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A Swim in a Pond on the Wards

I first wrote to author George Saunders in my senior year of high school. Thankful for everything his writing taught me about empathy, I sought advice as I crossed the “seemingly arbitrary line into adulthood.” Unsurprisingly, he responded to my naivety with grace and reassured me that I would “do beautifully just by following [my] own nose.” I started to consider a future in medicine, a field devoted to the well-being of others but notorious for burning out even the most well-intentioned people. I hoped my instincts would be enough.

Since then, I have reached the milestones that once felt impossibly far away. I made it to medical school, passed my boards and currently am months away from walking across a stage as a full-fledged doctor. After countless moments of awkwardly explaining to a patient that I was not exactly their doctor (but expanding that the medical information I was discussing with them was still, to my limited knowledge, sound), I would finally be one.

Yet, as I looked back on the challenges of learning the science and practicalities of medicine in my first stage of training, I wondered if I managed to live up to my idealistic goals. Had I cultivated these “patient-centered” values I hoped to practice throughout my career? Eight years after that first email and in my final year of medical school, I once again turned to Saunders for guidance. At the start of my sub-internship, I dipped my toes into the first few chapters of “A Swim in a Pond in the Rain,” a literary analysis Saunders published in 2021 on seven Russian short stories. In an essay following Ivan Turgenev’s “The Singers,” Saunders pulls back the curtain on his writing process. He starts with a simple sentence and reaches toward specificity through a series of incremental revisions. He gives the following (paraphrased) example:

“Bob was an asshole.” Going on to further examine how was Bob an asshole:
“Bob snapped impatiently at the barista.” Going on to further examine why Bob had snapped: “Bob snapped impatiently at the young barista, who reminded him of his dead wife” then paused to add, “whom he misses so much, especially now, at Christmas.”

When Bob was described as simply an asshole, I was left with less patience and curiosity towards him than I otherwise might. I was less inclined to ask, “But why?” in the first place. With three small additions, this one-dimensional curmudgeon became someone who, in response to the circumstances that have set his life upon a specific course, was struggling on a day far from his best.

The virtue of writing stories this way, particularly fiction, is not difficult to appreciate. A good story must be interesting enough to hold a reader’s attention. The description of Bob acting out in the context of grief makes me care much more than the simpler version. However, a well-told story in medicine tends to be judged on different virtues — brevity, objectivity and detachment. A lifetime’s worth of experiences, fears and ailments become reduced to snappy one-liners, easily digestible for presentation, diagnosis, treatment and discharge. In other words, if Bob was a patient presented on rounds, I would not need to know anything other than he “was an asshole.”

When discussing differential diagnoses and medical management, there is clear value to this efficiency. It protects patients by creating a shared vocabulary among complex teams of providers and trainees, reduces avoidable errors, optimizes care and keeps the machine chugging along. I had spent much of my clinical training until now trimming the fluff off my patient presentations while keying in on the medical facts of each case. Yet, reading Saunders’s take on Turgenev led me to wonder if taking the approach so valued in fiction could translate onto the wards. I give the following (deidentified) example:

Mr. X is an 84-year-old with a past medical history of systolic heart failure with reduced ejection fraction, status-post implantable cardioverter-defibrillator (ICD) presenting with fevers, chills, fatigue and leukocytosis found to have bacteremia concerning for endocarditis secondary to ICD seeding. He is responding well to antibiotics and is clinically stable, pending a transesophageal echocardiogram for further management.

Add: “He is incredibly upset, yelling at the medical student.”

Now, with a bit of information beyond his clinical status, the questions start asking themselves. Why is he upset? Is he always like this? Did the student wrong him in some way? What else is missing in this story?

Add: He was told “the echocardiogram would happen today” each morning since he was admitted three days earlier from various departments, without a clear answer of when or why it was delayed. He went on to plead: “What about the anxiety this causes me? What about the stress on my family? It feels like you’re playing with my life!”

The facts have not changed. While the patient is currently medically stable, he may have a life-threatening illness requiring risky surgery. We will not know until he receives an invasive diagnostic test that was rescheduled multiple times. Testing was likely rescheduled due to legitimate system-level reasons but was never communicated to him. He has heard over and over that his life might be on the line, but after many days of unexplained delays in his care, he still has no more answers for the many questions he and his loved ones had asked than when he arrived. Despite the best intentions and sound medical management, there were shortcomings in his care.

I got to know him well by the time he left our hospital a week later. He grew up during Jim Crow and witnessed his community transform over the decades. His father had worked his whole life to earn the dignity associated with the title “Mr. X,” leading my patient to request being called by just his first name whenever possible. Now as a father to adult children himself, he spoke about them with deep pride but felt it important not to burden his family with worry or to lose independence as he aged. Medically, we also learned that our worst fears had come true. The ICD was seeding infection, and he would need the complicated open-heart surgery that required his transfer to another facility.

While this knowledge did not change his management or the indicators we use to assess the quality of our care, it helped me be just a bit more attuned to his priorities when we had difficult conversations about the next steps in his care. I also hope it made him and his loved ones more comfortable with the unknown they faced as they approached hard, life-altering choices.

After presenting the reader with Bob, Saunders insists that the process that led to a better, kinder version of the story did not happen because he was “trying to be a good guy.” He just wanted to write a better story. Nonetheless, the act of revising made him feel that he was a better version of himself. One that is “smarter, wittier, more patient, funnier” and holds an overall “[wiser] view on the world.” When practicing medicine through a similar lens, I feel myself moving closer to the kind of physician I hoped to be. For even a few moments, I could see the person in front of me with greater clarity and felt more attuned to the unique joy that caring for another brings. 

Experiencing brief moments away from the science of medical practice and leaning into its art serves as a deep well from which I draw to maintain perspective and find gratitude during challenging moments.

Having those brief moments away from the science of medical practice and allowing myself to lean into its art, was a deep well I pulled from to keep perspective and find gratitude through the challenging moments.

Saunders, G. (2021). A Swim in a Pond In the Rain: In Which Four Russians Give a Master Class on Writing, Reading, and Life. New York: Random House.

Image credit: “Pond” (CC BY 2.0) by www.metaphoricalplatypus.com

WiTTY Wednesdays is an initiative showcasing the works of our Writers-in-Training Program writing interns. WiT is a year-long internship for budding medical student writers. Our interns receive intensive, one-on-one mentoring from our medical student program directors and publish at least 3 pieces during the course of their internship. If you are interested in learning more about the program, please contact us at editorinchief@in-training.org.

Pal Shah (1 Posts)

Writers-in-Training Intern and Contributing Writer

University of Illinois at Chicago College of Medicine

Pal is a medical student at the University of Illinois at Chicago College of Medicine in Chicago, IL, Class of 2024. In 2019, he graduated from the University of Illinois at Chicago with a Bachelor of Science in neuroscience. He enjoys playing basketball, trying out new recipes, and giving belly rubs to his two cats in his free time. After graduating medical school, Pal would like to pursue a career in Med-Peds.