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Literature about medicine may be all that can

save us
A new generation of doctor writers is investigating the mysteries of the medical profession, exploring the
vital intersection between science and art
Andrew Solomon
Friday 22 April 2016 12.00BST

he language gap frustrates your visit to your doctor. He seems not to understand the
problem because you cant describe it lucidly enough. You dont understand the proposed
treatment because he cant explain it. Ive sometimes foresworn medical help because the
complexity of voicing what is wrong has felt heavier than the sickness itself. This is especially
true for psychiatric illnesses such as the depression I have experienced, but it is true of
physical problems, too. It has been entirely manifest to me when Ive tried to explain the
problem with my left ear, in which I am partially deaf. Ive said what it feels like, to which my
consultant has repeatedly replied with various options. Ive said it doesnt feel like any of the
things in his multiple-choice list and theorised about what is actually wrong. He has resisted
my inexpert opinions, and I have battled with his inability to grasp the subtlety of my
experience. We are both articulate and we are both exasperated by this sticky communication.
Language is integral to medicine. It is hard to cure a condition you cannot describe, and few
treatments for those conditions go without names of their own. Even veterinarians, trained to
diagnose animals who cannot put their complaints into words, begin by labelling the illness
and proceed by specifying the treatment. The emerging eld of narrative medicine proposes
that patients can be treated correctly only when they can tell the story of their illness, often in
the context of a more extensive autobiography. A doctor usually begins by getting the patient
to describe their pain, and often arrives at diagnosis as much through that interaction as
through anything he can observe. Illness is temporal, and language helps to chart its course,
even when x-rays, MRIs, CAT scans and other images can represent its current state. A picture
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is not always worth a thousand words; sometimes, it is the words that tag the problem. You tell
the doctor how you felt yesterday and how you feel today; the doctor tells you how you should
feel tomorrow. That interaction is part of the cure; it is why a physicians bedside manner can
have such an enormous impact on his ecacy. We are embodied, but our minds order the
brokenness around us by imposing vocabulary on it. In fact, there is some evidence that people
who can speak more uently receive better medical care; patients deprived of language are
often subject to abuse.
We mustnt go back to the kind of medicine in which the benign smile of the doctor provides
comfort because the cures are somewhere between hypothesis and quackery
Many of the great doctors have been writers, and those who have not have required writers to
set down their insights. Hippocrates, Galen, Maimonides, Paracelsus and Vesalius all left
behind chronicles of their work and methods and of the principles driving them. So did
historic female doctors such as Trota of Salerno and Hildegard von Bingen, both of whom
wrote of their medical work in the 12th century. Medical knowledge is particularly cumulative,
and it cannot accrue without words. These doctors greatness lay not only in their
discernments, but also in their recording of them. Indeed, Galen titled one of his volumes That
the Best Physician Is also a Philosopher. The division between humanism and science is recent,
an Enlightenment idea, a Cartesian duality, and like many such ideas, it served at rst to
advance a discourse it may now impede. The two modes of thought are now too often posed as
opposites rather than as twin vocabularies for the same reality.
Any serious illness is a medical event, but it is lived in narrative terms. As religion has lost
ground to secularism and the split between body and soul has come to feel metaphoric rather
than literal, some people have rooted themselves in scientic explanations of the world, while
others seek truth in art, literature or even political idealism. Students bifurcate early, pursuing
a medical track or a literary/humanist one. It is as though we belong to dierent races. William
Osler, writing in the late 19th century, observed: It is much more important to know what sort
of a patient has a disease than what sort of a disease a patient has. We have not much heeded
his call.
In the heyday of modernism, doctors lionised specialisation, but patients have now turned to
holistic approaches that combine oncology, psychiatry, cardiology, neurology and a variety of
alternative treatments. After a long period when we focused primarily on depth of knowledge,
we have returned to the importance of breadth of knowledge. In telling the stories of illness,
we need to tell the stories of the lives within which illness is embedded. Neither humanism nor
medicine can explain much without the other, and so many people ricochet between two ways
of describing their very being. This is in part because medicine has become so much harder to
understand, with its designer molecules, bewildering toxins and digital cameras inserted into
parts of ourselves we have never seen, nor wanted to see.
On a recent visit to the Wellcome Medical Library in London, I was struck by the diversity of
materials in the collection: the notebooks from Victorian asylums with photos of the patients
and descriptions of their care; the leaets distributed by worthy organisations to encourage
the sick to avail themselves of medical services; the manuscripts written by medieval
physicians; the poetic reections on health and wholeness that set out to negotiate medicines
philosophical and moral conundrums. These collections indicate how much writing about
science there has always been beyond scientic writing.
But medical writing of today has its own complexion. As medical information has become
increasingly technical, patients are asked to trust what they cannot comprehend. Recondite
information complicates their already anguished experience of poor health. In a bid for
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control, such patients seek the logic behind their ailments and the proposed cures. More than
that, they seek to use available knowledge to make basic decisions about the value of their own
lives and those of the people they love. They need this information in order to resolve
dialectical thoughts about mortality and intervention, pleasure and pain, quality and length of
life.
A rising literature attempts to reconcile these modes of thought. Voltaire complained, Doctors
are men who prescribe medicines of which they know little, to cure diseases of which they
know less, in human beings of whom they know nothing. But a new run of books attempts to
address the last clause of Voltaires challenge. Such writings may not be remarkable as either
medical information or writing, but they rightly insist that coherence sits at the intersection of
science and art. The territory was laid out by a generation of older doctors, including Oliver
Sacks, Lewis Thomas and Sherwin Nuland. Echoing Osler, Sacks wrote: In examining disease,
we gain wisdom about anatomy and physiology and biology. In examining the person with
disease, we gain wisdom about life. Sackss mission was to describe human beings and all
their mucky complexity, not just the defects that had brought them to his notice. His oeuvre
has bred a healthy awe of word. Language, that most human invention, he wrote, can
enable what, in principle, should not be possible. It can allow all of us, even the congenitally
blind, to see with another persons eyes.
In the last decade or two, a new generation of doctor writers including Atul Gawande,
Abraham Verghese, Henry Marsh, Danielle Ofri, Siddhartha Mukherjee, Paul Kalanithi and
Gavin Francis have undertaken the mission of seeing in this fashion. For them, the ability to
string together twin narratives, that of the doctor and that of the patient, is the only path to
truth. The rst ingredient in their formula is humility. In Complications: A Surgeons Notes on
an Imperfect Science, Gawande writes: We look for medicine to be an orderly eld of
knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly
changing knowledge, uncertain information, fallible individuals and, at the same time, lives on
the line. There is science in what we do, yes, but also habit, intuition and sometimes plain old
guessing. The gap between what we know and what we aim for persists. And this gap
complicates everything we do. Gawande is a man of science, but he refuses to let science rule
either his writing or his practice as a physician. Echoing Sacks, he insists that seeing the arc of a
patients history is crucial to doctoring. In Being Mortal, he writes: In the end, people dont
view their life as merely the average of all its moments which, after all, is mostly nothing
much plus some sleep. For human beings, life is meaningful because it is a story. A story has a
sense of a whole, and its arc is determined by the signicant moments, the ones where
something happens. Measurements of peoples minute-by-minute levels of pleasure and pain
miss this fundamental aspect of human existence We have purposes larger than ourselves.
Writing in the New Yorker, he explains: We yearn for frictionless, technological solutions. But
people talking to people is still the way norms and standards change.
The exploration of the philosophical complexity that lies between sickness and health is perhaps
the most urgent matter facing medicine and literature
Yet the answer to that problem is not to throw away the specialised language, to go back to
some kind of gentle, intimate, ignorant medicine, in which the benign smile of the doctor
provides comfort because the cures are somewhere between hypothesis and quackery.
Verghese, too, writes of the importance of fallibility, of how imperfect thinking is not only
inevitable, but also the engine of medicines advancement. I think we learn from medicine
everywhere that it is, at its heart, a human endeavour, he writes in an interview in the San
Francisco Chronicle, requiring good science but also a limitless curiosity and interest in your
fellow human being. That sounds antithetical to the encounters many of us have had with
consultants and specialists, but in Vergheses view, clinical abstraction is a manufactured
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problem, the consequence of our false presumption that there is such a thing as scientic
neutrality. What we need in medical schools is not to teach empathy, as much as to preserve
it, he writes in the Atlantic. The process of learning huge volumes of information about
disease, of learning a specialised language, can ironically make one lose sight of the patient
one came to serve; empathy can be replaced by cynicism.
Marsh, British neurosurgeon and author of Do No Harm: Stories of Life, Death and Brain
Surgery (2014), addresses this gap, summoned into it by confronting his own dying mother. In
neuroscience it is called the binding problem the extraordinary fact, which nobody can even
begin to explain, that mere brute matter can give rise to consciousness and sensation. I had
such a strong sensation, as she lay dying, that some deeper, real person was still there behind
the death mask. He observes the intense emotional complexity of surgery that involved the
brain, the mysterious substrate of all thought and feeling The operation was elegant,
delicate, dangerous and full of profound meaning. What could be ner, I thought, than to be a
neurosurgeon? Yet like all surgeons, Marsh is guilty of errors, and it is the human failure more
than the scientic one that pains him; he quails at the sight of patients he feels he could and
should have served better. He describes one patient to whom he has to deliver the news that
there was no longer anything to be done for his brain tumours. I felt shame, not at my failure
to save his life his treatment had been as good as it could be but at my loss of professional
detachment and what felt like the vulgarity of my distress compared to his composure and his
familys suering, to which I could only bear impotent witness. These feelings do not abate
with experience, but rather expand. Marsh writes: I became hardened in the way that doctors
have to become hardened [but] now that I am reaching the end of my career this detachment
has started to fade.
There have been relatively few female doctors writing about medicine in this philosophical
way since Our Bodies, Our Selves: A Book By and For Women was rst published in 1973, but
Ofri, a doctor at Bellevue hospital in New York, has produced four impressive books and
numerous articles, all striking for their reversion to empathy, their willingness to sense not
only the physical life of a patient, but also the emotional. She sets out deliberately to keep her
own engagement vital. In What Doctors Feel, she explains: Fear is a primal emotion in
medicine a thread of sorrow weaves through the daily life of medicine. That is to say that
ones heart breaks for the patients one cannot save. In Singular Intimacies: Becoming a Doctor
at Bellevue, she describes a patient who was pulled back from the brink of death: There was
no sweeter music than that silvery Parisian accent oating into my ears The arc of her words
shimmered in the air and her history settled softly into mine. Ofris focus is on empathy:
empathy for the patient, for the patients family, for the medical professionals involved in a
patients care. It is also on happiness, the medical urgency of which is evident throughout her
work. We in the healthcare professions need to notice and inquire about happiness the same
way we do other aspects of our patients lives, she wrote in the New York Times. Lately Ive
started asking about it, and besides getting a much more nuanced understanding of who they
are as people, I learn what their priorities are (often quite dierent from mine as their
physician). I also inquire about obstacles to their happiness, and brainstorm with them on
ways to ease some of these. I dont presume that these challenges are facile to solve, but
hopefully our conversation helps let patients know that their happiness matters as much as
their cholesterol.
It would seem to make sense that doctors start o with youthful emotion and then graduate to
a self-protective distancing, but in his award-winning The Emperor of All Maladies: A Biography
of Cancer, New York-based oncologist Mukherjee likewise speaks of being propelled willy-nilly
into humanism: I had never expected medicine to be such a lawless, uncertain world. I
wondered if the compulsive naming of parts, diseases and chemical reactions frenulum,
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otitis, glycolysis was a mechanism invented by doctors to defend themselves against a largely
unknowable sphere of knowledge. Writing is a means to ght back against that defence. A
doctor needs defences but not too many. It is an old complaint about the practice of
medicine that it inures you to the idea of death, Mukherjee writes. But when medicine inures
you to the idea of life, to survival, then it has failed utterly. And elsewhere he observes: Good
physicians are rarely dispassionate. They agonise and self-doubt over patients. He adds: An
ecient, thrumming, technically accomplished laboratory is like a robot orchestra that
produces perfectly pitched tunes but no music. Mukherjee chronicles his gradual revelation
that while benevolence without discipline is an ineective cure, precision without empathy is
tone-deaf; his books, including the forthcoming The Gene: An Intimate History, can feel like
overcompensation for the eciency of his life as a physician.
How to bridge this gap? Part of it had to come from a study of what had gone before, but
Mukherjee had a novices hunger for history, but also a novices inability to envision it. His
books chronicle the emergence of that envisioning as he learned to reveal the vulnerability he
shares with his patients. Medicine begins with storytelling, he concludes. Patients tell
stories to describe illness; doctors tell stories to understand it. Science tells its own story to
explain diseases. In other words, explaining what is going on is part of the treatment itself.
Nowhere is that drama played out more explicitly than in the writing of a doctor who was
himself a patient. Kalanithi, a neurosurgeon, wrote what will sadly be his only book, one about
his reckoning with his own untimely mortality; he died at 37, and the nal chapter of his
bestselling memoir When Breath Becomes Air is by his widow. He describes how he resisted the
human stories of his patients, acting not as deaths enemy, but as its ambassador. Then
came his own diagnosis. My relationship with statistics changed as soon as I became one, he
explains. And that was a humanist revolution. Science may provide the most useful way to
organise empirical, reproducible data, he writes, but its power to do so is predicated on its
inability to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy,
honour, weakness, striving, suering, virtue. Kalanithi recognises how remarkable science is
and how limited. He defends its limitation, which is the necessary armour that allows a
surgeon to go about his daily work. When objectivity breaks down, medicine ceases to
function. And yet when objectivity reigns, human beings cease to function, because we are
subjective in every breath we take.
If Kalanithi writes from the standpoint of an accelerated wisdom, Francis is still a fresh-faced
novice, to borrow Mukherjees phrase. Francis writes of a journey though the most intimate
landscape of all: our own bodies. But his journey through bodies has turned out to be a
journey through souls as well. What I didnt bargain for were the stories, Francis writes in
Adventures in Human Being. Like the others, he seeks an escape from dualism. Since
Descartes weve had a tendency to believe that from the chin down we are just meat and
plumbing there is more to us than that in some way we become aware when a valve is no
longer working. He describes his own work as an exploration of lifes possibilities: an
adventure in human being in which we charge our bodies with meaning, whether funny or
solemn. He describes imagining the body as a mirror of the world that sustains us. The body
is our world, nothing less than that.
The exploration of the philosophical complexity that lies between sickness and health is
perhaps the most urgent matter facing medicine and literature, because scientic denitions
of illness often run up against humanist denitions of identity. I know whereof I speak: I have
an identity that was long deemed an illness. The literature on homosexuality as a disease is
amply represented in medical libraries, and it is my own history, even though I disbelieve it.
The process through which gay identity was rescued from medical textbooks launched
humanisms upstaging of medicine. It reects the common clinical presumption that variation
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from the norm constitutes pathology. When we dene an illness, we have a grave eect on
those who are subject to it. Alan Turing, Oscar Wilde and a panoply of less prominent gay
people were brought up to know themselves as diseased to the very core, and so we lost much
of their brilliance and their joy.
We face these questions about the boundaries of illness and health on a daily basis. What does
it mean when we are exhorted to treat and so pathologise grief? What does it mean when my
children get assessed by their schools and we are told that they have a little bit of ADD? Is it
helpful to secure treatment, or is it better to bring them up thinking that they are whole just as
they are? These issues are amply explored in Steve Silbermans recent NeuroTribes, which
makes the argument that autism is, like homosexuality, part of the variety in humanity that
constitutes a rich world. But it surfaces repeatedly, because medicines inexactitude is a
problem not only of primitive science, but also of a sometimes crude view of human beings.
Literature about medicine may be all that can save us.
Most hospitals now provide translation services for people who are unable to speak in English.
Those are a meaningful social service, important for the fair treatment of immigrants, deaf
people and others who would be imprisoned in Babel without this access to unfettered
communication. But translation is a crucial part of every doctors job. How to ensure that
knowledge does not fall short of kindness? Hippocrates averred that mental illnesses in
particular were problems of the brain best treated with oral remedies. Plato maintained that
they were philosophical problems best resolved through dialogue. That opposition between
biological and psychosocial models of consciousness is fought out by psychologists and
psychiatrists around the globe. But it is not merely a question of mental illness; physical
illness, too, is remedied in part by medication or surgery and in part by discourse. Marcel
Proust, that infamous neurasthenic, wrote: Three-quarters of the sicknesses of intelligent
people comes from their intelligence. They need at least a doctor who can understand this
sickness. It is not simply that intelligence awakens the imagination to somaticised psychic
distress in physical symptoms, but that illness has to be understood as both metaphor and
reality. Verghese speaks of the aspects of cure that are achieved not with the hands but with
the ear.
It seems winningly ambitious for a doctor to write; the role of an open spirit in a primarily
technical discipline is subject to debate. In psychology, however, communication is the
practice, and words are the medicine itself. Adam Phillips, our greatest writer on psychology,
points out that the ambition of medicine is to know other people; the disappointing revelation
of psychology is that this is impossible. In an article in the Threepenny Review, he explains
that psychoanalysis weans people from their compulsion to understand and be understood; it
is an after-education in not getting it. In Missing Out: In Praise of the Unlived Life, he expands
the idea, writing: There is nothing we could know about ourselves or another that can solve
the problem that other people actually exist, and we are utterly dependent on them There is
nothing to know apart from this, and everything else we know, or claim to know, or are
supposed to know, or not know, follows on from this. If we expect to be understood fully, he
adds, we will be constantly disappointed and then, how could we ever be anything other
than permanently enraged? If Phillipss message of accommodating incomprehension is
pertinent to Eros, family and friends, it is likewise central to our interaction with the doctors
who heal our bodies, or fail to do so. We want our doctors to understand us, and, in many
ways, they never will, and accepting that frustration requires the literary language at which all
the physicians mentioned in this article succeed.
Chekhov famously quipped: Medicine is my lawful wife and literature my mistress; when I
get tired of one, I spend the night with the other. What is most striking among these writers is
that they seem not to uctuate between two practices, but to experience them as components
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of a coherent whole. Language itself is a physical act; it comes of neurons, of activation of

Brocas area and Wernickes area in the brain, of lips and tongues and throats that speak, hands
that write or type. To treat it as a distracting adjunct to corporeality is to deny its nature.
The Bible reverts to metaphors of medicine because they are metaphors of identity: from the
missing balm in Gilead to the raising of Lazarus to the ministrations of the Good Samaritan.
The healing of the body is perhaps the greatest of the proven miracles; in Psalm 103, it is the
Lord who forgiveth all thine iniquities; who healeth all thy diseases. Medicine can contribute
to literature; narrative practice can strengthen medicine. It behoves writers and doctors to
learn each others uencies, because their disparate approaches can add up to singular truths.
The winner of the 2016 Wellcome book prize for a book on medicine, health or illness is
announced on 25 April. This years shortlisted authors will at be The Tabernacle, London W11,
on Sunday, visit 5x15.com. Andrew Solomons Far from the Tree won the prize in 2014. The
shortlisted books are available at the Guardian Bookshop.

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