Does Cancer Care Inspire Great Writing?

Oncologists face unique emotional challenges because of the processes of illness and death they witness, which may be unparalleled among other specialties. "We see tragedy after tragedy. And then we go to see the next patient." Dr. Bill Eley of Emory University in Atlanta, Georgia, once summed it up this way.

Dr. Riyaz Shah of the Kent Oncology Centre in England tweeted last year about how this uniqueness creates a need for communication. "Oncology is a strange thing. Daily, if not hourly, exposure to human distress. Very few people understand what we do, and fewer do it. There are not many people we can talk to."

They Do Not Just Read; They Also Write...

But oncologists do not just read and talk; they also write, often for one another. Some oncologists believe that their unusual working lives can sometimes produce transformative and even great writing, whether a bestselling book or a "narrative essay" published in a medical journal.

Dr. Jennifer Lycette of Providence Oncology and Hematology Care Clinic-Seaside in rural Oregon, who also blogs about being a physician caring for cancer patients, says: "Because we grapple with life and death every day, at some point we need an outlet to share that struggle."

Kathryn Hitchcock, a radiation oncologist and writer at the University of Florida in Gainesville, says: "I definitely think oncology produces great writing." It is a "high-stakes game" that strips away life's unnecessary things, she adds.

Of course, doctors in other specialties also face emotional challenges and put their experiences into writing.

Dr. Lidia Schapira, who works at Stanford University in Palo Alto, California, and edits Journal of Clinical Oncology (JCO)'s essay section, Art of Oncology, says: "I have no illusion that oncology alone produces great writing by healthcare professionals." She says: "But I think oncology brings us into a very intimate space with patients and into close contact because of existential concerns."

Dr. Preeti Malani, a geriatrician at the University of Michigan in Ann Arbor (and also a JAMA editor), says that oncology provides a significant share of contributions to JAMA's weekly medical story column, A Piece of My Mind, now in its 41st year. The column covers all specialties and general medicine.

Malani says: "Ultimately, stories from any specialty's efforts to infuse humanity with medicine are what we are all trying to do in our daily work."

A Common Theme

Schapira spent 20 years as a reviewer, going back to the beginning of the column series, and for the past 5 years has edited Art of Oncology.

Shapira explains that storytelling in JCO evolved from essays on emerging topics such as palliative medicine and medical education, ultimately becoming more about oncologists' inner lives and, in many cases, honoring the life of a particular patient.

"The message here is that the authors have very deep respect for the patients they treat." she says.

Schapira says that, in portrayals of doctors in the media, especially television, "this part has been completely overlooked."

Hitchcock of Florida demonstrates this kind of respect for a cancer patient in an article in JCO last month entitled "Knuckles" (meaning the finger joints).

The author's opening 2 sentences are striking: "The swastikas on his knuckles kept stealing my attention. I tried not to look, but whenever he gestured to emphasize his words, my gaze returned there."

After approximately 1600 suspenseful words, a surprise emerges that dozens of JCO readers from as far away as Australia appreciated, emailing notes of thanks to the radiation oncologist.

Many readers told Hitchcock that this essay, in which both she and the patient triumphed after taking risks, differed from the usual oncology pieces saying, "I was caring for this patient, and the situation made me very sad."

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Malani, who reviews approximately 2000 stories each year for 48 publication slots, says no topic is too ordinary for an essay in JAMA's Piece of My Mind. This is one of the journal's most widely read sections, and she observes that its writers often receive thousands of emails in response.

Malani, who was a newspaper reporter before medical school and earned a master's degree in journalism, says the keys to great storytelling in medicine include a fresh perspective, high-quality writing, and an emotional layer.

Malani admits: "I often choose the piece that makes me cry." She says, "Many stories are about patients, and many are difficult and sad." echoing Schapira's comments.

However, she says first-time writers tend to submit ordinary stories. For example, a topical subject repeatedly submitted to A Piece of My Mind is medical students' stories of "Why I Hate Online Medical Education".

Malani also notes that writing about cancer has undergone a major transformation over the past 40 to 50 years. "Cancer has moved from stigmatization (labeling or marking an individual because of a particular disease), which meant no one wrote about it, to something that helps build community." she observes.

Journals have recognized the appeal of narratives that build communities. JCO is joined by JAMA Oncology (Cancer Care Chronicles) and The Lancet Oncology (Perspectives), among other cancer journals with sections for storytelling or nontraditional (that is, non-data-driven) editorials.

JCO's Art of Oncology column was described as much loved on the ASCO Post website last year and was voluntarily adapted into podcasts by veteran professional actors from Holywood, such as Susan Sullivan and JoBeth Williams.

Stories Can Inspire Change

In recent years, laypeople and physicians have written about cancer in books such as When Breath Becomes Air and Radical Remision; these have become bestselling books.

But perhaps most notably, the Pulitzer Prize-winning book on the history of cancer treatment, The Emperor of All Maladies, grew out of everyday oncology practice (the author's other book: The Gene: An Intimate History – Summary of an Oncologist's Book)

In an interview with Medscape editor-in-chief Eric Topol, Dr. Sid Mukherjee, a medical oncologist at Columbia University in New York City, described how the idea for the book came to him.

Mukherjee said: "I was an academic." He said, "A cancer patient asked me a very simple question: 'I want to go on, but I need to know what I am fighting'. I was astonished by the idea that cancer, one of the great families of diseases in our history, had no intellectual history. So I searched for one myself, tried to find it, and when I could not, decided to write it myself." (That was exactly my aim when I embarked on the journey of my personal website, drozdogan.com ). 

Mukherjee is widely credited with a talent for combining science with storytelling.

JCO editor Schapira says: "We overlook the importance of storytelling in the tragedies in our own lives." She says, "Stories can inspire change."

JAMA editor Malani agrees. She highlights an essay by Dr. Jessica Colburn of Johns Hopkins University in Baltimore, Maryland. Colburn writes as the mother of an 8-year-old girl complaining of headaches, who soon undergoes an MRI that reveals her brain tumor.

The essay's lasting impression, Malani says, is the mother's appreciation of the kindness shown to her and her frightened child by the imaging technician and neuroradiologist. "When you read something like that, you say to yourself, 'I will be kinder.'"

A beautiful, recent example of such writing is Learning How to Die – Lessons From the Irish Wake.

Lycette began writing after working in oncology for about a decade, settling into a life serving patients in rural coastal areas. "A combination of personal and professional challenges culminated in my wrestling with a larger question: What is hope? I was consumed by a strong inner need to write about it." Ultimately, through "Practicing Hope," the first essay she published as a result, Lycette discovered it was her patients who had taught her.

In writing, Lycette explores her life and oncology in depth, perhaps the opposite of much of the medical literature, which is usually a calculated statement intended to specify an outcome.

She says: "I am always surprised by the direction writing takes me. Where I end up is never a place my conscious mind could have predicted."

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