Atul Gawande and the Art of Medical Writing

Don’t read this.

That is, if you have a limited amount of time for reading today, I’d rather you read Atul Gawande’s essay on end-of-life care in this month’s New Yorker than this blog.

But if you can spare a little time, I’ll be focusing on some of the techniques Gawande uses to make his writing so lyrical and memorable. Whether you write yourself or limit your storytelling to cocktail parties and presenting H&P’s on morning rounds, lessons abound. Here are a few, gleaned from this month’s piece, “Letting Go: What Should Medicine Do When It Can’t Save Your Life?”:

Make the First Sentence Count

I lecture frequently and think a lot about what makes for a good talk. One lesson is that the first few minutes are crucial: the speaker begins his or her talk knowing and caring more about the topic than the audience does. He or she has exactly three minutes to get the crowd to care enough to listen and learn. In my experience, about one-in-twenty speakers does this well; most launch directly into Fact One, shoveling coal into the engine and leaving the audience behind at the station, staring at the back of the caboose for the next 45 minutes.

Good writing is the same – the first sentence must grab the reader and telegraph where he or she is going to be transported.

Gawande begins his essay with this gem, as perfect in prose as it is nightmarish in image:

Sara Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die.

Enough said.

Use Everyday Language

In On Writing, Stephen King observes the tendency of writers to try to impress their readers with big words:

One of the really bad things you can do to your writing is to dress up the vocabulary, looking for long words because you’re maybe a little bit ashamed of your short ones. This is like dressing up a household pet in evening clothes. The pet is embarrassed and the person who committed this act of premeditated cuteness should be even more embarrassed.

In “Letting Go,” Atul uses one term I’d never heard before, saying that those who have embraced the rituals of hospice “are helping to negotiate an ars moriendi for our age.” Luckily, he defines the term early in the article; it means “The Art of Dying” and refers to two 15th century books that offered advice on dying well.

But more typical are sentences like these, which follow that extraordinary opening line:

It started with a cough and a pain in her back. Then a chest X-ray showed that her left lung had collapsed, and her chest was filled with fluid… Instead of an infection, as everyone had expected, it was lung cancer, and it had already spread to the lining of her chest…. Her mother, who had lost her best friend to lung cancer, began crying.

Notice the simple declarative sentences, with no more words – or syllables – than absolutely necessary. Not only is this easy to read, but it makes Gawande’s poetic turns of phrase all the more powerful – gorgeous splashes of color against a stark white background. Here are a few:

Words like ‘respond’ and ‘long-term’ provide a reassuring gloss on a dire reality. [After the oncologist tells Sara that many patients respond to chemo and ‘some of these responses can be long-term’.]

And still Sara, her family, and her medical team remained in battle mode. [After several rounds of chemo had failed and brain mets were discovered.]

You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. [On the fate of many ICU patients with terminal diseases.]

Tell Stories Rather Than Facts

Gawande begins and ends with the story of Sara Monopoli, but inserts an ICU physician’s lament (“I’m running a warehouse for the dying”), a story about hospice care, and the account of Susan Block’s (a prominent Harvard palliative care specialist) elderly father’s choice to have life-saving surgery. Each story has a clear purpose – we see the patient’s perspective, the family’s perspective, and the physician’s perspective. Each is memorable and moves the narrative forward, though the Monopoli tale is the thread that weaves the pieces together.

But the essay is far more than a collection of stories. Research findings bolster key arguments – their appearance help support, not replace, the lessons that emerge from the stories. For example, Gawande quotes a 2007 study that found that some patients (those with pancreatic cancer, lung cancer, and heart failure) who received hospice care lived longer, by several weeks to a few months, than those who didn’t. That nugget prompts him to paint this memorable word picture of the value of hospice:

The lesson seems almost Zen: you live longer only when you stop trying to live longer.

Similarly, he illustrates the value of end-of-life discussions with the story of La Crosse, Wisconsin, which began a campaign two decades ago to get physicians and patients to discuss end-of-life preferences. After five years, 85% of La Crosse residents possessed written advance directives at the time of their deaths, up from 15% at the start of the initiative. The result: people in La Crosse spend half as many days in the hospital before death, and end-of-life costs are just over half the national average. Echoing a point he made in The Checklist Manifesto, he writes, “The discussion [about end-of-life care], not the list, was what mattered most.”

Finally, to illustrate how modern technology has changed how we die, most writers would say something like, “People used to die of untreatable infections or vascular catastrophes, swiftly and without handwringing about their care options…” Gawande’s instinct, however, is to tell a story:

Consider how our presidents died before the modern era. George Washington developed a throat infection… that killed him by the next morning.

He goes on to recount briefly the deaths of eight other presidents, setting up his point that in the past,

people usually experienced life-threatening illness the way they experienced bad weather – as something that struck with little warning – and you either got through it or you didn’t.

Brilliant.

Don’t Edit Out Inconvenient Truths

Complex topics are, well, complex. One of things I admire most about Gawande’s writing is that he doesn’t whitewash the messiness. Here are three examples:

First, when the pregnant woman, Sara Thomas Monopoli, dies at the end of the article, it is not the peaceful storybook ending that the reader may have expected from a lifetime of watching Disney movies. After losing consciousness, her husband recalled,

there was this awful groaning… Whether it was with inhaling or exhaling, I don’t remember, but it was horrible, horrible, horrible to listen to.

“There is no prettifying death,”  adds Gawande.

Second, in his poignant description of the deaths of two hospice patients, the usual storyline would be that both died peacefully at home, a clear illustration of the virtue of hospice care. As it happened, one of them did, but the other did not. “…as if to show just how resistant to formula human lives are,” Gawande writes, “Cox had never reconciled herself to the incurability of her illness.” Based on her wishes, the family called 911 at the moment of her death, which led to a futile CPR effort.

Finally, building on this point, Gawande describes an “extraordinary essay,” written in 1985 by paleontologist Stephen Jay Gould, entitled “The Median Isn’t the Message.” In it, Gould describes his own case of abdominal mesothelioma, a fast-growing tumor with a terrible prognosis. Gould observes that while the median survival was about eight months, there was tremendous variation around the median, with a few patients living for several years. Gould used this observation to fight what he saw as an emerging orthodoxy about The Good Death:

It has become, in my view, a bit too trendy to regard the acceptance of death as something tantamount to intrinsic dignity. Of course I agree with the preacher of Ecclesiastes that there is a time to live and a time to die – and when my skein runs out I hope to face the end calmly and in my own way. For most situations, however, I prefer the more martial view that death is the ultimate enemy – and I find nothing reproachable in those who rage mightily against the dying of the light.

Gawande uses this quote like a researcher might use the limitations section of a peer-reviewed manuscript: as an opportunity to raise the objections of critics before the critics do so themselves, and then to answer them. Here, Gawande is saying: I get it. People will cling to hope and fight like hell for life – and there is nothing shameful in that.

But having legitimized this natural reaction to fatal illness, he returns to his central thesis: that our failure to prepare ourselves, and our patients, for the inevitability of dying leads to many terrible consequences – sure, unsustainable costs, but far worse, horrible, painful endings stripped of dignity and closure.

“What’s wrong about looking for the glimmer of hope, the long tail of survival?” Gawande asks rhetorically.

Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail… Hope is not a plan, but hope is our plan.

Be Humble

Gawande’s message emerges slowly – the reader sees hints of it early in the essay, and then comes upon a lynchpin line, right after the La Crosse story. La Crosse, he points out, vividly illustrates that the key thing is that doctors and patients talk about end-of-life care before the moment of truth. “It was that simple – and that complicated.”

It’s complicated because none of us are any good at conducting these painful discussions about end-of-life care, and few of us know very much about hospice. Rather than state these as general facts, Atul casts himself as poster child, admitting his own ignorance and fallibility so that we can more easily face up to our own. Such admissions help separate Gawande from other medical writers. (My counter example is another Harvard physician-author, Jerome Groopman, whose writing always strikes me as having a “see how clever I am” subtext.)

Here’s Gawande describing his experience shadowing a hospice nurse on her daily rounds:

The picture I had of hospice was of a morphine drip. It was not of this brown-haired and blue-eyed former ICU nurse with a stethoscope, knocking on Lee Cox’s door on a quiet street in Boston’s Mattapan neighborhood.

Even more impressively, Gawande illustrates how difficult it is for doctors to be honest with patients about fatal prognoses by recalling a discussion he had with a patient he’d just operated on, after he found her abdomen filled with widely metastatic colon cancer at surgery.

I said that it had not been possible to remove all the disease. But I found myself almost immediately minimizing what I’d said. ‘We’ll bring in an oncologist,’ I hastened to add. ‘Chemotherapy can be very effective in these situations.’

She absorbed the news in silence, looking down at the blankets drawn over her mutinous body. Then she looked up at me. ‘Am I going to die?’

I flinched. ‘No, no,’ I said. ‘Of course not.’

What doctor or nurse can’t identify with Gawande’s predicament, and his response? In a stroke, he reminds us that discussions about end-of-life care are intensely fraught, and that even the best among us are apt to get weak-kneed.

Take the High Road

The beauty of Gawande’s writing can cause one to forget that he’s not some ethereal poet – he is a policy wonk and a pragmatist. In 1992-93, he served as a senior healthcare policy advisor to the Clinton White House. He wrote his McAllen, Texas article because he wanted to introduce the Dartmouth Atlas’s arcane research findings into the national debate about healthcare legislation. He told me at dinner one night that he penned his piece that drew analogies between pilot programs in agriculture and the emerging healthcare legislation because he wanted to inject some optimism into the discussion about the latter. And, although I haven’t talked to him about this, I’m virtually certain that the inspiration for “Letting Go” was Sarah Palin’s Death Panels.

So, you might think that the article would have Death Panels in its crosshairs. If so, you’d probably scan it for a detailed policy prescription for promoting hospice care and paying for end-of-life discussions. Don’t bother – they’re not there.

In this several thousand word article, I counted two, yes two, brief mentions of Death Panels, both scarcely more than asides. Instead, Gawande focuses on the deeper issues, ones that are far more complex and important than any cynical political posturing. In doing so, he elevates the debate to a higher plane and, one hopes, brings a little shame to those who would blasphemously exploit these issues for talking points. In today’s healthcare system, he laments, we ask patients and families to let us know when they want to stop aggressive treatment.

All-out treatment, we tell the terminally ill, is a train you can get off at any time – just say when. But for most patients and their families this is asking too much. They remain riven by doubt and fear and desperation; some are deluded by a fantasy of what medical science can achieve. But our responsibility, in medicine, is to deal with human beings as they are. People die only once. They have no experience to draw upon. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come – and to escape a warehoused oblivion that few really want.

 

In this month’s piece, Gawande continues to tackle the most important healthcare issues of our day. By doing this with such clarity and beauty, he makes us all a little smarter, wiser, and more sensitive. His writing is a gift.

11 Responses to “Atul Gawande and the Art of Medical Writing”

  1. menoalittle August 14, 2010 at 12:43 am #

    Bob (and Atul),

    It is easier for the watched than the watchers. The bod and mind of the sickest have remarkable powers to protect and adjust when ill.

    Best regards,

    Menoalittle

  2. George Bodegon, MD August 14, 2010 at 2:12 am #

    Thank you Bob for this post. Discussions about death and end of life care is where Medicine as an art comes in and the science takes a back seat.

  3. Sir William Bailey August 14, 2010 at 6:23 am #

    Sometimes, in spite of treatment, a condition or illness will cause death. In those cases, patients can decide what they do and do not want done. They can decide whether they want aggressive treatment that might prolong life or whether they prefer to stop treatment, which could mean dying sooner but more comfortably. They may want to plan their own funeral.

    Care at the end of life focuses on making patients comfortable. They still receive medicines and treatments to control pain and other symptoms.

  4. Brad Stephan August 14, 2010 at 2:01 pm #

    Good analysis, Bob, and thank you for bringing in the Palin “death panel” connection – which was such a disservice to this essential topic. And, God bless Gawande for, once again, leading the way. If we are serious about optimizing our escalating healthcare budget, these discussions should be reimbursed for the provider and, indeed, mandated for the beneficiary. Think of the Advance Directive as a form of immunization for seniors – it controls unnecessary expenditures, while preventing an untoward outcome.

  5. Jack Harvey, MD August 14, 2010 at 3:06 pm #

    A worried well 43 year old presented with the desire to talk about the quality of her death when it comes. Hmmm. A perfect use of professionals’ time. Every person who gets Medicare or Medicaid, as a condition for this entitlement ought be required to have a quality of death declaration.

  6. Maria O'Reilly, RN August 14, 2010 at 4:32 pm #

    Thank you for this post.

    At a time when doctors and nurses have their faces glued to the computer screens (as I do now), as if there is a magic youth regaining potion buried in its code that will cure the illness of a 96 year old with mets cancer, along comes Atul (with your reinforcements) to suggest putting down the clicker and talk with the patient and family. What a brilliant idea! When in doubt, speak with and examine the patient.

    Most shocking is that this is coming from a SURGEON, a unique group whose communication is usually by scalpel and laser.

    EMRs and CPOE and e-mailer clickers should be banned from being involved with end of life care. The quality of death will increase exponentially.

  7. exodus August 14, 2010 at 8:38 pm #

    A few years ago, a speaker at my institution was speaking on biomedical ethics and the benefits of having an ethics team in house. The question inevitably came up – how do you finance your team and the consultations provided? He was aghast and found the idea of having ethics consultations coded and billed for, abhorent.

    Until there’s a regulatory framework and financing for palliative care, it is hard to imagine the best and the brightest making this a career choice. This may sound cynical but the muted conversations and the paused sociological research will continue to ensure the medical-industrial complex is the way end-of-life care is approached.

  8. Davis Liu, MD August 14, 2010 at 10:42 pm #

    As someone who aspires to write as well as you and Atul, thank you for this.

    Davis Liu, MD
    Author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America’s Healthcare System
    (available in hardcover, Kindle, and iPad / iBooks)
    Website: http://www.davisliumd.com
    Blog: http://www.davisliumd.blogspot.com
    Twitter: davisliumd

  9. Fifdy Cents August 21, 2010 at 11:49 am #

    Finally, to illustrate how modern technology has changed how we die…… Its predeclared who will and how will die.

  10. Barnice September 14, 2010 at 12:07 pm #

    Thanks for Your Information

  11. MelissaO September 28, 2010 at 1:50 pm #

    As a hospitalist in a medium-sized academic community hospital, the scenarios in Atul’s article hit close to home. While we have a palliative care service, they cannot possibly consult all of the patients & their family’s who need to address the 4 questions that Dr. Block talks about. We all need to work on the art of discussing end of life care. Thanks for the link to the NYer article.

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