Why Physicians Should Write Fiction

Ostensibly, one writes to get published and-because publishers express love through the cash advances they offer-to make money. But there is yet another reason, as exemplified by the following story.

When, in his eighties, world-famous physicist Hans Bethe confided to a friend that he had written a personalized account of the creation of the first atomic bomb but, because of the prevailing political climate, did not plan to publish it, his friend asked, "Then why did you write it?" "I wrote it for God," Bethe allegedly proclaimed. Gently, the friend protested, "Hans, don't you think God already knows the story?" Whereupon Bethe shot back, "He doesn't know my version!"

It's important that the public knows what generations of physicians think and how their thinking has become accommodated to the rapidly changing medical scene; the eternal conflict between what is best for an individual patient and what is best for science or society.

Although physicians are not deities, novelists are. They're the creators of their characters and, if they work hard enough to get to know them, the characters will come alive and tell them what to write. They will also become close friends.

As Anne Morrow Lindbergh once said, "Writing is even more than living: it is being conscious of living." Because all fiction writing is essentially autobiographical, it's a way of learning more about yourself.

You must do something in fiction that you seldom do in real life: Think things through to a conclusion. In life, something happens, you react. Something else happens, you react again-but, for as long as you live, never to any lasting conclusion.

Moreover, once you are into it, writing provides a great release from the headaches and heartaches of the everyday world. Who else but writers of fiction can lead double lives: make great medical discoveries without grant support, fell villains with karate chops that actually work, have torrid love affairs without paying the consequences?

Ernest Hemingway said, "The job of a writer is to tell what happened and how he feels about it." And physicians are the logical people to write about medicine because they can do so from the inside. Unlike other art forms, fiction allows physicians to tell readers what they really think and feel when facing desperate personal or professional situations. In Dr. Roger Bone's extremely moving account of how he coped with his impending death [1], the renowned pulmonologist and teacher wrote that he found the greatest solace in the works of such classic writers as Leo Tolstoy and Thornton Wilder.

For me, the most compelling reasons to write fiction (although they don't happen often; maybe in one of every five working sessions) are those special moments when I know I'm not so much creating as recording, possibly with some mysterious outside help. The scene becomes crystal clear in my mind's eye; I gain insights into my characters-and myself-that I've never consciously thought of before. Whether, when in this glorious mode, I'm tapping into some "collective unconscious" or into the core of my creativity, it's a "high" that those fortunate enough to have experienced it know is both incomparable and addictive. In anticipation of it, I still write the first drafts of chapters in longhand, using a medical shorthand to capture on paper the thoughts and actions of my characters as they reveal them to me.

How To Get Started

"It's easier to write when you have something to say" (Somerset Maugham). In other words, you must have a theme, preferably original, that you can express in a few sentences. Here, for example, is the theme of my novel, The Anatomy Lesson: A first-year medical student becomes so obsessed about the identity of the cadaver that he has drawn and who may have murdered him that his pursuit of the answers jeopardizes not only his medical career but his life.

A good way to derive a theme is to ask yourself one or more "what if" questions, such as: What if a 40-year-old neurologist discovers a means to increase his nerve conduction velocity so that he becomes much quicker than anyone else, thus transforming himself as if by magic into a world-class athlete? For many middle-aged men, it's their favorite fantasy-although, as with the protagonist in my novel Nerve, it comes with a price to pay.

Once you have your theme, you must move on to the other essential elements of a novel: plot; characters; mood; movement; conflict; and a resolution that leaves few, if any, loose ends and is satisfying to the reader. There are two broad approaches to use in plotting. If writing a mystery, a real whodunit, it's best to start with the ending clearly in mind. Otherwise, you can introduce your main characters, get them in play, and see where they take you.

A cautionary work about conflict, the key ingredient that moves the plot. One reason why the once-popular TV physician shows, such as "Dr. Kildare" and "Marcus Welby, M.D.," virtually disappeared from the small screen for 20 years was that their physician-heroes were too predictable: They always did the right thing in the end. Robin Cook avoided this dramatic pitfall by writing about fiendish physicians. But that doesn't work for me. Although I've met my share of strange physicians, none were truly evil, and I try to base my characters on people I know. (Maybe the onslaught of managed care types will change that.)

As for style and technique, I offer the following six rules from the masters to guide you:

Stendahl: "Above all, be clear!"

F. Scott Fitzgerald: "Start with a person in mind and you can create a character, but start with a character (stereotype) in mind and you create nothing."

Mark Twain: "The difference between fiction and reality is that fiction has to make sense."

Ken Kay: "Everything you write should do one of three things: develop character, set mood, or move the plot. If not, it had better be a damned good diversion, or else eliminate it."

Somerset Maugham: "Think before you write; write about what you know."

Anatole France: "Rewrite, rewrite, rewrite!"

The last rule deserves emphasis. As the great French novelist once described his composition method to an admirer: "The first draft could've been written just as well by a high school student; the second draft by a college student; the third draft by a graduate student; the fourth draft by a member of the French Academy of Literature; and the fifth draft only by Anatole France!"

After many years of writing and publishing medical novels, I still average 8 to 12 hours of solid writing-not researching or daydreaming-per typed page. Ironically, what takes most of my time (if I do it right, the reader doesn't know I've done it at all) is getting a good rhythm in my sentences that makes for easy reading. (For example, Charles Dickens: "It was the best of times; it was the worst of times; it was the Spring of Hope; it was the Winter of Despair ...")

How do you learn to create a good rhythm? By reading good writers. In the years when I could come home from the hospital with enough energy to start writing, I'd make the transition by reading something by F. Scott Fitzgerald, who seemed incapable of writing a bad sentence.

How To Get Published

Having at last written "The End" to your story or novel, you can now call yourself a fiction writer, whether your work ever makes it into print or not. And for that, you need a literary agent. It helps if you know any published authors who can introduce you to their agents. Short of that, you have to consult the New York City telephone book, the Internet, The Writer magazine, or the Literary Marketplace to find out which agents are accepting new clients. Don't send a completed manuscript with your inquiring letter. A better approach is to enclose a chapter or two-the best you've written that will give them a feel for the novel-plus a tight 4-or 5-page synopsis of the plot. Should this be enough to intrigue, the agent will request the full work.

That's the standard way to go about hiring an agent, but there is an alternative. There are now many freelance editors who, for a fee, will read your novel, work with you on it if it seems promising, and even help you find a good agent. They are listed in the Literary Marketplace. Depending on the amount of effort such editors put in, they will charge you between $1000 and $2500. But they are well connected and reputable, and the money you pay out can be worth it.

Moreover, there's no compelling reason why you should start by writing a novel, medical or otherwise-although, compared with a short story, it's easier to get published. Rather than science fiction, I prefer writing "science in fiction." Nonetheless, there is a burgeoning market for "sci fi," as well as agents who specialize in it, and if this is what you yourself like to read, try writing it.

What To Do, or Avoid Doing, with a Work in Progress

Most writers need immediate feedback, usually from a spouse or close friend. But beyond that, don't go soliciting too many opinions, especially from professional writer-friends or colleagues who seldom read novels; they're bound to be conflicting and possibly dead wrong. The rule I try to follow is, "Don't make changes in your manuscript unless someone-namely, a publisher-is paying you to make them." If you're not at this stage, the best advice you can probably get is from friends or neighbors who are avid novel readers and know what they like. And don't worry about the competition from other professional writers. One reason why so many geniuses are young is that they're naive: They don't know what they're up against, so they just go ahead and do it. It's much the same with successful first authors; whatever they may lack in technique, they make up for in originality-and it's the story that counts.

And, oh, what thrilling moments await if you succeed! The phone call from your agent telling you the book has sold. The first copy to arrive in the mail. Perhaps a promotional tour; appearances on local television; and. if you're lucky, "The Today Show" and the pinnacle, "Oprah." But be warned-there is a Catch-22 in the book business that goes like this: A publisher will advertise and promote your book in order to sell it, providing that it sells. What this means is that your work is on its own for the first several weeks. If it gets a rave in Publisher's Weekly (which reviews new books before publication) or in a major newspaper or magazine, the promised promotional money comes through. If not-better luck next time. Which is why many authors, including myself, keep changing publishers.

You should also be aware of the vast changes that the publishing industry has undergone in recent years. Where once there were 20 or more major publishers, now there are only 7 or 8-none American-owned. Where once your chances of a profitable paperback sale were good if your novel was published in hardback, it's much harder nowadays to get your book on the paperback lists. Most drugstore or supermarket book racks no longer display a wide variety of titles, just the Top Ten.

Editors who truly love books and will work closely with you to make yours the best it can be still exist, but they're a vanishing species. Most editors these days are hired or fired on the basis of how much they contribute to the company's coffers. Therefore, your best chance of attracting their interest is to write a medical thriller. And if you think you can, do! Then, having established a reputation and relationships in the industry, you might try your hand at a serious medical novel-but take notice of how few of these get published anymore. As for me, I'm unwilling to spend 2 years of my life writing a novel that contains thrills galore but very little in the way of insights into our profession or significance for future generations.

On Inspiration

Like luck and chance, inspiration favors the prepared mind. Each writer seeks it in different ways and places. I have two: shaving and walking to the hospital in the morning (the latter presents something of a hazard if I don't pay attention to the traffic lights when crossing the street).

You may not be able to inspire chronically tired medical students to write more than a decent case history, but you can get them to read and appreciate some of the great medical novels, such as Arrowsmith and The Cry and the Covenant, by threatening to give a written test on them.

In my early days, I wrote for the usual reasons: fame and fortune. But I write now because I can't stop: It fills too important a place in my life. And as one of our greatest sportswriters, Red Smith, put it: "There's nothing to writing. All you do is sit down at a typewriter and open a vein."