By Ranjana Srivastava, MBBS, FRACP, OAM

 It was nearing the 10th anniversary of the loss of my twin pregnancy when I felt an urge to write about it.¹ I can’t say that I had been dwelling substantially on the loss or that the 10th year felt any more significant than, say, the 1-year or the 5-year mark. If truth be told, life had been very good to me after that tragedy, with the healthy arrival of three children, a fulfilling profession, and much more. The valuable perspective gained from a career as an oncologist meant that my grief wasn’t as paralyzing as I had feared. But clearly, as the anniversary approached, the event must have been somewhere in my subconscious because I felt the need to expunge it.

That column ended up becoming one of the world’s most widely read and shared columns in the Guardian that year. What touched me most was the tenderness and humanity of exchanges the column elicited in what truly felt like a global village. Complete strangers sent me their wishes and forwarded the essay to others going through the same experience. Voltaire was right: writing is the painting of the voice.

I am a medical oncologist and writer. I have written books and essays, and for the past few years, I have been a regular columnist on medicine and society for the Guardian, which was founded in 1821 as the Manchester Guardian and now has a global reach. I am also an essayist for the New England Journal of Medicine. In this personal reflection, I will track my own journey while answering some of the commonly asked questions of why, what, and when to write.

Why write?

This is the easiest one. As oncologists, we are witness to life’s deepest and most intimate moments. These moments move, inspire, frighten, teach, and challenge us. Who do we tell about the pregnant mother with advanced breast cancer or the successful businessman with metastatic melanoma who goes from diagnosis to death in 4 weeks? Who will share our heartache at looking after a grandfather whose greatest lament is not that he is dying but that his children can’t find the time to visit? Who will admire with the same intensity the patient whose face glows with dignity and courage even as cancer invades her skin? Our patients stir a range of emotions with us, not all of which we necessarily feel like speaking aloud. We fear that our family and friends may not understand us or that they may find our stories gloomy or upsetting. But we know that acknowledging our raw emotions, our learnings and feelings, is critical if we are to be better doctors. Human beings find meaning through stories, we connect through stories—and our stories demand to be written, though not everything we write needs to be published.

I started writing when I was 11, but it is only in the past decade that I have started publishing widely.² Most of what I write is for private consumption, catharsis, and making sense of the world. My writing centers me; knowing this means that if the market for my writing were to fall away, I’d still gain personal satisfaction from the habit.

What to write

The history of medicine is replete with fine writers, and it’s really no wonder when you think of the fertile grounds for writing that being a doctor provides. We just have to turn up to work to stumble upon stories. The lives of our patients and our own lives intertwine to provide us with rich experiences and powerful learnings, and as long as we tune into human stories, there will never be a shortage of ideas.

However, one thing that concerns doctor-writers is the matter of consent. Is it ethical to write about our patients, who trust us with their secrets? Should one always seek consent when writing? What happens if we unintentionally end up offending a patient, or for that matter a colleague, through our writing? The impetus, and the temptation, to be published can exert such a pull that it’s easy to cross the line between telling a story and breaching patient confidentiality.

Something every modern writer must be aware of nowadays is that writing has an unprecedented digital footprint. Once you hit send, you can’t control the ways your work is read, interpreted, and used. It is also always and readily available, even if you’d like it to go away. This is something I have become increasingly aware of in writing for high-profile platforms such as the Guardian and the New England Journal of Medicine. Editorial assistance is important, but it’s just that, assistance; as the author, one must own and defend one’s writing.

It is impractical and unnecessary to always get consent to write. Furthermore, I think that the very act of seeking consent changes the nature of writing—it’s difficult to render a totally honest interpretation of an event and write without fear or favor. At the same time, no doctor wants to hurt a patient or jeopardize a valuable and therapeutic relationship. Because I write almost exclusively about patients, here are some rules of thumb I follow.

I ask myself why it’s important to write about what happened. Is there a meaningful and universal message to share? Could what I write inform, educate, or empower someone? Or is it because I am annoyed and need to vent? I work mostly in a highly socioeconomically disadvantaged community with a high proportion of non-English-speaking refugees and asylum seekers. It’s safe to say that the vast majority of my patients would never come across my writing, but I always ask myself how they would feel if they were to stumble upon it. Would they be hurt, or would they feel heard? Would they feel exploited or understood? Would they say I had misrepresented them, or would they consider me their advocate?

There are things I never write about without prior consent. These have included attending the funeral of a patient I was fond of, acknowledging a gift from a dying patient, reporting an intimate but unique consultation, and encounters for which it would be immediately obvious to a reader that the story was about him or her or a loved one. No one has ever withheld consent when I have explained the reason for my writing; patients and their relatives are very generous and thoughtful in offering their experiences as teaching moments. Across many years of writing, I have attracted the ire of only one patient, who believed that I had been loose with the facts of her case. She chastised me for abusing my position and refused to accept my apology. In fact, her story was an all too common one, but in telling it, I had obviously skirted unacceptably close to her personal experience. This was one of the lowest points of my writing career, as I felt guilty about causing a dying patient distress and sad that I had not had an opportunity to make amends. But her rebuke has stayed with me and made me more cautious and more considerate.

Ultimately, writing about medicine relies on personal integrity and having a moral compass that detects right from wrong before an editor or one’s audience has the opportunity to do it. It means thinking deeply about one’s intent, endeavoring to set aside personal bias, and then having the courage of one’s conviction.

Finally, this is a one-line mental checklist I tick each time I write: “Will I be able to hold my head high in clinic tomorrow if I publish this?”

When to write

“How do you find the time?” I once asked a famous writer. “And what do you do about writer’s block?”

“Nonsense,” she said briskly. “When you show up to work, do you suffer from oncologist’s block? Writing is a job. It takes commitment.”

Several of my colleagues lament that they used to write well until careers in medicine put waste to their dreams of becoming authors. Now, between juggling patients, configuring career progression, and raising their families, they just don’t have the time to write.

A barrier I identified early on in my writing career is that the idea of having unlimited time, no distractions, a spotless desk, a cabin in the woods, or a house overlooking the ocean was never going to be my reality! With a busy clinical load and young children, there was never a good time to write. I spent the day doing my regular job, and by nighttime, I was too exhausted to write.

But I never gave up writing a journal, filling it with mostly mundane observations and reflections, not realizing that the mere habit of writing was important. I stuck to nice pens and sought out beautiful leather-bound journals to enhance the meditative quality of longhand writing.

But it didn’t feel like enough. Finally, the urge to write more and communicate with an audience became so great that I had to confront the reality: I could either write amid the chaos of work and home or not write at all. So, slowly, I trained myself to write among the chatter of children, keeping an eye on the trampoline and another on the screen. I became adept at stealing moments to write: between school pickups and sports drop-offs, while waiting in the car for swim school to finish, or perched on the edge of a bath. I learned to write a few lines if a patient unexpectedly canceled or if a meeting was delayed. I also learned to write in my head when I went jogging. Going for a run in the early morning before the hustle and bustle of the day begins is a fine way of sifting through my thoughts. Now, with a deadline every fortnight,
I must and can write almost anywhere.

I have no set time to write, but I do know that when an encounter lingers in my mind, it’s a signal to write. I turn the encounter in my mind, let myself feel uncomfortable or challenged or gratified, until gradually the essence of the experience becomes clearer and I am ready to write. Then, the words seem to tumble out. The hardest part of writing is getting started. Now, I worry less about perfection and more about getting the words down on paper. It’s much easier to edit than get started.

I have had to make some compromises. I love the slowness of writing by hand, which allows you to turn your thoughts in your mind, but I can write like this only in my journal now. The rest of my work is done on a laptop, but because I don’t like carrying it everywhere, I save my work in the cloud so I can access it from anywhere in the world. In the same way as many people work on talks and presentations in the airport lounge or on a flight, I write wherever I can.

But perhaps the most deliberate, and the hardest, decision I have had to make is to not undertake full-time clinical work to make some room for writing and its necessary companion, reflection. This has inevitably meant somewhat restricted career opportunities, with academic and financial ramifications, but for me it seems like a fair price to pay for the tremendous job satisfaction of being a doctor and a writer, able to serve not only my patients but a world of people. To have a few hours in the week to read widely, experiment with different forms of writing, and reflect upon the meaning of being a doctor seems like a luxury that many of our time-starved, emotionally fatigued colleagues are eager to embrace. They need to know that if good medicine is about advocacy, we can serve society through various means. Research and clinical work are two time-honored ways, but writing and public speaking are legitimate means of democratizing medicine.

The celebrated physician and writer Anton Chekov observed, “Medicine is my lawfully wedded wife and writing my mistress. When I tire of one, I spend the night with the other. Though it’s disorderly, it’s not so dull, and besides neither of them loses anything from my infidelity.”³

Nurturing the art of medicine through reflection and writing is important. It allows the development of a therapeutic, creative, and educational outlet. We must not consider it an unaffordable luxury but an essential tool for improving our own lives and those of our patients.

References

1. Srivastava R. Losing my twin baby boys forever changed the way I treat my patients. The Guardian. https://www.theguardian.com/commentisfree/2015/jun/15/losing-my-twin-baby-boys-forever-changed-the-way-i-treat-my-patients. Accessed January 30, 2017.
2. Rajana Srivastava. The Guardian. https://www.theguardian.com/profile/ranjana-srivastava. Accessed February 1, 2017.
3. Anton Pavlovich Chekhov (1860-1904). http://www.eldritchpress.org/ac/chekhov.html. Accessed January 30, 2017.

This issue’s “Current Insights in Oncology” is excerpted from the 2017 ASCO Educational Book, an NLM-indexed collection of articles written by ASCO Annual Meeting faculty and invited leaders from ASCO’s meetings. The complete article, “For Our Patients, for Ourselves: The Value of Personal Reflection in Oncology,” is coauthored by Lidia Schapira, MD, and Jane Lowe Meisel, MD.

Published annually, each volume of the ASCO Educational Book highlights the most compelling research and developments across the multidisciplinary fields of oncology.