Trouble on the Mountainside (from nanofiction - Andrew Looney) "Death!" Chris cried triumphantly. Flashlight beams danced together on the plastic floor as rain pattered lightly on the canvas above. "Death by Chocolate means I win!" Suddenly there were noises outside. Everyone froze. A face peers in through the flap. "Lights out was an hour ago," said the scoutmaster, "and... hey, Fluxx! Can I play?"

Recently I read an essay in the Canadian Medical Association Journal that focused on an interesting topic arts topic. The article entitle "Why we write (and how we can do it better)" discusses why clinicians decide to write and publish their experiences, focusing around five common errors that the author, Allen Peterkin, MD (founding editor of Ars Medica) sees as he reviews submissions.

"I've been forced to reflect on why doctors write, how and when we do it and whether there are mistakes we make as we go along. It occurs to me that this new wave of composition is not always honest, helpful or even benign. As educators, policy-makers and clinicians, we should reflect on what writing and sharing stories means to us, how we approach the task and then contemplate what the risks are to our integrity as physicians"

He starts off with some more basic writing-for-publication type issues. One mistake he sees is too much cutting to the chase, writing more of a case report than a story. He find that doctors "favour tidy endings, epiphanies and accounts of patients who exhibit courage and triumph over adversity." He feels stories about our failures are much more honest and interesting. He also sees that often doctors forget who they are writing for. The story may be more for the author and not for the reader.

As an example of the fourth error, he gives a story told by novelist Margaret Laurence. While at a dinner party, a neurosurgeon told her that he planned to write novels after he quit surgery. She replied "What a coincidence- when I stop writing, I plan to take up brain surgery." He finds that the clinician (specifically physician) writer often lacks humility and patience for the writing process.

The most serious error that he sees is that the clinician feels that the stories heard and experienced in the clinical setting belong to him/her. This error is the ethical and professional issues surrounding publishing a patient's story without permission.

This article really focuses on the patient centered narrative writing we do to be published. I think there is a lot of writing that we do just for ourselves. I don't keep a journal but every once in awhile I do sit down and write out a story. It's always for myself, most often trying to get out some emotion that I didn't feel I could have expressed at the time. It's no great work of literature and often gets erased a few days later. But I think that was Peterkin's point. Not to discourage writing but to point out that there should be a difference in the kind of writing we do in patient charts, for case studies, for ourselves and that which we do and submit for public consumption. For anyone interested in this type of writing, it definitely gives you something to think about.

Thanks to Thomas Quinn who sent me this article.

In 1918 when the influenza epidemic hit Philadelphia, Isaac Starr was a third-year medical student. With so many medical practitioners away in the army, the third and fourth year students were called upon to act as nurses and interns. Starr wrote about his experiences in an essay that was published in 1976 then republished in 2006 (free PDF) in the Annals of Internal Medicine. (Picture: Emergency hospital during 1918 influenza epidemic, Camp Funston, Kansas)

As a third-year, Starr was assigned duties of head nurse. The epidemic started mildly with most of his patients admitted with just a febrile illness because their families were all ill and there was no one at home to care for them. This soon changed. He vividly describes the progression of the illness.

"As their lungs filled with rales the patients became short of breath and increasingly cyanotic. After gasping for several hours they became delirious and incontinent, and many died struggling to clear their airways of a blood-tinged froth that sometimes gushed from their nose and mouth."

The physicians he had supervising him were mostly retired specialists. "I recall a laryngologist who seeing herpes labialis on a gasping cyanotic patient was much interested in it and prescribed application of guaiac." He was taught "cupping" by another physician. He was reprimanded for not leaving the windows open as this was the practice of the time for treating pneumonia (perhaps treating the dyspnea associated with it?).

Starr had few therapeutic options available. "When the pulmonary froth endangered life I gave atropine; when the patient was moribund and the pulse weak I injected camphor in oil." At the peak of the epidemic, the death toll was over 25% per night.

Starr wrote his account of the 1918 epidemic to share his experiences so that we might be better prepared if this should happen in the future. In reading his essay, I can't help feeling the helplessness they must have been experiencing. To see such death and suffering and know that there wasn't much that you could do to make it better, or even slow it down. I can't imagine what it was like to be still in medical school and charged with caring for a ward of dying patients. Even with all our medical advances, I find Starr's descriptions to be terrifying. It seems that an influenza epidemic is just as much a threat today as it was in 1918.

Reference: Starr, Isaac, Annals of Internal Medicine 2006; 145:138-140