Writing Hurts

Writing the blog is sometimes very painful. It’s not because I don’t like to write, because I do. It’s not because it’s difficult, although I do agree with the fictional author in The Angel’s Game who notes that sometimes to write you just have to sit down, squeeze your brain, and see what comes out.

The writing is painful because I can’t tell you the stories I really want to tell.

The good stories, the real stories, the stories worth telling in medicine are not the ones I write for you. The ones you see are the easy ones. They are the stories with set beginnings and endings, stories with no harm and no foul. They are stories that live in a world of black and white, a world where things are both defined and definite, and where thought is not required but is nice work if you can get it.

That’s not the real world of emergency medicine, at least not where the good stuff lies. The world that’s interesting , challenging, where souls are searched, doubts are harbored, and sleep is lost is a world of grays where the edge of the knife is often unseen and days of sheer boredom are punctuated by moments of utter madness. It’s a world of maybes and possiblys, of probablys and I-don’t-think-so’s, a world where every step into the subjective morass we call humanity is haunted by thoughts of doing too much and what we might miss. It’s a world where things just happen, and whether you do or don’t do something about it seems to make no difference at all. It’s a world where people die for no explicable reason, and where people who should be dead, or need to be, aren’t.

The best medical writing in ages past dealt with these very issues. Especially in the days before effective therapy, physicians would write about the real practice of medicine, about comforting the hopeless, trying to make sense of suffering, standing alone against tidal waves of uncertainty, plunging into the unknown chasm between science and faith. But the reader trying to understand the practice of medicine in our times will find nothing but tales of difficult but successful cases, lots of thoughts on the business of medicine, and a slew of soulless technical reports.

The reason is that it’s just become too dangerous to put reality into words. We live in a society where everything is foreseen through hindsight, and where the mists of time do nothing but sharpen the view. We’ve done such a good job advertising medical advances that nothing less than perfection is accepted; if something happens, it must be someone’s fault. And while we may acknowledge that nature may have her whims, we still cast about for someone to blame for her damage. (I think ED folks have an inherent understanding of nature’s victories. We know that when it’s car versus tree, the tree always wins…even if it’s been turned into a telephone pole.)

So why can’t I write the stories I want to tell? It’s because I’m scared to do so. Terrified, in fact. If I tell you these stories, I have no way to know that someone won’t pick up on the tale and trace it back to a patient. Within medical culture, judgment calls are automatic reasons for criticism. Indeed, there’s a whole academic industry called the Morbidity and Mortality Conference in which physicians who have never actually seen the patient nor work in the same field roundly dissect the care provided by another doctor. There’s also the system of Peer Review, which seems much less concerned with improving care than finding someone to take the fall for failures of the health care system. And that’s not even talking about the medicolegal climate, where anything is fair game for a lawsuit and there’s always an expert to tell you you’re wrong. (I say this as someone who’s done expert witness case review). A clinical tale might be traced back to an actual incident, and what is intended as an expression of the real challenges of care becomes ammunition for an assault on my integrity and my livelihood.

So I probably will never be able to write the kind of stories I really want to, at least until the statue of limitations runs out and I’m truly retired for good with all my assets in trust. Until then, continue to enjoy the pieces of fluff I put out. You’ll never really know what you’re missing.