Province, India, in 1947, two weeks after partition, 13 days after independence, the second of six children of a petty bureaucrat and a housewife with repressed artistic ambitions that seeped out in silent tears and storms of uncontrolled hilarity. Two, by age 10, her hair reached below her buttocks. She never cut it. Three, she did well in school and hoped to go to college. Her father said no. Four, at 17, she had her first bout of depression, or so we assume. All we really know is that she stayed in bed for a year, and neither the local healers nor the specialists her father took her to see in Bombay offered a plausible diagnosis or effective treatment. Five, during that year, she read all of Jane Austen, the Bronte sisters, George Elliott, Thomas Hardy, and D.H. Lawrence, twice. Six, to everyone's surprise, she married well. The youngest son from a good family, a doctor with a growing practice in Springfield, Illinois, and aloofness reminiscent of Mr. Darcy in a skin condition that sometimes stained his shirt and trousers. The year was 1967. They were the only Gujarati in central Illinois. Seven, her husband worked long hours and expected her to manage everything else. He didn't love her, and she knew it. Eight, she had one son, then five miscarriages. After the first four, she took root on their living room couch. Her husband prescribed antidepressants, which she flushed down the toilet. Life's disappointments, she explained to her boy, one cannot be treating with pills. Of that time, her son recalls a heavy set woman hired by his father to keep house, pale bland foods, and relatively happy afternoons spent combing the tangles from his mother's hair as she began to recover. Nine, after the fifth miscarriage, she moved into the great room and enrolled in classes at the university. Three years later, she graduated with honors on a double major in English literature and business administration. Ten, that summer, her husband announced he was relocating to Kentucky with his nurse, who though neither especially young nor particularly pretty, was five months pregnant with his child and belonged to a pink-skinned but surprisingly open-minded extended family outside Louisville. Eleven, after her husband's departure, she spent a week in the hammock on the screened back porch in what turned out to be her last such sojourn. Her son shopped and cooked and cleaned until one afternoon, he returned from the store to find his mother trying on business suits. Before that day, he'd never seen her in anything but a sari. Twelve, for the next 12 years, she worked at the university from which she'd graduated, first as the administrative assistant to the chairman of the English department, then as the dean's special assistant, and finally as the registrar of the College of Arts and Sciences. Thirteen, when her son was a sophomore in college, her ex-husband collapsed in the smoking lounge at the Dallas-Fort Worth International Airport. Attempts at resuscitation were unsuccessful. At the time of his death, he had four children. His estate went to the three youngest. Fourteen, her husband was the only man she ever slept with. Love, she told her son, especially romantic love, is an invention meant to distract the lower classes by compelling them to strive for the unimportant and unsustainable. Fifteen, when her son inquired how she could feel as she did about love on the one hand and study romantic literature on the other, she said her accent thickening as it always did when she was annoyed, you are too much focusing on logic and science. Sixteen, when several years later, her son told her he'd been accepted to the University of California, San Francisco School of Medicine. She said, I suppose you must learn for yourself that form is not always content's container. He had no idea what she was talking about. Seventeen, she was one semester short of her PhD in 19th century British literature when she was diagnosed with widely metastatic cancer. Her son flew home from San Francisco where he was midway through his fourth and final year of medical school. Scans and biopsies revealed an aggressive, primitive tumor of unclear origin for which there were no good treatment options. Go back to school, she commanded her son. There is nothing to be done here. Eighteen, upon hearing her fate, she took up walking. Before and after work and all day on weekends, she crisscrossed the small city and the university campus, sometimes venturing so far as the surrounding farms and fields, always in pain. When she became too weak to walk, her son took a leave of absence and moved home to care for her. Nineteen, people he'd never heard of sent flowers, books, and a remarkable array of foods. The breads and curries of his childhood arrived from small towns in Illinois, Wisconsin, and Indiana, while neighbors and coworkers dropped off such exotic dishes as fried chicken with bacon stuffing, mashed sweet potatoes with marshmallows, and jello molds with canned pineapple. The less his mother ate, the hungrier he became until one morning he could barely button his jeans. Twenty, she died 16 days later. Twenty-one, her son sat with the body reviewing his every memory of his mother, and in the end he concluded that he had never seen her happy, only less sad. Twenty-two, in her top dresser drawer, he found plane tickets to India in her name and his for the 10-day break between his medical school graduation and internship, and also a stack of airgrams to which were stapled photographs of young women, the ones on top gazing right at the camera, the bottom ones with downcast eyes and demure expressions. Twenty-three, if she hadn't died that April, her son might not have married me, a fellow Indian who has never been to India, a modern girl who is both a doctor like his father and a romantic like his mother, and so sometimes kisses her patients and admits that she loves them. Twenty-four, her only child became a radiologist. He spends his time scrutinizing and analyzing those parts of people that remain invisible to the rest of us. To this day, he claims strictly intellectual origins for his professional interests. Twenty-five, she never met her grandchildren, though the youngest, a girl, looks just like her. Whenever that child sleeps in, her son holds his breath, and when she laughs, he closes his eyes as a once blind man might upon waking to the excruciating beauty of an ordinary, sunlit morning. I read that story for a few reasons. One is as short enough I can read you the whole story, without putting everyone to sleep. The other thing is it does one of the things I like doing, which is playing with form. And I think that's farmed from a literary perspective, but also from a medical perspective. So that one was a list, and I'm an internist by training, and we very much like to make lists, and maybe all of us in healthcare like to do that. And the best part of the list, of course, is checking things off, and sometimes you put things on it, you've already done, so you can check them off. So it seemed that a list needed to be part of this. There are other ones. There's one that's a fake DSM-5 diagnosis, and it actually took me so long to write the book that there is a DSM-5, which was sort of fortuitous, but accidental. And then we can play with form in other ways. So the first story is a series of photographs. It's narratives describing the photographs, but I think what I was trying to do there was speak to how we think we know people in life and in medicine. And what we're seeing is one photograph or a series of photographs. And of course, if you put a series of photographs together, it's like those booklets where you can use your thumb, and it'll create a moving image, but you're missing so much in between. And so what is it that we see and that we don't see? I also wanted to deal with cultures. I practiced in San Francisco, and although my intention was not to write about medicine, it was hard not to in part because medicine was the world, and the world came into my office door, or I went to them as I do house calls. And the thing I learned about that was that it taught me to write, but it also, I think, made me a better doctor in that having to see something from someone else's perspective truly is different. You think you're being empathetic. You think you're really listening, but you're still seeing it usually from your lens. So I gave myself some challenges. Just gonna read the beginning of another story, which is the story of a child. And you'll see as I get into it that she is very different from me, but I think that's one of the beauties of literature in medicine is letting us into somebody else's world and life. And I think if we could do that more and better, we might have less of what we call the non-compliant patient. We're really, I think, there's a disconnect there as opposed to somebody not doing what they're told. So this one's called an American problem. The water dreams began the summer before first grade, third grade. In the dreams, Bhopal ran through hot rain and crowds of muddy naked legs and blurred grown-up faces or tumbled like garbage in the gutter runoff that coursed down Eddie Street outside her family's apartment after a big storm. Eventually the cold and wet got so real she woke up. Until the water dreams, she thought she'd forgotten the trip across Cambodia in her mother's stomach and the refugee camp where she learned to crawl and talk and play. The first time it happened, Bhopal removed her night shirt and underpants and curled herself up on the top half of the mattress, hoping the wet would be dry by morning. It wasn't, but she made the bed anyway and then she forgot all about the stain until her sister pulled back the covers that night. Neary paused and sniffed, then dragged her mother into the room by her arm and pointed. Bhopal's mother covered the wet sheet quickly and without comment, while her father sat in the other room in front of the television, picking at his teeth with the very long nail of his left fifth finger. At ban, her mother said, lowering her voice. It doesn't work. And Bhopal promised not to do it again. The next morning her bed was dry, but the following night the water dreams returned. They came again two nights later and three nights after that, until by mid-July there were nightly occurrences and Neary moved on to the mattress across the room to sleep with their two little brothers. At first Bhopal's mother took the wet sheets to the laundromat on Turk Street, finding money for the machines in places that made Bhopal and Neary laugh. Behind the big can of rice under the kitchen sink in a plastic bag floating inside the toilet's tall back. In the stomach of their baby brother's single toy, a little red monkey with a long curly tail. You must stop, Bhopal's mother whispered one morning at the end of the month, dropping the soiled items into the bathtub and turning on the hot water. Before shutting the bathroom door, she glanced over to where Bhopal's father lay snoring on the couch. One crema cinched around his waist like a skirt and another thrown over his eyes. In early August, a moist summer fog hung over the city, retreating to the coast for only a few hours at midday. As a result, Bhopal's sheets and night shirt thrown over the firescape railing each morning didn't know his drive by bedtime. For three nights in a row, she climbed into a damp bed in the evening and out of a wet one the next day. On the fourth night, she dreamed she fell into a bucket of boiling water and couldn't get out. She woke screaming, kicking the covers away. Her mother came running and turned on the light to reveal an angry red rash from Bhopal's waist to the middle of her thighs. There were tears that night. Her mother's, not Bhopal's, Bhopal never cried and from her father, lots of yelling. His face turned the dark purple of grape juice and he used his hands for emphasis, waving them wildly and occasionally aiming his debaco stained fingertips at Bhopal's face. While he shouted about bad behavior and wasted money in letting the family down, she compared his bare feet so broad and flat and pale with her own tiny brown toes and high rounded arches. She stood with her legs apart because the air felt good on the burn beneath her night shirt. Suddenly, Bhopal felt a tight pinching pain in the upper parts of her arms and the floor pulled away from her feet. Her father lifted her into their faces and her eyes were nearly level. Pay attention, he yelled, his mouth leaking the familiar sour smell of ashtray bottoms and whiskey. Bhopal held her breath until she got a funny feeling in her head and made her eyes wanna close. Across the room, her mother repeated a single word like an incantation. At first, Bhopal couldn't make out what she was saying and then she recognized that it was a name, Vanak. Her father must have heard it too. Without warning, he let go and she fell to her knees. For a second, the apartment was perfectly quiet. Then her father grabbed his coat and left, slamming the door behind him. Immediately, the baby wailed. And soon enough, the others joined him. Bhopal too felt something hot and hard in her throat like a small animal trying to get out but she swallowed again and again until she made it go away. Later, she asked about Vanak. Her mother said he was a cousin who'd been arrested in Rhode Island after treating his son's backache with cupping and coining. The teacher had seen the large round bruises and long red lines under the boy's shirt and called the police. Vanak had spent nine months in prison and when he came out, no one would give him a job. In America, her mother explained, a man could discipline his wife but he must never leave marks on his children. So the story continues but I'm gonna stop there. Someone earlier mentioned that this wasn't the most uplifting of books, which is true. And I think part of it is that it's easier early on to have dramatic things happen and that if you think about happy stories, there are relatively few and it leads us more towards sentimentality and hallmark cards, that it's a hard line. And yet for me, the characters in here as with so many patients and colleagues often have happy endings or have a degree of heroism or resilience or just strength of self that I find inspiring and moving even though they're made up people for the most part. So an issue sometimes raised is why fiction, right? Why wouldn't you write something true? The whole point of a writing by a doctor would be that it should tell us truth. Well, a couple reasons for that. One is I didn't think anybody would read it so it didn't really matter what I did. And I wanted to write fiction. But I think the more important reason is distinguishing truth, sort of little t fact from truth with a big t. And if you think about the books or the works that endure, they tend to be fiction or literature. And I think that's getting at the big t truth, the universals. And that happens so much in medicine too because we're right up against life and death and those other universals. Another advantage to fiction is that you don't invade anybody's privacy or give away their secrets. And that if you've had a career for a while, you can take all of that and imbue it into a single character. Whereas one person's experience might give you part of the picture. If you can pull them together into a real fake person, you can probably get a little further. So those were a couple stories more about patients. And I'm going to read one now that is one of the more doctor stories. It's been interesting in that the most common response from people who aren't in medicine is to say that they now understand things about doctors that they didn't really understand before. And by that it seems to mean it's a recognition that they're human beings, which is sort of an interesting thing. Which I would think might be obvious, but maybe not. And that might be some of the barriers we set up. So this is a story called giving good death. And I'm going to read the beginning of it. And then I'm going to move to the middle where the events that got this guy where he is began to occur. Giving good death. In many ways, Robert's arrest was liberating. In the county jail, he ate lunch sitting down, exercised regularly, and with the benefits of 24 seven lighting and permanent lockdown because of what the pedophile one cage over called their VEP or very endangered person status began tackling some of the great books, large and small. He'd always meant to read, but never quite seemed to have time for. Middle March and the Magic Mountain, William Carlos Williams, the doctor stories, and the collected works of Anton Chekhov. After his arrest, Robert had at most one appointment a day and he was the patient. Twice a week at 1015, a guard escorted him through the multiple locked doors of a facility that had been hailed in the San Francisco Chronicle as quote, a stunning victory for architectural freedom over bureaucratic stupidity, end quote, by a Pulitzer Prize winning architecture critic who'd obviously never experienced the place from inside its frosted windows. Unlike the architect, Robert's experience of the building had nothing to do with freedom. The guard marched him down the corridors, shackled at wrists and ankles, then shoved him into the windowless line green room where he was expected to spend a county designated psychiatric hour, 40 minutes, discussing his past. The room had two hardwood chairs that made Robert nostalgic for the comforts of his steel bunk and a metal table screwed into the floor. The psychiatrist who introduced herself simply as Dr. Song often worked for the DA, though in Robert's case she served as a mutually agreed upon consultant. She was business-like, younger than he. He guessed late 30s and wore the weary, harassed expression of a woman with too much to do. From a smudge on the hem of her skirt, he suspected young children, though he never found out for sure. She gave nothing away, which was okay by him. With little to do, he appreciated the challenge. At their introductory meeting, Dr. Song said that her job was to provide the judge and jury with an accurate portrait of the defendant and that they'd see a lot of each other because she wanted to understand how Robert came to be the person he was. Robert told her that most people saw what they wanted to see and precious little in life couldn't be looked at from a variety of equally valid angles. Though a tape recorder captured his every word, Dr. Song wrote that sentence down. And so Robert added that one of the reasons he was a doctor and not, say, a lawyer, was that suffering was universal and while the law varied by state and country, and as a result sometimes what was right wasn't legal. Dr. Song wrote that down too. Earlier that week, Dr. Robert's attorney, Nick Barton, had told him that most prisoners didn't get wireless electronic readers or the time and attention he would get from Dr. Song and that he would get Dr. Song's attention because he was paying for it and he was paying for it because the usual rapid and ruthless forensic psychology evaluation led to just one conclusion, crazy or not, which in his case wouldn't be useful. Why not, Robert had asked. You're not crazy, Nick replied. So why the psychiatrist? The DA will try to argue this sort of thing is always murder. Nick, for Christ's sake, she was dying, then she died. All I did, Nick held up a hand, I know. Save the next go round for the head shrinker. I'm gonna move forward fairly far in the story and in between what you see is a lot about his marriage and you'll see how that's going in the section I'm gonna read. The day Consuela Alvarez's grandson had wheeled her into Robert's office and lifted her onto the exam table, a fluke winter heatwave had begun that would bake the city for three days straight. Outside people wore shorts and t-shirts. In Robert's office downtown, the heater remained on, programmed at some mysterious central location. His staff opened the windows, which helped some, but not enough. Robert sweated in his shirt sleeves, but tiny Consuela was burning up. Her grandson wondered about fever and infection, but Robert didn't think that was the problem. When he told Consuela that he needed to send her to the emergency department, she refused. You won't have to stay long, he argued. It's because of the Parkinson's, because you can't sweat. Her grandson stroked her head. Can't you care for her here, please? Asking the grandson to step outside, he and his nurse undressed Consuela. As always, her fingers and jaw shook in short, rapid rolling movements, but they managed to tape ice packs and cool compresses on her forehead, neck, and wrists and cover her with a single thin sheet that he told her grandson to jiggle periodically, creating a fan. While he saw patients in the other room, the nurse gave him regular reports as Consuela's temperature slowly decreased. Midday, her grandson went out to pick up lunch. In a low voice garbled by saliva and interrupted by coughing fits that left her red-faced and panting, Consuela told Robert that she needed his help. Robert said he certainly would help if he possibly could. Consuela spoke so slowly that several times he had to sing the happy birthday song in his head to keep himself from interrupting. She blinked once every 40 seconds, and it took 12 blinks for her to explain what she wanted. That same day, Paul Massey kept awake at night by the searing twitches of his right facial nerve fell asleep at the wheel and drove his car into a stop sign, luckily with only minor injuries, though clearly he needed to be seen that afternoon. Serena Chang was in the ER seizing. Harry Cohen wouldn't discuss how he was managing without the use of the right side of his body. Latrice Jones, only 37, had an MRI that revealed several new white matter lesions. Tom Julevitz needed a hospital bed, a commode, a night nurse, more medications, a shower chair, a wheelchair, a ramp for the front steps, a nightlight, a pill cutter, and a new nervous system. 10 patients had been scheduled for Robert's morning session 12 for the afternoon. These figures did not include his hospital rounds with the urgent add-on of Paul Massey. There were also five messages on his voicemail, 76 emails in his inbox, three piles of reports for review, and as Consuela described her terror, a choking repeatedly on her own secretions so she couldn't catch her breath and felt as if she were drowning, a courier waiting for him to sign the divorce papers that had arrived by certified mail from Kate in Wyoming. So I'm gonna not read more of that story, but it goes on. I wanted to deal with this issue of the complexities and lack of black and white in medicine and in human life and sort of, so one of the questions with that story that people ask is, did he do it? Did he do something wrong, right? And there isn't really an answer to that because it might depend on where you draw that line. And I think that's one of the things, one of the ambiguities that I wanted to bring up in lots of different places by putting real faces on these stories. There had been something in the paper about a person like this. But I think thinking about how a person who might be just like us can get himself into that situation was really helpful for me. Another thing I wanted to do because I'm a geriatrician was show some things about old age that we don't always see. And some of this, it actually took me so long to write this book that there had been the whole hubbub with the death panels and Sarah Palin. And some of this was to say that it's just not that simple, not that there's an answer or that I have an answer, but to not talk about the end of life when that's the one thing that we're all gonna have to face just didn't make sense to me. So I tried to deal with that in lots of different ways. I'm now gonna read the end of another story that sheds light on this also. So this is a story about a doctor who was a family physician and retired and did house calls. So it's why one sort of homage to our house calls practice, although his is quite different from ours. I'm just gonna read the first paragraph where you hear a bit about who this woman is and then some from the end. It's called The Promise. Hattie Robinson was a jazz singer in the 1930s, the only female black labor leader in Northern California in the 50s and a regular in the Letters to the Editor section of the San Francisco Chronicle for decades. At 96, she began nude painting, not portraiture of disrobed others, but art made by her in a totally naked state and in the absence of most other social conventions. I met her the following summer, called to her home by a social worker for adult protective services. I'm gonna skip towards the end. Again, leaving out whole story lines, but just to give you a flavor of things. What happens to this woman is she ends up in the hospital and when people ask about what's true and what isn't here, I can say that this story, this person didn't exist, but this story came from an experience I had early on. I think I was just newly in practice. And a patient of mine in somewhat similar circumstances very clearly didn't want things done and got admitted to the hospital, at my current hospital at UCSF and had all kinds of things done overnight. And what they basically said was, well, we can't withhold care. And so I wanted to kind of talk about whether what they're thinking of as care is what everybody would consider care, depending on the state of the person. I think what they were thinking was, we can't withhold our standard diagnostics and treatments, which isn't always the same as care. So seven months after Hattie's hospitalization, I made an exception to my usual practice and went to the large skilled nursing facility in the Western Edition, where a patient of mine had been taken temporarily upon the hospitalization of his wife. Since it was my first visit to the institution about which I'd heard both horror stories and great praise, when the administrator offered me a tour, I accepted. Hattie sat in a recliner in a large room labeled activities, though the only apparent activity of the many patients parked in two neat rows of wheelchairs and recliners was sleeping. The recreational therapist must be on break, said my guide. Walking past, I almost didn't recognize Hattie. She'd gained weight and lost hair, but her left hand gave her away. It wove through the air, fluid and purposeful, as if she were painting a large invisible canvas. I went over to pay my respects. Sitting by her bed, I could smell the sweet liquid now entering her body through a tube that disappeared under her bed covers and also its inevitable aftermath, pungent and foul and what must have been a full diaper. Greasy hair splattered her forehead and she wore a faded patient gown imprinted on the chest with the words California Pacific Medical Center. Looking around, I saw that they all wore them, though the colors and hospital names varied. St. Luke's Hospital, UCSF, St. Mary's Medical Center, San Francisco General. A parallel image flashed through my mind. My grandson's birthday party where each small boy wore the jersey of his favorite major league team. Across the room, my guide looked at his watch. I walked back between the twin rows of patients to rejoin him and resume my tour. I tried reaching Patricia, that's Hattie's daughter, that evening and discovered that the phone number had been disconnected. The next day I drove by the old Victorian and saw that it had recently been sold. The following week, though I could more efficiently have phoned or faxed, I made a second trip to the nursing facility to discharge my patient home to his wife. On that visit, I didn't check in with the administrator, just walked around, peering into rooms until I found Hattie's. It's an unspoken truth that a man of my age in race with a stethoscope slung over his shoulder, an authoritative expression, has free reign in most medical settings. When I said hello to Hattie, she farted. Her left hand swooped, dived, fluttered, and her feeding machine clicked and purred. Unlike the magnificent Victorian house with its art and photographs, the walls and surfaces of Hattie's current personal space offered no clues about her life. On her bedside table lay a box of blue latex gloves size small and a cheap black barbershop comb. I used the comb to move the hair off her face and neck. She blinked once, a reflex, and campaigning the air. After just three passes of the comb through her hair, flakes of skin covered the black plastic like pox. I looked around but found myself the only fully sentient and still functional person in the room. Hattie's roommate's eyes were open but staring into some space to which I didn't have access. I pulled the curtain around Hattie's bed, opened my work bag, and from the forest of syringe and tourniquet and swab filled plastic bags selected the one I'd packed that morning with Hattie in mind. Donning gloves, I poured the liquid into one palm then rubbed the waterless shampoo into Hattie's scalp. She leaned into my hands like a kitten. With her hair returned to a thin but lustrous white, I washed her face, applied my wife's moisture cream to her cheeks and forehead and put Vaseline on her lips. I hadn't asked to borrow Carly's cream but I felt sure she wouldn't mind. Before leaving, I placed the toiletries on Hattie's bedside table, took a business card out of my pocket and circled my phone number. Then I wrote call any time beside my name and prop the card against the box of latex gloves. That one also continues a bit. But I think another thing I was trying to do here was sort of define caring as caring that we shouldn't make a distinction between medical care and care. Care is care. And sometimes I think we confuse health care with medical care where health is care of the wellness and the well-being of the person and medical care is more about medical treatments. So those are some heavy notes. I'm just gonna read one little other part that's a little lighter. And then stop for some questions. Okay, so this was a play on gender in medicine. It's a one section of a longer story called Becoming a Doctor. And each of the sections is labeled with the name of a book. It's called In a Different Voice. It was whispered that one of our immunology professors was a shoe in for the Nobel Prize in Medicine. As the first year progressed, fewer and fewer students showed up for class, but the day of the great professor's talk, the lecture hall was packed. That evening, my friend Althea and I headed over to Hank and Ted's to study. On the walkover, Althea said, I don't even deserve to be in medical school. I didn't understand one word that guy said today. I stopped walking and stared at her, both scared and relieved. I didn't really understand it either. Althea looked as if she might cry. I don't mean I couldn't follow the diagrams. I mean I didn't have the first clue what he was talking about or how his topic fit in with the rest of the course. Althea had won the history prize at Yale and spent two years working for the LA Times before medical school. Even Hank talked about how brilliant she was. I had majored in biology at the University of Washington and come straight to medical school from college. My only claims to fame were a two minute video and having coxswain for the women's crew team that won nationals. Both decent achievements to be sure but not exactly intellectual. If Althea wasn't smart enough for medical school, I was a dead woman walking. When we arrived at Hank and Ted's apartment, they were talking about the lecture too. Can you believe that asshole, Ted asked? He opened a bag of chips and threw it on their kitchen table where we'd be studying. Lazy prick, Hank agreed. Like being hot stuff in the lab entitles him to give an incomprehensible piece of shit lecture. Althea and I looked at each other and burst out laughing. It had never occurred to either one of us that the problem might lie anywhere but within. So just to show there is humor. And I'm gonna close by reading part of the last story. So the last story speaks to everything that's happened in the rest of the book and people often ask if it's an essay. And it is in fact a story, although it's essayistic. And it sort of speaks to stories in medicine. So I'm not gonna read the story but what I'm gonna do is read you some of the first lines with which I was trying to address what we do and don't say with our stories. It's called a medical story. So much of medicine is stories or potential stories. So many medical stories are about death or potential death. Medical training had done something to my attention span. This is a classic medical story. It was three in the morning. Of course what most doctors call stories aren't really stories at all, they're anecdotes. It seemed that in the process of becoming a doctor I'd also become quite literal. This is an old story. Most doctors have one that's more or less the same. Some medical stories never get told in quite the right way, once upon a time. It's rare but not unheard of for a medical story to start as an anecdote but because it appears to be about one thing when really it's about something else entirely end up one step closer to being an actual and successful story. Not infrequently medical stories tend towards sentimentality or humor as if outrage at the injustice of illness and the necessary violence of medical care are downers better left to novelists and bloggers. To ensure objectivity and accuracy doctors notes avoid the first person pronoun. This next medical story though an official chapter in the history of medicine in America is considered sacred by some and blasphemy by others. Good medical stories capitalize on the myriad opportunities for imagery, analogy and metaphor offered on a daily basis in medical encounters and settings. At the county hospital where the neighborhood health center admitted its patients the residents called admissions hits unless they called them hurts. As is the case for all medical stories with the exception of things I've altered in a Bay Sons of the Health Insurance Patient Protection Act and at my husband's insistence for reasons of aesthetics and art everything I've written here is true. For their sakes I had to change patients' names and biographical details. For my sake I had to downplay some aspects of my professional and personal lives. The heartbreak but also the joy in real life there was more of it. In real life if you're lucky as I have been with work that's long on characters, drama and significance there's always more joy but that doesn't make for much of a story. I'll stop there, thank you for your attention. I think we have time for questions if we'll have any. Hopefully other people are thinking about questions they might wanna ask. We have microphones on either side of the auditorium so if you have a question in mind please make your way over to the microphone. So we were talking a little bit earlier about a line from one of your stories that had struck me and you read it here tonight in the first piece and in the setting of the young man announcing to his mother that he was going to go to medical school. She said I suppose you'll find out for yourself that form is not always content's container. Got it right. And then you went on to tell us how that related to some of the different styles, the form that you were using in several of your stories but I took that on many different levels myself as I read it and one level was what was happening in that narrative which is the son saying to his mom I'm gonna be a doctor and she says aha but. And I just wonder if you had an experience when you went to medical school of finding out that it wasn't exactly what you thought it was or that medicine really wasn't what you had anticipated. Oh, that's interesting. I didn't think it would go that way. I was thinking for him it was more that he was trying, can you hear me? Is this working? That he was trying to be like his father and be conventional in a way and that she was saying and you can put all those trappings on but your still, your content is still what it is. For me, I actually never intended to be a doctor. I actually chose my undergraduate school because it had no math or science requirements. So my expectations for medical school, I had worked part of the refugee stuff was I had worked on the Thai Cambodian border and that had made me excited about having skills to actually do something meaningful for people. And I think I got there and I knew for a long time that I wasn't having fun. And yet it was hard to think of anything other than medicine that would give you both kind of the credibility in society and with that the job security, et cetera and allow you to do something good. And there were all these other things I might have done but the form actually mattered. So I think it did influence me and it was a poet that I heard say that but it seemed to me it has a lot to do with everything and that it can play either way that the form can lead you to expect one kind of content and you can be right or wrong about that but certainly I toughed it out and I was glad I did by the time I got to the patients in third year. So I'll confess that I actually went and Googled that quote after I read it because it was so resonant and so interesting to me I couldn't find it attributed to anybody else. So one of the reactions that I had in reading your book was that your capacity to imagine the experience of the other even when that other is vastly different from you was quite extraordinary and I have gone around this campus likening you to Meryl Streep who is my favorite actress because Meryl Streep can as easily convince you that she's the editor of Vogue magazine as she can convince you that she's an aging Jewish male rabbi and if you've seen some of those vignettes she's extraordinary. And so I just wonder if you could give us a teeny tiny little window of how do you do that? How can you imagine yourself to be a female surgeon who's burned out or a male psychiatrist whose marriage is messed up? How do you do it? I think I do some of it more successfully than others. I mean I think if you're really a surgeon and you read this you can tell I'm not one. The surgical specialties are somewhat token because I do have trouble. I have more trouble being a surgeon than I do being a small Cambodian who's wetting her bed. And that's just me, so I tried but I also was careful not to do things I knew I would fail at so there are surgeons but I don't think they're as surgical as they might be but it also helped me to think about why not. I mean the point of this book was to show the world of medicine in our life now through many different characters of different ages and backgrounds and from different neighborhoods in my city of San Francisco. But I also found that I learned things about me so it wasn't, that was not the intent and yet the ways in which I could not become a surgeon told me a lot about what I valued most and my prejudices about surgeons as well which was helpful. For most of them the key thing and I think this is, this is the thing that was the biggest pleasure of writing this was that the key thing was just to imagine yourself in that situation first. Because there is this kernel of shared humanity. If I were a little girl wetting my bed, yes my father might not be doing what this father is doing and we wouldn't have a conversation about coining and cupping in my household but some of the other things would be the same and then to bring in the culture on top of that and some of that had to do with cultures that I know so I worked with Cambodians for several years that was part of why I went to medical school. I work with a lot of Latinos in California so I have that experience. I have friends from all backgrounds so I would do my best and then I might give it to people and see how they responded and then sometimes you just Google things and then you throw those things in and you see if it changes what the person does or what you know and so I learned a lot but I think getting to that core of humanity was the most interesting and instructive part of the process. Ironically I am a female surgeon and can you help me? And I will just admit I have not read the book I'll buy it afterwards but I wanted to ask you because you said it several times you never intended to publish the book and so I sort of had a different question as to why did you publish the book and what was that process like and how have people reacted because my reaction just to reading about the book was well why did she make it fiction that's just rude because I'm interested in the real story and you know we do have and then the second thing I would ask you is what are your aspirations for your book? There's a lot of medical writing out there now we see on TV you know and we see from our specialty the ENT surgeon and his name is alluding me at Harvard or who has written about us I think one of his books is called Complications and he's read about written. A tool for one day. Yes thank you and so I've enjoyed his work and I kinda wonder do you want to make this into you know a PBS special what is your aspiration for your own book and what was your impetus go ahead and publish? I'll see if I can remember all of those. So the reason I didn't think I'd publish it was when I started writing I was terrible and I really some of the stuff that I just read about anecdotes versus stories I could not write a story I mean I did my master's thesis on what do you do when you get to the middle I could do the situation which is the anecdote which is what we tell each other all the time but to make it a true story in the Aristotelian fashion took me years I just wasn't very good at it I could do a decent sentence but I couldn't actually do a story so I really didn't think it would ever be worthy of anyone reading it other than a few close friends and family members who were repeatedly tortured. And then it started improving and then actually strangely what writers will tell you to do to become a better writer is to write regularly and read a lot and I had been in the community and went back to academics at which point my time for writing and reading got much much much smaller as I got this very interesting academic career and the strange thing there was that the work got much better and I think part of that was not that they're wrong when they say to read and write a lot because that probably is a good idea but that I had distance from it so I might have started it a story with one impetus and then if I didn't look at it for nine months it was like editing someone else's work which is always so much easier you can just cross off their whole paragraphs because what's it to you? So I could make it better and I could see them as separate entities and as I changed they changed and I still thought well maybe I'd send it to a contest but I had these faithful readers read it and some of them said you know at this point you should give it a try and I'd send out some stories and so people had approached me so that's how that happened. But it's kind of a nice way to go in because if you expect nothing everything that happens is frosting so it's really been a whole year of pleasant surprises. What do I think it offers when there's so much out there? I think part of it is there's a degree of realism and that's where this fiction versus nonfiction thing comes in nicely I think. At one of my early readings a friend of mine heard a man say and he was probably a doctor was her best guess that he was really looking forward to the book and now that he heard it was fiction he just didn't even know if he was gonna read it and I guess what I would say to that is to me this is 100% true. I mean it's my truth. Are these people, particular people that I knew there are moments but they are people that to me are true to my experience but I couldn't, if I wrote fact A it would be less interesting because I'd be confined to the facts. B it'd probably be really inaccurate because there have been a lot of discussions recently about fiction versus nonfiction how much nonfiction is fiction because think about it can you tell what happened in a conversation you had even this morning much less 10 years ago or 50 years ago I couldn't tell you accurately a conversation I had an hour ago so there is a degree to which nonfiction is all fiction too. I wanted to be clear I really enjoyed your talking I will buy it and I probably will read it all tonight cause that's just how I am cause you know the surgeons we like to finish the test right and then move on but so I didn't want you to get an impression that I didn't really enjoy it. No no no I wasn't saying it that way but I'm just saying this keeps coming up and I think it's a really interesting discussion about what's true and I think, I guess my point is we too often confuse fact with truth and I think the overlap but the difference. No I love your big T little t tooth and then would you wanna see this on you know as a TV vignette or something like that? That was my last question. I think it would be interesting I've had a few places where people have done readings of it and to watch someone else interpret what you did is always fascinating cause you see things that you probably put there but couldn't see before and then you see what they bring to it so I think that would be interesting. Thank you. Well thank you for writing it's fabulous and I think you're a great storyteller and I'm sure you're also a great geriatrician and I'm thinking it's not a coincidence that you're probably good at both you probably like stories and being a geriatrician probably lets you hear great stories. Totally. So thank you and keep it up. You mentioned the tool Gawanda I had a chance as in training to meet a tool Gawanda and I tend to put physician writers on pedestals I just you know I love it and I was you know into humanities and writing and narrative and so you know looking up dough I did a tool Gawanda I asked a lob of a question don't you think medical students should read and write and practice narrative and whether or not they're going into radiology or surgery or internal medicine, geriatrics, obstetrics don't you think they should go through the practice of narrating and interpreting narratives and I was completely heartbroken when he said no. Did he say why? Why not? That's why I can't be a surgeon. Well I did I mean I think you saw in my expression that he needed to explain and I think he in the answer was somewhat unsatisfactory something along the lines of well not all doctors need to be good writers and be good readers and I toil over that and have since then so I wanted your opinion literally on what do you think of the role of narrative and that could be interpreted in any variety of ways for medical students, for residents should we require even radiologists to looking at the black and white how to interpret stories and read physician writers or good literature that's one question the other question is writing is hard you put a lot of heart into it and you also probably put a lot of heart into your practice how do you get through you set a sentence and then a story how do you put all your heart into your writing like that and not then feel like it's also this other thing that is heavy and difficult and emotionally exhausting does it make burning out hard do you get fired up by it or does it make it harder to do what you do great questions maybe I'll do the second one first since it's in my head and maybe in yours which was how do you balance those things and I actually think they nourish each other tremendously practice is very interactive and you're on and you're dealing with the patient and the caregivers and the other people in the practice and writing is very solitary and I like to be gregarious and social and I also like to be quiet and read and write so that's at one very basic level but also in working on a craft in having something that's your own that you develop that you think about that sort of nurtures me I really felt it made me a better doctor both by having me think about these things but also by nurturing a part of me that I valued and I think the happier you are the better you are as a clinician and so what I did in the years I was writing this for much of it was to get up very early and do this first thing so I had done something that mattered and something that sort of engaged my brain and emotions by the time I went to work and that probably in a really good mindset when I arrived at work do I think this will work for everyone no does jogging sometimes have the same effect on me yes but I found it really helpful in that regard and I think I've lost part of that question but I'm gonna move to the writing one now and a tool's answer to that I think I would disagree but I think he's also conflating writing generally with writing really well so most of us or at least I know speaking for myself I can't do what he does and what he does is really impressive and really important and I wish I could but you know I can't so that's fine but there's a difference between being able to write at that level and being able to write it all when I got to UCSF we started doing reflective writing with the students it was a we were asked to do it and people said well we can't have them right because when we admitted them we didn't tell them they'd have to write right so we're giving them a doctorate and it's not okay to ask them to write we weren't asking for Tolstoy it was just to talk about the experience so I think if somebody's getting a doctorate expecting that they can be able to write in a way that another person can understand it is totally fair game I also think although the electronic medical record has distracted us with checkboxes and all kinds of information that none of us wants to know that one of the original intention of the note was actually to communicate about the patient and your thoughts about the patient to others and so that again is a written skill I think even if you're dictating it it's sort of telling those stories so should people be able to write I think they probably should but do they need to write well as he said that's a different issue and that could be elective some people will write well and some people will do research and some people will be great sailors or gardeners or whatever else and that's fine but I do think there's a role for writing in medicine and that there may also be something in addition to that which is a sort of analytic synthetic ability that you get with writing you may think you understand something and then when you try and write it you realize you don't understand it well enough or you can't communicate it well enough and that's also an important skill and you know you said radiologist a few times and I think interpreting an x-ray and interpreting something that's happened onto a page are not dissimilar cognitive tasks did I miss anything? I'm thinking now about the physician in giving good death and that terrible day that you described where everything was happening all hell was breaking loose with his patients they were add-ons, people were suffering and there were 75 unread emails in his inbox and my brain went yes that's what my life is like and actually it kind of made me want to cry when I heard you say it tonight because that's what you know at moments your life can be like as a physician but in that story the doctor doesn't find his way back to normalcy by writing but he is reading an awful lot and so I thought that was interesting he's reading great classics right well you know some of that was just my bias you know that there are a few stories in which that's mentioned because that's what I was thinking about but I did for him I also thought if he has a moment finally to reflect you know to think and to consider and someone said to me somewhere that oh but he leaves medicine and I don't see it that way oh I don't think he's left medicine I think his practice will change after it's been shut down with an accusation of murder but he loves what he does in my senses that he's good at it the paragraph you mentioned is a tough one because to me that is primary care in many ways and it's almost a problem so people have said I never really understood it until I read that paragraph and I hadn't particularly noticed that paragraph as that until it was commented upon many times and then I think to myself oh my god we have a primary care crisis and now I'm adding fuel to the fire of why you should not do this and yet I think it all I hope it also shows in this story some of the really great things about it which are the relationships and the caring and the continuity that comes with that responsibility and commitment that I think are really magnificent and that this Dr. Robert embodies nicely. Hi. Well I'm a first year medical student so pardon me if there's there's a lot I don't know about being a doctor but I had a question about so we do clinical skills and we do our practice comprehensive histories and I imagine that because you wrote these stories about patients that you're really interested in your patient's stories and for me I never finished getting my history within the time allotted because I just get really pulled into the fake stories that we're listening to and I wanted to know how do you balance like your desire to hear your patient's full stories with the time constraints and you wanna hear certain things at the same time you also have to diagnose and treat your patients so how do you balance the two? Right, so that's a great question it's really hard but our job isn't if you were an anthropologist or someone whose entire job was to get the story you could do more of that so that's sort of a career decision point and when you decide on medicine it means much of the time you won't get as much of it as you want. That is another one of the advantages to having a continuity practice though because you don't have to get the whole story all at once you can get pieces of it from the patient and from the family and over time I probably spent a little longer than I should more often than I should I have been happiest in practice settings where there wasn't a clock ticking and I was happy to work a little longer but do it the way I wanted to do it which I felt was more satisfying to me and more satisfying to patients because I could listen and I could let them shape their story in whatever way they saw fit which really helped but are there times where I have to be on track I think it helps I have it in here and I can't remember what the statistic is but the average doctor interrupts like nanoseconds into a conversation and so I think to have certain basic rules of if you ask the first opening question let the person actually answer that question and if you're gonna steer from that particularly if you can say it sincerely like I sometimes say to people and if it's appropriate I'll touch some of them because I'm really feeling that I would really like to hear more of this because usually I really would but if I've got a whole bunch of other people waiting that's not fair to anyone but if you say it like you mean it people hear it that way and then say hopefully we'll get to discuss this more but now I really need to hear a little bit more about those pains you're having in your chest Thank you for all that you've written and said tonight and I'm a physician who is a medical writer and I've yet to attempt fiction it's something I probably have no talent for whatsoever but I love to write and I love that solitary time in my study where it's just me and the words and the computer because these days you don't do it without a computer like probably if I had to do it with a typewriter I never would have because I always hated how you had to retype a page when you made a mistake on it that just drove me nuts but in any case one of the things that I do is I take a lot of photographs of my patients and I put their pictures in my books and I'm always so interested how patients love the fact that they're in my book and then when they come back and I do also have continuity with my patients I can show them years later how their picture made it into my book and they want to buy the book they just think it's just so incredible so my question is I know that while you write fiction it's based on reality and therefore you probably have some had some experience with some patients somewhere that made you think about writing a story have you ever kind of shared with any of your patients that somehow they inspired a story that you wrote? That's a great question these took so long and changed I mean literally it would be one sentence or one event and then this fake person grew up over it there is one super sex was really came from this patient that I just adored and the sad part is I can't now distinguish him from the character and he did die but I feel like it's a tribute to him even though now I can't distinguish them I am writing more and more non-fiction so one of the great things that came from doing this was starting to do more writing at the medical school and realizing that the same skills we can use for narrative advocacy and those often we do use real patients and you're right if you ask them and you say whether the outcome was good or bad like we think your experience or the experience of your family was so important we wanna use it to make the world better for other people people love that I do think you have to be a little careful so Abraham Varghese who I'm sure was here wrote something great in the annals maybe early 2000s about one of maybe the 90s actually one of the earliest cases he wrote up he had this great case and he asked the guy's permission and he writes it up for an infectious disease journal and he's so excited and the guy comes in and he shows it to them and he reads the whole thing and then he says I'm not in this because it was so clinical it wasn't really him and who he was but increasingly we're doing narrative advocacy writing with our students and residents and actually we have this very successful writing for change program with the residents and they do tell patient stories and use that to advocate for change and it's really the same skills so I think you know you can do the same work in many different ways but patients definitely appreciate it thank you thank you