Over the years, various people – media and others – have interviewed Abraham Verghese about his life, his books, his writing style, as well as about his work as a physician, teacher and author. Since website viewers often have the same questions, we have grouped a selection of these Q/As under different headings for ease of access.
Click on a topic or read the entire series.
Books – General
Cutting for Stone
Cutting for Stone, Origin of the Title
Medicine and Writing
Training as a Writer
You talk a lot about the lost art of bedside diagnosis. Can you describe what that is and why losing it is a bad thing?
As we’ve gotten very fancy in technology and the incredible detail with which we can see the body, we sometimes lose sight of how much we can see about the body just from examining the patient. The physical exam really allows you to order tests more judiciously and to ask better questions of the test.
Tell us about your vision for teaching medical students and physicians.
Yes. I’ve learned by coming full circle that the most important way we have to influence medical students and residents is really at the bedside, one by one. There really is no shortcut; there is no classroom lecture that can substitute. Stanford has such a wonderful reputation for research, and we wanted to try and make sure that it also had an equivalent reputation for the clinical training of our students and our residents.
So the clinical encounter at the bedside is terribly important. In other words, you can have all the theoretical knowledge in the world, and if your interaction with the patient is somehow clumsy and not done well, the relationship won’t even begin.
The computerized medical record, along with burgeoning technology, has seriously threatened the patient/physician interaction in the hospital.
I would contend, and I will keep saying this till the day it stops being true, that the patient in the bed has now become an icon for the real patient, who is in the computer, the patient I call the iPatient. The patient in the bed simply exists to signify that there is a file in the computer.
Now, of course, I’m being facetious. We clearly pay attention to the person in the bed, but what I mean to say is that looking at the body, orienting oneself from the body has become almost passé. The body is viewed as incidental, in many cases for good reason, because a mammogram or CT scan can perhaps see much more clearly than the human hand. Nevertheless, there are things that only the human hand can find, like whether it’s painful in a particular spot. That’s not something that any machine can tell you. There isn’t any machine in the world that can do a knee reflex and convey the information of a tendon reflex. There are elements of this exam that are so important, and in this era of biomarkers and other sexy tests, we have forgotten the value of the good physical.
What is it about the practice of medicine today that prompts doctors to rush into ordering tests vs. taking their time to do the bedside diagnosis?
For one thing, the tests are very, very good. The kind of detail you can get from a CAT scan is far superior to what your hand can tell you. On the other hand, only your hand can tell you where it hurts by pushing on a certain place. … We’re all intrinsically prone to allowing technology to take the place of common sense and I think that’s a danger. … The tests have become an easy shortcut. They’re an efficient, quick way to get information. But the great danger I see is this: I think that people fail to really connect with patients when they don’t examine them. I think the carefully done physical is a wonderful way to convey your attentiveness to the patient.
Do you think patients want to feel that you have really seen them, rather than that you have just read about them somewhere else?
Yes, I think people want to feel you’ve really seen them, but I think it’s more than that. My bias is that if you do the bedside stuff well, if you really have confidence in your exam, it leads you to order tests judiciously based on good hunches, and then I think you are more cost-efficient, and you are ahead of people who have to wait for all the test results to fall out of the sky to get a clue as to what is going on…
There are so many anecdotes I can think of – we all have them – where an exam of the patient completely changed the course of everything, or where failure to recognize a finding on the exam proved costly. Not doing a careful history and physical exposes patients to so much unnecessary testing, so much unnecessary ‘stuff.’
How did your own medical training abroad shape the way you practice medicine in the U.S.? What unique perspective does this training enable foreign physicians to bring to the practice of medicine here?
Foreign doctors have all kinds of different forms of training. But many are united by one common factor that seems to be operative especially in the Commonwealth countries — a great emphasis on the bedside exam and on clinical skills. In part, [this approach] was driven by the lack of ready access to all the kinds of sophisticated testing that we have now. But I think that kind of clinical training still serves me very well.
It’s almost embarrassing to see how little emphasis we put on that here where the most glaring finding, one that could have been discovered by either a good history or by a discerning exam, instead requires this $2,000 MRI and interpretation to discover something that was really there for everyone to see and recognize had they only learned how to do that.
How can professors and medical schools help address the primary care shortfall?
It’s a struggle … but if you’re going to do it, you’re going to do it only by showing them the charm and the magic of being at the bedside. There is no passion and romance that you can illustrate to them in front of a computer, which is where a lot of care takes place these days. The only way to excite students about medicine is to do it one by one, by them seeing you being the kind of physician that they’d like to be.
Books – General
Your two non-fiction books are very autobiographical. What’s the difference between penning fiction and non-fiction? How was the process of writing Cutting for Stone different for you than penning the other books?
I must say that fiction was always my first love; indeed, one of my first published stories as a very dark AIDS story titled ‘Lilacs’ which appeared in the New Yorker. That led to my getting a contract to write My Own Country, a non-fiction book about my AIDS practice and experience in small town Tennessee, followed by another memoir, The Tennis Partner (the story of the loss of a physician friend to drug addiction and suicide). These were things I had witnessed that I had to tell, but when I was done with the second book, I was keen to get back to fiction.
What was so different about writing a novel for me was that sense of discovering the story (unlike non-fiction, where you sort of know what happened and what you will write about–the story has presented itself so to speak, and now it is about selection). My ambition for the novel was tell a great story, an old-fashioned, truth-telling story.
All I had at the outset was an image of a beautiful Indian nun giving birth in a mission hospital in Africa, a place redolent with Dettol and carbolic acid scents, a place so basic, so unadorned, that nothing separates doctor and patient, no layers of paperwork, cubicles and forms. That is all I had. I did not know the whole plot or how it ended. (and see answer to next question as to how I eventually did plot, and even then there were surprises).
I did know that I wanted the whole novel to be of medicine, by which I mean I wanted every person, scene and place to be informed by medicine, kind of the way that Zola’s novels are of Paris. I wanted very much to celebrate an aspect of medicine that gets buried in the way television depicts the practice: I wanted the reader to see how entering medicine was a quest, a romantic pursuit, a spiritual calling, an undertaking that could put you at some personal risk (of losing your selfhood, your obligation to family) but which could also save you. It’s a view of medicine I don’t think too many of my students see – we live in a world of haste where physicians and nurses are hunkered down behind computer monitors, and patients are whisked off here and there for this and that test, that side of medicine gets lost.
What inspired you to write each of your books? Was there a moment of epiphany for each one, when you decided that you simply had to put that story down on paper?
Many moments of epiphany in all of my books. There was no real moment in time when any of them started, but very often for me, writing about something is a way to understand it better, or just understand it in the first place. I became a character in the stories with a sense of discovering the import as I wrote rather than writing because I understood it.
Living through the time of AIDS in Tennessee, and helplessly with David as he was spiraling down in El Paso – writing these first two books helped me more deeply understand those experiences. With Cutting for Stone, I arbitrarily chose twins, then twins became the motive for the story, and ultimately they were the focus for the characters’ redemption. I could not have anticipated any of that when I began writing, but it became clear as I progressed. A series of epiphanies, you could say.
Cutting for Stone
Was there a single idea behind or genesis for Cutting for Stone?
My ambition as a writer was to tell a great story, an old-fashioned, truth-telling story. But beyond that, my single goal was to portray an aspect of medicine that gets buried in the way television depicts the practice: I wanted the reader to see how entering medicine was a passionate quest, a romantic pursuit, a spiritual calling, a privileged yet hazardous undertaking.
It’s a view of medicine I don’t think too many young people see in the West because, frankly, in the sterile hallways of modern medical-industrial complexes where physicians and nurses are hunkered down behind computer monitors, and patients are whisked off here and there for this and that test, that side of medicine gets lost.
So I began with the image of a mission hospital in Africa, redolent with Dettol, the antiseptic of choice of the tropics; I wanted to portray a place so basic, so unadorned, that nothing separates doctor and patient, no layers of paperwork, technology or specialists, no disguising of the nature of the patient’s experience or the raw physician experience. It’s a setting where the nature of the suffering, the fiduciary responsibility and moral obligation to the patient and society are no longer abstract terms. In that setting I wanted to put very human, fallible characters-people like Sister Mary Joseph Praise and Thomas Stone. I wanted the whole novel to be of medicine, populated by people in medicine, the way Zola’s novels are of Paris.
Where did the idea for the story of these twins germinate and how did it grow?
When I actually sat down to begin to write this book, what kept recurring was an image of a beautiful, south-Indian nun who suddenly and precipitously goes into labor in a mission hospital in Africa. That act of her going into labor throws everyone for a loop and causes utter confusion at the hospital. That’s all I had to begin with.
I saw her succumbing in that labor, and I saw one of the twins becoming the narrator of the story and looking back in somewhat of an antique voice. So I kept writing, developing the ideas, themes, and characters.
When I reached about two hundred pages, I convinced my agent, against her better judgment, I might add, to tentatively shop a portion of the book around – an unusual and risky approach for fiction. But I wanted some affirmation that this was interesting to anybody. I didn’t want to spend another three or four years only to find that nobody wanted this. My writing time is too precious to spend on something that isn’t of interest.
How did you think of the idea for Cutting for Stone? Did you write out the whole plotlines in advance, or did you just start writing and then follow where the story took you? How long did it take you to write Cutting for Stone?
All I had was an image of a beautiful, south-Indian nun who suddenly and precipitously goes into labor in a mission hospital in Africa. That act of her going into labor throws everyone for a loop and causes utter confusion at the hospital. That’s really all I had. That and an antique voice in my head, the voice of an old fashioned storyteller.
I found some reassurance in a quote by E.L. Doctorow who says about writing that, ‘It’s like driving a car at night. You never see further than your headlights, but you can make the whole trip that way.’ It was often nerve wracking not to know what lay ahead. I’d heard master storytellers like John Irving say that if you’re just making it up as you go along, if you have no plot, then you weren’t a writer, but an ordinary liar!
Halfway through the book, I felt my characters were so alive that their choices were infinite. I had to know what was going to happen, so I met with my editor and we hammered out a plot. My relief at that point was huge; I could concentrate on language and the telling. What surprised me is that even then there were so many discoveries, so many truths that emerged unexpectedly. It affirms for me what I most love about writing, and that is that it is not a rational, logical process.
Though you confront serious issues in the novel, there is much humor, too. Was it a conscious choice to use humor, and if so, why? Levity finds its way into many of the medical scenes (Ghosh performing a vasectomy, for example); was there an element of wanting to make medicine less intimidating?
The humor surprised me. I didn’t set out to be funny or to inject comedy into the novel. And that’s probably a good thing, because it’s difficult to deliberately try to write humorous stuff. That said, there are many occasions for side-splitting laughter in medicine, but one has to be careful that the patient never construes this as our being light-hearted about his or her suffering.
I’ve drawn on some of my most memorable professors, the ones who told the bawdiest stories that were therefore unforgettable. I so much want to tell my students these stories, but common sense stops me. We’ve become so sensitive. I once, in print, called the coronary artery bypass operation the great blow-job of American medicine: lucrative for one, satisfying for the other, but biologically a dead end. Many were not amused, let me tell you.
One of the most striking elements of Cutting for Stone is the intimacy with not just one character, but an entire cast. Though Marion tells the story, we become deeply involved in each person’s struggles, not just his own. Which characters did you feel closest to while writing the book? And why did others feel more distant?
Characters, by the way, do not start out rounded. They emerge. I think Ghosh is the character whose emergence and whose full blossoming I loved most. He is essentially fair, kind and eminently faithful, a family man, and above all patient – all the qualities I would like to have myself, but don’t always. He is the consummate internist too, which I also aspire to be. He gives me something to strive for.
Hema, too, is someone I deeply understood – or understand as well as a male writing a novel can understand a woman. Thomas Stone is both more alien and familiar – a doctor caught up in the illusion that work can redeem his character failings. Shiva – I let him be distant, impenetrable, because that is the nature of his character. My editor would sometimes be frustrated with me because she could not ‘see’ Shiva, and I would say to her, ‘Yes! That is the point. There is a quality to him, an Asperger’s-like patina, that makes him hard to know.’
Ghosh offers a thought-provoking statement in Cutting for Stone: ‘Not only our actions, but also our omissions, become our destiny.’ Which characters were particularly ruled by their omissions?
This is a well-known phrase in the analysis of stories and fairy tales. I think it applies to all of us, and certainly to all characters in any novel. Thomas Stone was clearly ruled by his omissions, what he didn’t do – he didn’t stay to mourn Sister Mary Joseph Praise, and he did not raise his twin boys. He omitted to tell Mary Joseph Praise about his feelings until it was far too late. And Ghosh’s character was defined by the actions he did take, the sacrifices he did make.
The question, ‘What treatment is administered in an emergency by ear?’ is important to many of the characters in this novel. Perhaps you can tell us the correct answer, and also tell us how the answer informs the book.
The answer to this trick question that recurs in the book is of course, ‘words of comfort.’ It’s the sort of thing examiners like to ask in the British system, in the places that still have the viva voce – the terrifying oral exams – and that still test physicians on real patients, not make-believe patients.
Alas, in America, we are getting so ‘virtual’ that board-certified internists become board-certified by taking a multiple-choice examination. No one really tests that they can feel an enlarged spleen, or diagnose and put together physical signs at the bedside.
‘Words of comfort’ relate to a sense I have that the patient in America is becoming invisible. The patient is unseen and unheard. The patient is presented to me by the intern and resident team in a conference room far away from where the patient lies. The patient’ illness has been translated into binary signals stored in the computer. When we do go to the bedside to make rounds, often physicians are no longer at ease. It is as if the patient in the bed is merely an icon for the real patient, who exists in the computer. But none of these tests done at a distance substitute for being with the patient, for the ‘words of comfort’ aspect of treatment.
When one knows how to look, the patient’s body reveals many things – it is an illuminated manuscript. I am no Luddite and have no illusions that the kind of exam I do is superior to a CAT scan or MRI. But a skilled exam can do two things: first, it can allow us to practice cost-effective medicine by generating a reasonable diagnosis at the bedside and ordering selective tests, rather than the shotgun approach, where we tick off everything that seems remotely interesting on the lab and radiology slips. Secondly, the skilled exam done with courtesy and done well conveys something important about caring and about professionalism to the patient; indeed it is a key component to building a good physician-patient relationship.
Particularly in patients with chronic illness, where there are few dramatic interventions that one can prescribe, a good physician-patient relationship can support the patient through the ups and downs of an illness; the physician’s presence, the ‘words of comfort’ aspect, can be therapeutic in itself.
The fact that patients with chronic illness increasingly seek the attention of naturopaths, refelexologists, acupuncturists, and others has a lot to do with the fact that these individuals will spend time and put hands on the patient, where the physician does that infrequently or in a cursory fashion. When your head is wrapped around the latest gene-array test or ‘evidence-based medicine’ (as though what preceded it was witchcraft), then you might underestimate the importance of ‘words of comfort.’
In your earlier books, you touch on the breakup of your personal life due to the strain of practicing medicine. Do these experiences echo through Dr. Stone’s choosing work over life – and to what degree?
Yes, I felt a great empathy for Stone and his feeling that medical work is the most wonderful work you can ever do and yet how he hurt the people around him by losing himself in a love for his work that was so extreme.
An aim of the novel was to show just how medicine and the magic word, ‘work’ can both heal and cripple, how it is a trap and yet it is a balm and as Yeats would say, the challenge is to find that balance between the ‘perfection of the life or of the work’ and in the book there are characters who exemplify both ends of that spectrum. Dr. Stone was very skilled, he focused on the moment and had great knowledge and wisdom, but it was not enough to save him. Perhaps there is some of my own life in that thought, who knows?
At the heart of this novel there is a love story – that of Sister Mary Joseph Praise and Dr. Thomas Stone – which informs almost everything that happens to each character in the book, and yet one of these characters is dead and one has not been seen by anyone for decades. How did you conceive of their relationship, and how do they exert such force on the novel even though neither is present for the majority of it?
Love to me has a quality to it like a trip wire – hence we ‘fall’ in love, instead of simply ‘arriving’ to love. Love comes down to a set of wills trying to match and sometimes mismatching in spectacular fashion; I think all love is unrequited unless we have a clone of ourselves and even then the love is unrequited. In my day job I see all too often that people’s appreciation of the existence of love, of the meaning of love, or of the idea that the meaning of life turns out to be love – all these are arrived at too late, when the love is long lost, or arrived at just before the moment of death.
Perhaps what love seeks is not reciprocity but redemption, the sense that who you are is worthy and was always worthy of love.?Thomas Stone and Sister Mary Joseph Praise’s love is hidden even from them by the strict boundaries of their chosen professions and then even more so by their professional relationships. It takes a miracle or a catastrophe or both for it to be revealed to them and to others. I suppose it makes for an unusual love story, one that never really happens in real time, one where possession is out of the question – and yet it is a love story that has the power to drive every event in the book directly or indirectly.
The medical passages were fascinating. Do you keep a medical journal?
I don’t keep a journal as much as I write notes when I observe something I want to remember later, so I can recall the situation – the feelings, the interaction – at a later time. I have always scribbled. For some of the intense medical situations in the book, some very fine, accomplished surgeons allowed me over the years to be present as they worked, understanding that I wanted to be able to convey the wonder of surgery, of curing, of healing. It was an honor and I am deeply grateful to have been able to do this.
Cutting for Stone, Origin of the Title
Where does the title ‘Cutting for Stone’ come from?
There is a line in the Hippocratic Oath that says: … I will not cut for stone, even for patients in whom the disease is manifest … It stems from the days when bladder stones were epidemic, a cause of great suffering, probably from bad water and who knows what else. Adults and children suffered so much with these – and died prematurely of infection and kidney failure.
There were itinerant stone cutters – lithologists – who could cut either into the bladder or the perineum and get the stone out, but because they cleaned the knife by wiping it on their blood-stiffened surgical aprons, patients usually died of infection the next day.
Hence the proscription, ‘hou shall not cut for stone.’ It has always seemed to me a curious thing to say when we recite the oath in this day and age. But I love the Hippocratic Oath (or oaths, because its origins and authorship are far from clear), and always try to attend medical school commencement. When the new graduates stand and take the oath, all the physicians in the room are invited to rise and retake the oath.
You see many physician parents and physician siblings standing as their son or daughter or brother or sister takes the oath. It chokes me up every time. Not only am I renewing my faith, but I am bursting with pride in seeing my students graduate – another part of the oath is ‘to teach them this art, if they desire to learn it; to give a share of precepts and oral instruction and all the other learning to my children and to the children of those who instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law.’
How does all this relate to my novel? It isn’t just that the main characters have the surname ‘stone’; I was hoping the phrase would resonate for the reader just as it does for me, and that it would have several levels of meaning in the context of the narrative.
You allude to a Greek text about lithotomy in your title, Cutting for Stone. Could you just elaborate on the multiple meanings of this title – as they relate to medicine and to the narrative?
In Greek, ‘lithos’ is stone and ‘tomos’ is cut, and lithotomy refers to the surgical method of removal of kidney or bladder stones. Hippocrates noted it as ‘lethal’ work that should be left to surgeons.
In the Hippocratic Oath, there used to be a line there that said, ‘I will not cut for stone.’ It stems from the fact that in medieval times and perhaps more recently than that – Victorian times – bladder stones were epidemic. The population suffered . . . little kids and adults were in agony because they had stones that were blocking the bladder. So there were these people who traveled from city to city who would ‘cut for stone’ – obviously without anesthetic and using the same knife again and again. They were expert at doing it and they would relieve your suffering, but of course, that would cause infection, and you’d be dead the next day, and they would have left town.
So I think that’s where the proscription came, ‘thou shall not cut for stone.’ It’s always seemed a curious thing for us to be saying since it really doesn’t have applicability now, and yet I liked saying it – I thought it was a nice line. And the characters in my book are surnamed Stone, so I was hoping that the title would resonate on many different levels. And I include the actual quote in the third section as an epigram.
You bring Ethiopia to life so vividly – its contradictions of beauty and poverty. Addis Ababa (and Missing Hospital) is so much a part of each character though some come to it from other places or leave it for other places. Why did you decide to set much of this novel there? And how do you think the atmosphere of the place affected your life?
Even in this era of the visual, I think a novel can bring out the feel of a place better than almost any vehicle. It’s another thing that Somerset Maugham did so well. The few images one sees of Ethiopia are uniformly negative, about war and poverty. I wanted to depict my love for that land and its people, for their incredible beauty and grace and their wonderful character.
I wanted also to convey the loss many felt when the old order gave way to the new. Ethiopia had the blight of being ruled by a man named Mengistu for too many years, a man propped up by Russia and Cuba. My medical school education was actually interrupted when Mengistu came to power and the emperor went to jail. As an expatriate, I had to leave. It was my moment of loss. Many of my medical schoolmates became guerilla fighters, trying to unseat the government. Some died in the struggle. One of them fought for over twenty years, and his forces finally toppled the dictator.
Meles Zenaweis, now Prime Minister of Ethiopia, was a year behind me in medical school. I went through hard times because of the disruption, but I eventually finished my medical education in India. But what I went through was nothing compared to what others went through – they were willing to die for their cause.
Could you tell me a bit about how your family came to be in Ethiopia and the background of Malayalis in that country?
I am told that Emperor Haile Selassie of Ethiopia came to India on a state visit shortly after his country was liberated from Italy. As the head of an old Christian nation, he was interested in seeing the churches of Saint Thomas in Kerala. Apparently during that visit he was so impressed by the sight of all these school kids in uniform going to school and clogging the roads that he hired all his teachers for the schools he was building all across his nation from this one state, Kerala.
My parents came separately within a week of each other, and in a group of several hundred. There were enough of them in Addis to have their own Syrian Christian church service. My father and mother met in Addis Ababa and married, and my brothers and I were born there.
What’s your personal, emotional relationship to Ethiopia like? Do you still consider it to be your homeland? Or is it less simple than that? Where/what is ‘your own country’?
I was born there and I had most of my schooling there including beginning medical school in a school started by the British Council in East Africa. About the third year of my medical school, the emperor was deposed and civil war broke out. The university was closed and the students sent to the countryside in a Cambodian style effort to get the intellectuals out of the cities. I was told that as an ‘expatriate,’ I should leave. I had never heard that term ‘expatriate,’ before. What it meant was I didn’t really belong, even though I thought I did.
But being an eternal outsider has enabled me to see things and given me great advantages as a writer. Ethiopia was my homeland. I loved the beauty of the land and the lovely people who are so different from the stereotype so many people have. But that displacement caused me to come to India to finish my studies and it deepened the existing bond I had with India from my many visits during the holidays. For me, home is really a state of mind, where you feel comfortable, needed and I refer to that in ‘Cutting for Stone.’ It’s the place where you are wanted and needed. I became an American citizen years ago, an act that was very moving and emotional for me, not a cynical act of convenience by any means. It is not contradiction for me to be American and yet have roots in Africa and India.
In your book, Cutting for Stone, Marion returns to Ethiopia. Do you ever think about doing the same, and why?
For more than 16 years I lived in Texas. I have lived in Tennessee and Boston and am now in California. My children are here and my family is here. My parents who had retired from their positions in America were going back and forth, living in India and America. But now they have decided to join us in California. I think it would be difficult for me to go back to Ethiopia in any permanent way-there are political reasons for that and also my sense is that when I left, the connection was broken – though obviously there is more than a little nostalgia. I have been back there twice and to India many, many times. I do hope and plan for the arc of my life to allow me to at one stage to work in a setting in India where my services would be most needed.
A lot of the book takes place in Addis Ababa. There is a real sense of place and you describe it so exquisitely. Clearly the setting for the book was really important to you?
I think a novel can bring out the feel of a place better than almost any vehicle. So often what you see of Ethiopia is negative – wrenching poverty, lives torn by strife and suffering. I wanted to depict my love for that land where I grew up and for its people, for their incredible beauty and grace, and their wonderful character. I wanted to convey the sense of loss many, including myself, felt when the old order gave way to the new. I was in medical school there at the time, and, as an expatriate, had to leave. It was a very alienating experience.
What do India and Ethiopia mean to you now?
I have dear friends and relatives in India. And I have classmates in Ethiopia with whom I correspond. I have been back to Ethiopia twice and I go to India regularly. But clearly, America is home.
Favorite Books, Writers
Who are the writers you admire yourself and why?
I like big epic stories, where you feel you enter a world, live through many years and many events, and when you are done and come back it’s still Tuesday but you have learned the lessons of a lifetime.
So I like Marquez, Gunter Grass, John Irving, Amitav Ghosh, Dickens, Tolstoy – i really anyone who writes on that scale.
Who’s the greatest stylist currently writing?
I think John Irving is a masterful storyteller, very respectful of the reader’s experience, and his kind of storytelling certainly inspires me, as does the fiction of Gunter Grass, Gabriel Garcia Marquez, or reaching back further, Dickens, Tolstoy and others. As you can see, I am partial to the epic and multigenerational story – a life or several lives playing out on a large canvas.
What books have made the most difference in your life?
Several books were seminal in my coming to medicine, allowing me to see medicine as a calling, a romantic and noble pursuit. Of Human Bondage by Somerset Maugham was one such book. Also A.J. Cronin’s The Citadel and Keys of the Kingdom. That used to be how people came to be drawn to medical school. Now, perhaps television and movies fulfill that role.
My favorite novel has little to do with medicine despite its name, and happens to be a great love story – it’s Love in the Time of Cholera by Gabriel Garcia Marquez. Some writers read George Eliot’s Middlemarch every year. I read Love in the Time of Cholera.
Your writing has been compared to Salman Rushdie, Gabriel Garcia-Marquez and John Irving. Can you tell us about writers and genres you enjoy reading or who/what inspires you?
That is high praise as these are among my favourite writers and I am honoured that you put me in a list with them. John Irving is a true master, and I admire how he pulls off his big, sweeping stories. I also love Marquez’ Love in the Time of Cholera. Michael Ondaatje is a great favourite..
What’s the best way to get a child interested in reading?
I don’t know the best way, and I wish someone would show me! But I do know it’s important. What we often forget is that when we read and enjoy a good novel, we are engaging in a collaborative act with the writer. The writer gives us the words, we provide the imagination, and somewhere in middle space, we jointly create this fictional dream, this mental movie. It requires effort on our part – it is not a passive act, but a creative one to read a book. The writer has to give you just enough words, not too many; just enough so that you can imagine the rest. If you have ever been horribly disappointed when your favorite book was made into a movie, because the actor looked nothing like the person you had conjured up in my mind, then you know what I mean.
I believe that, as the writer John Fowles has said, that if you don’t practice this skill of taking words on a page and turning them into pictures, then a part of the brain atrophies. I try to make this point with our medical students: that reading stories, novels, keeps a part of the brain alive, and it relates to the clinical imagination. I don’t know a single clinician I have greatly admired over the years who has not also enjoyed good literature or some aspect of the arts. I think it is no coincidence. That is where the right brain comes in. Medicine is, and will always be – no matter how much technology we introduce – an art and a science. You need both.
Who are your favorite writers, past or present? And have any of them made an impact on how you view the art of writing?
Some of my favorite writers are Gabriel Garcia Marquez, Charles Dickens, Michael Ondaatje, John Irving, John LeCarré, CJ Forrester with the Hornblower series, and, of course, AJ Cronin – with the Citadel in my formative years. All these, and others, have had an impact on how I write and how I view writing. And I’m grateful to have known some of these writers personally and discussed the art of writing, different styles, with them.
What book are you currently reading?
I’m reading The Cat’s Table by Michael Ondaatje and John Irving’s new book, In One Person, which will be released in May.
Would you recommend any books on writing?
One book I recommend is a book by Francine Prose called Reading like a Writer: A Guide for People Who Love Books. John Gardener’s books, The Art of Fiction and Becoming a Novelist are very good, as is Eudora Welty’s One Writer’s Beginnings. But truly the most important thing to do is to keep reading and keep writing. It is 99 percent perspiration and 1 percent inspiration.
Your first two books are non-fiction, but you’ve said that you have always thought of yourself as a fiction writer first. How so?
Fiction is truly my first love. To paraphrase Dorothy Allison, fiction is the great lie that tells the truth about how the world really lives. It is why in teaching medical students I use Tolstoy’s The Death of Ivan Ilych to teach about end-of-life, and Bastard out of Carolina to help students really understand child abuse. A textbook rarely gives them the kind of truth or understanding achieved in the best fiction.
One of my first published short stories was ‘Lilacs,’ in which the protagonist has HIV. Its appearance in The New Yorker in 1991 was a part of what led to my contract to write My Own Country, a memoir of my years of caring for persons with HIV in rural Tennessee. While writing that book I found myself living through an intense personal story of friendship and loss that led to a second non-fiction book, The Tennis Partner. But after that, I passed up on an offer to write a third non-fiction book. I was keen to get back to fiction, to explore that kind of truth.
You wrote two memoirs before your debut novel, Cutting for Stone. Did you encounter any unexpected challenges shifting from nonfiction to fiction? After writing both forms, is there one that you prefer more than the other?
My preference is fiction by far and I think you have to work harder at fiction to get your reader involved. What you are writing about didn’t happen, but readers need to feel that it did. It’s freeing because you can let your imagination go. With nonfiction, it’s a lot clearer what you are writing about and that it’s not made up.
Indeed, I would say that is what you have going for you – the fact that it really happened makes it inherently interesting to us. But it’s also somewhat limiting as you can’t invent, only rearrange and dramatize.
What is next for you? Do you anticipate both practicing medicine and writing fiction and nonfiction in the future? Anything in the works right now?
As to what is next: I have a collection of short stories, most of them published in various magazines, but a few that are yet to come. But after a little break, I’d love to embark on the next novel. I learned invaluable lessons about form, structure, stamina, and pacing in the course of writing this one-painful lessons that should not go to waste. I’ve also been steadily doing shorter things, op-ed pieces for the Wall Street Journal and the New York Times Magazine all through the years I wrote the novel. I’d like to do that more regularly.
I’d like to practice medicine till my last breath without actually collapsing on the patient – that would be bad form. I hope my mind and body will allow this. Being a physician is central to my life, truly my refuge, and so I don’t think I can give it up. If it’s a calling, then you can’t be a dilettante and wander off because you think something else calls. My writing emanates from a very personal stance wrapped up in the privilege of practicing medicine. I recognize that I have a world view colored by that fact. Still, what I think matters most is the words on the page, not the credentials or vocation of the writer.
What would you like readers to take from your work?
That love endures; that we will remember on our deathbeds the acts of kindness that illumine our lives. I especially want college students and high school kids to read the book and see medicine as a romantic pursuit, a passionate pursuit, one that demands all of you, and which in return will build for you an enduring edifice of character.
I treasure the letters that come to me where a young person says that one of my book brought them to a career in medicine. I am very proud of that, and it reaffirms for me that my writing flows out of my doctorhood-it is not a separate entity. It is all one.
If you could offer a younger version of yourself a piece of advice, with the perspective you’ve gained as a father, doctor, teacher, and writer, what would it be?
I think my advice would be equally not to take yourself too seriously, but also to take yourself seriously. Life is not a dress rehearsal and it moves along fast. Little things you do over the years stack up and make you who you are.
You’ve lived in many different places. What would you describe as home?
This is a question I get a lot as I have moved around and lived in greatly different places over the years. I guess my answer is that home is a place in your heart. It’s not necessarily where your parents are, or where you live. As Hema pondered in Cutting for Stone about the definition of home, ‘Not where you are from, but where you are wanted.’ Wanted and valued, I’d say.
What’s your personal, emotional relationship to Ethiopia like? Do you still consider it to be your homeland?
But being an eternal outsider has enabled me to see things and given me great advantages as a writer. Ethiopia was my homeland. I loved the beauty of the land and the lovely people who are so different from the stereotype so many people have.
But that displacement caused me to come to India to finish my studies and it deepened the existing bond I had with India from my many visits during the holidays. For me, home is really a state of mind, where you feel comfortable, needed and I refer to that in ‘Cutting for Stone.’ It’s the place where you are wanted and needed.
I became an American citizen years ago, an act that was very moving and emotional for me, not a cynical act of convenience by any means. It is not contradiction for me to be American and yet have roots in Africa and India.
Each of the characters in Cutting for Stone is drawn to medicine in different ways and for different personal reasons. What drew you to medicine?
I was the middle of three sons of Indian parents who taught college physics. My brothers had a precocious ability with numbers, while I had no head for math – or much else in the curriculum. For middle-class Indian parents only three professions exist: medicine, engineering, and law.
My older brother announced he was going to be an engineer, which delighted my parents. I felt obliged to proclaim that I intended to be a doctor. I figured that my propensity to fall and bleed, my unseemly interest in witnessing chickens and sheep being slaughtered for the kitchen, and my fascination with watching animals give birth could now be viewed as a form of scholarship. This was my false call to medicine.
My true call to medicine came in the form of a book. By the time I picked up Of Human Bondage by Somerset Maugham I had already read Lolita and Lady Chatterley’s Lover. I was twelve, I think. Maugham’s protagonist, Philip, sets out for Paris to become an artist. Money is tight, and he lives on the brink of starvation, and finally finds he does not have the talent. He is crushed and disappointed but also relieved to have discovered what is not to be his calling. He returns to London and enters medical school. When after years of slogging away he enters the outpatient clinic for the first time, he realizes he has made the right choice. The particular lines that stayed with me, that have haunted me, were: ‘there was humanity there in the rough, the materials the artist worked on; and Philip felt a curious thrill when it occurred to him that he was in the position of the artist…’
The phrase ‘humanity there in the rough’ spoke directly to my twelve-year-old mind. I took it to mean that if one had no God-given talent to be an artist (or mathematician), one could aspire to be a doctor, perhaps even a good one. The beauty of medicine is that it is proletarian, and its prime prerequisite is that you have an interest in humanity in the rough. Many of us also come to medicine because we are wounded in some way. Thomas Stone is a great example, but so is Marion Stone.
The book has some wonderful passages in which you describe how the characters use their senses to diagnose their patients’ problems. Do doctors really use their sense of smell to pinpoint diseases?
Absolutely, but perhaps not as much as we used to. There are distinctive odors of liver failure, kidney failure, upper gastrointestinal bleeding resulting in melena, or the diarrhea caused by Clostridium difficile. But physicians of old described a litany of odors, some of which seem pretty incredible – the freshly-baked-bread odor of typhoid fever, the freshly-plucked-chicken-feathers odor of rubella and so on. I do think in this era of dependence on technology, we don’t seem to trust our senses. I joke that if you are missing a finger, no one will believe you until they have an X-ray, bone scan and MRI for good measure.
The overall message of your novel seems to be a humanistic one. As a leading advocate of bedside medicine, did you consciously set out to literalize your arguments against dehumanizing patients? What were some of the themes you definitely knew you wanted to convey?
I did not set out necessarily to write a polemic or advance a certain agenda. I think it is not surprising and usually the case that the novelist’s biases come out in the work.
One of my pet peeves is over-reliance on science and technology at the expense of a caring doctor-patient relationship. There’s a subtext in our interaction with physicians where we also want them to say, ‘Don’t worry, it’ll be alright.’ Or ‘Don’t worry – this is not your fault.’ Or ‘don’t worry; I’ll be with you this through the end – no matter what it takes.’
One of the things I hope this book does is to portray that very well. Because I think people are starting to assume, ‘I guess that’s how medicine is: you show up and somebody sees you here and orders 17 tests and sends you somewhere else, sends you to someone else, and pretty soon you’ve seen all these people and you have no idea who you really belong to as a patient. This profession is a ministry of healing, it is a calling, and that sense has become greatly threatened.
There’s a theme of very literary medicinal texts running through the book – most brilliantly written into the description of Ghosh’s first surgery. Where do you see yourself in the history of these real and imagined texts? What does it say about your views on medicine as both a science and an art?
In the pre-Internet era, we all used to form relationships with textbooks. They were like mentors we carried around. They had a voice that we admired and found to be unique. I think students at least in America get their information from Google and other sources in little bytes and they miss the notion of a ‘voice’ in a textbook. That is what I wanted to capture.
You’ve spoken elsewhere about wanting to bring back a sense of excitement and usefulness about practicing medicine, and have argued that the way to do this is to increase compassion for those who are suffering rather than preach detachment. Could you elaborate briefly on why you feel this is necessary today and how you hope your book might work towards recognition of that need?
I love medicine and the study of medicine. I do see it as a passionate and romantic pursuit. To me, medicine is life. Sometimes the most elemental struggles – to have food to eat, to have money to clothe oneself, to be able to feed one’s children, to have their suffering relieved – these societal problems are often first encountered by physicians.
They are medical problems at one level, but they are really political and social problems at another level. It would be tough to write a novel about medicine that does not engage with these issues, unless the novelist turns an eye to the nature of suffering.
But you are right, I did want the college age reader who is embarking on a career to realize that the house of medicine is huge and has room for everyone, and that inherently medicine is a human pursuit, a calling in which one must believe in the Samaritan function of being a physician.
Medicine plays a big part in your novel, and it is also something that unites people of different races and religions in Cutting for Stone: Hindus, Christians, Indians, Africans and Westerners all work for a common goal: curing the patient. Is this the message of your book?
Indeed, I wanted the whole novel to be of medicine, populated by people in medicine, the way Zola’s novels are of Paris. If I begin with a mission hospital in Africa, a place redolent with Dettol and carbolic acid scents, it is because I think that in a place so basic, the nature of the suffering, the fiduciary responsibility and moral obligation to the patient and society are no longer abstract terms. Indeed, nothing separates doctor and patient, no layers of paperwork, technology or specialists and you can’t disguise the nature of the patient’s experience or the raw physician experience.
Then I put in very human, fallible characters — people like Sister Mary Joseph Praise, Thomas Stone. To take the story to America was to contrast this world with Western medicine, its power and beauty, but also its failings. Contrasting an inner city underfunded non-academic center with a ‘Mecca’ of a tertiary referral center was also I think a good way to point out the strengths and weaknesses of both and also to highlight the very different people who inhabit such places.
But ultimately, I think the intent was to point out that even though medicine changes, the fundamental role of the physician, the need for their presence, does not change, and the importance of that presence is greater than ever. Cure is laudable but not always something we achieve, but comforting and healing is something we can do. It is the healing or Samaritan or priestly function of being a physician that we seem loath to claim.
And you also talk about healing. That a physician’s job is not only about curing, but also about healing. You say somewhere in Cutting for Stone: ‘What treatment is administered by the ear?” And the answer is “Words of comfort.” This was something I really liked. Can you tell me something about this?
If you ever have your house broken in to and you come home to see all your valuables missing, you will be devastated. And if the police come by a few days later and say they found the person who did this, and they hand you all your stuff back, well you will be ‘cured’ . . . but you will not be ‘healed’. Your sense of violation might be so great that you might even move from that house.
I think all disease is like that -there is a physical aspect – the break in. But there is also a sense of violation, even when it is something like a broken finger. So what I was getting at with ‘words of comfort’ is that an attentive, thoughtful presence at the bedside by the physician cannot be underestimated – one might ‘cure’ without seeing a patient, but to ‘heal’ a patient requires presence.
Having trained in infectious diseases just before HIV arrived, I see myself as having been caught up in the conceit of medicine, the sense that cure was all that mattered. But in dealing with an incurable disease that resulted in death (in those early days), in not having a cure to dispense, I think many of us learned or stumbled onto the realization that we could heal, by simply engaging with the patients, particularly by seeing them in their homes and when we did that we were addressing their sense of spiritual violation.
Medicine and Writing
How has being a doctor influenced you as a writer and vice versa? Do you think practicing one has helped you practice the other?
I think sometimes we make too much of the doctor-writer business – it’s in danger of becoming a cliché. I’ve not put MD behind my name on any books, except one that was called ‘Infections in Nursing Home and Long Term Care Facilities.’ Unless I’m writing a diet book or a textbook like the one above, the doctoring seems kind of irrelevant – the writing has to stand on its own, don’t you think? Or else every writer should put their AB, and JD, and MFA and whatnot after their name on the title.
That said, I confess that my love of medicine feeds this book and much of my other writing. There are lots of parallels between writing and medicine. I remember hearing the aphorism ‘God is in the details’ both in medical school and also at the Writers’ Workshop. When we see a patient we take a ‘history’ – the word ‘story’ is in there. As a consultant, when I see a patient whom others have seen before me, if I can shed light on the problem it is often because the particular patient story resonates with my repertoire of stories and so I know where it is heading. I have given Ghosh – the internal medicine specialist at Cutting for Stone’s Missing hospital – some of these attributes.
Internal medicine, which is also my field, is so much about details, about tying together disparate clues to come up with a unifying diagnosis and about close observation. Medicine is full of wonderful aphorisms I love, like, ‘beware of the woman with the glass eye and the big liver’ (which refers to the fact that melanoma of the eye, a common cause for an eye to be removed, can be followed many years later with liver metastases).
And as for metaphors, to list just a few fruit metaphors, we have the strawberry tongue of scarlet fever (which becomes the raspberry tongue the next day), and the cherry red spot in the retina, the peau d’orange appearance of the breast, the melon seed body of TB, the currant jelly stools of intussusception…(It is very revealing that modern medicine with so many new diseases – AIDS, SARS, Lyme – has not to my knowledge in the last fifty years come up with a metaphor as colorful as the mulberry molar or the cracked-pot skull or the saber-shinned tibia. It speaks of a disturbing atrophy of the imagination, an obsession with the science at the expense of the art. If I hear the word ‘evidence-based’ medicine any more, I think I’ll be sick.)
So, to answer your question, being in medicine is helpful, particularly for the novel I chose to write. But it provides no short cuts. Writing is still hard, and the real art is in the revision, the real talent is in having the stamina, in being able to delay gratification over the many years it takes to get it right.
Recognizing that much of your work has to do with the physician-patient relationship, how do you think that reading and writing tangibly improves the ability of physicians to interact with and treat their patients?
First and foremost, through medicine, one has the great privilege of having an intimate view of one’s fellow humans, the privilege of being there and helping at their most vulnerable moments. Also, in medicine you’re taught to observe closely, you’re looking for ways to synthesize things, and I think those are also useful traits for a writer. I remember hearing the expression ‘God is in the details’ both when I was at the Iowa Writers Workshop and in medical school. Reading has influenced so many choices and directions in my life, as I am sure it has for many others. Arthur Conan Doyle, Somerset Maugham, Anton Chekhov, Tolstoy wrote about the human condition, death, illness. Reading, and reading fiction especially, teaches you so much about how the world lives.
How have you seen this in your own career?
I use Tolstoy’s The Death of Ivan Ilyich to teach about end-of-life issues and Bastard out of Carolina to help students really understand child abuse. There are many, many instances where I have learned from something I have read, where a story someone has written has proven to be a wake-up call, or has increased my awareness of a situation or a diagnosis.
You are a physician. How did you start writing?
I had always enjoyed writing and reading – if I had grown up in the west, I might have been aware of the possibility of a career as a journalist or writer. But growing up in Africa, the very idea of a career related to writing was nonexistent.
I went into medicine out of love for that field. But when I was an intern and resident I began writing largely for my pleasure. Later, when I was working as an internist and infectious diseases specialist, I was soon in the heart of the HIV epidemic (the subject of my first book My Own Country).
I wrote short stories and essays, as a way of keeping sane during those intense days. As I published a few of those, I decided I would apply to the Iowa Writers Workshop, send in my two stories, and if they took me, I would go. Well, Iowa took me and that was the start of my taking my writing very seriously.
Do you think of yourself as a physician or as a writer? Does the writing affect your job as a physician? I have read in an interview you mentioned the death of Chekhov. Does this story attract you as a doctor or as a writer?
Being a physician for me is central to my being, akin to my skin colour or my mother tongue. It is the stance from which I see the world; it is my nationhood, in a sense. I feel privileged to serve not only patients, but to serve the profession, to honor its ideals, to celebrate its grand history and to support the Samaritan function of being a physician.
The writing, whatever form it takes – fiction, non-fiction, op-ed, obituary, reviews, essay – emerges as being a function of that grand privilege and that stance of being a physician, which, in my case is everything.
So, I resist the definition of the writer as being a separate entity, as if one has to choose this or that. After all what matters is the writing itself – in other words, the reader judges you by the words on the page, and for the reader entering your story, it should not matter whether the author is a lawyer or doctor or social worker.
The Chekhov story you mention is a great example of that: it attracts me as neither doctor nor writer, but as reader primarily. I believe that fiction is ‘the great lie that tells the truth about how the world lives’ and so I am drawn to any story that has that kind of truth in it. And if the story is better informed because Chekhov was a physician, well that’s a nice thing to discover after the fact.
There is a long line of doctors who are also, or became, authors – from William Carlos Williams to Ethan Canin, Richard Selzer to Oliver Sacks, Lewis Carroll to Somerset Maugham, Robin Cook to Anton Chekhov, Boris Pasternak to Oliver Wendell Holmes… What is the connection between being a doctor and being a writer?
Don’t forget my favorite, Somerset Maugham, who did not practice much. I think the foremost connection is the great privilege of having an intimate view of one’s fellow humans, the privilege of being there and helping at their most vulnerable moments. But also, in medicine you’re taught to observe closely, you’re looking for ways to synthesize things, and I think those are also useful traits.
I remember hearing the expression ‘God is in the details’ both when I was at the Iowa Writers Workshop and in medical school. Then again, when you take a ‘history’ from a patient, what is a history but a story; as a physician I trying to take the pieces of the story I am hearing from the patient and to match it with my repertoire of illness stories, or else the patient’s story reminds me of one element of a particular story, and so you go looking for the rest.
Also, medicine itself is a treasure trove: rich history, aphorisms (like the ‘Five F’ rule in my book) and metaphors. For example, I can name some fruit metaphors from medicine: the strawberry tongue of scarlet fever (which becomes the raspberry tongue the next day), the cherry red spot in the retina, the peau d’orange appearance of the breast, the melon seed body of TB . . . its endless.
But medicine offers no short cuts, you know? The hard stuff is sitting down, building up the pages, being able to throw most of them away and keep the good stuff. The real art is in revision, and for that you need stamina.
It seems a lot of doctors yearn to write and many of them do and are very good at it. You are a case in point. What is the connection between medicine and literature? These would seem to involve two different sides of the brain.
Well I don’t think of writing as that big a leap from medicine. We speak of the ‘art of medicine.’ Medicine is art and science, and involves both sides of the brain, although I think increasingly it seems to patients that it is all science, all technology and tests and procedures-the biggest critique I hear of modern medicine is that the heart, the compassion, the attentiveness, the caring seem to be missing.
But to come back to literature, I think all physicians are involved in the stories of their patients’ lives. The ‘history’ part of the history and physical is nothing but story. When I’m called in as a consultant and if I am able to help, it is amazing how many times my contribution is not some special knowledge that solves the case. Instead, it is back to the story. Perhaps I get more of the story than the intern, or the story relates to something in my repertoire of stories that I recognize. I think writing too, is a similar discipline of technique and attention to detail – that matters a whole lot more than extraordinary knowledge or extraordinary creativity. I remember hearing the same aphorism at the Iowa Writers’ Workshop as I did in medical school: God is in the details.
I love the tradition and the rich history of the bedside exam, the ability to divine so much and in such detail by carefully examining the patient. These are skills we are neglecting because technology gives us those answers, albeit at great expense. But I feel that kind of old-fashioned bedside examination conveys something critical to our patients: an attentiveness. If you are trained in that kind of medicine, a kind of training that characterized a generation of physicians but which is fast disappearing in the technological age, you have had great training for being a writer. After all, a good writer is not about what computer or word processor he or she uses: it is about attentiveness, observation, detail, imagination and stamina.
What is a typical ‘writing’ day for you?
There is no typical day for me – like many people, I am pulled in many different directions all the time. Given my day job, which I love, writing for a set amount of time every day is not going to happen. Something that really helps is that I have a secret second office, without even a sign on the door, where I escape a few half days a week to write. It is a great source of peace and gives me time to be reflective and write.
Of course, I also do a lot of writing at nights, early mornings and over the weekend, and sometimes that is hard on my family. But they have had great forbearance.
The storyline in Cutting for Stone is complex, with many unexpected turns. Did you plot the entire tale before you began writing, or did it evolve over time?
The reason this first novel took so long to come to fruition is probably because I didn’t have the entire story in my head before I began writing. Many writers do have the ending clear to them before they start, and John Irving – a hero of mine – is a shining example of that approach. But I don’t, can’t write like that. I would like to. I wish I knew the story that way. So, I let my characters develop and grow and go running after them. But this approach often requires a lot of cutting and reworking when the characters meander so far off base that they – and I – have to be reeled in! I have my editor Robin Desser to thank for her great patience – and her timing – in knowing when to rein me in, in forcing me, almost, to think of the conclusion.
Do you have any writing techniques that you’ve developed over the course of three books?
The only technique I know is to sit in the chair and it does not always mean you produce anything, but you have to be sitting there and trying. It does not happen anywhere else for me – not walking in the woods, not strolling on the beach. It is the hardest and simplest thing in the world – sit in the chair.
Where is your favorite place to write?
I write in many places. I write at home late at night when things are quieter than during the day. I write on vacation and can settle in just about anywhere, really. I also have a second – hidden – office at Stanford, which has no phone or name on the door and take myself away there when I have free time. I also make writing time for myself and go there. It’s a peaceful environment where I can just let my mind go.
For many years, you have identified yourself as a perennial outsider. Certainly there are a lot of incongruous pins in your map, if you will: Ethiopia, Africa, India, Tennessee, Texas, etc… But with Cutting for Stone being named Best Book of 2009 by Amazon and Publisher’s Weekly, with the prestigious position at Stanford, etc., how much longer can you really be on the outside? Tell me how your life has changed with this book’s success.
The outsiderness is a perspective that I think is always there. I am an American, and the morning I became a citizen some twenty years ago was one of the most moving moments of my life-I was quite unprepared for how emotional I felt about it. You read the world news now, Iraq, Guinea, Zimbabwe, Afghanistan, Iran and you treasure freedom and democracy.
America is home, Stanford is home, but the fact is that I don’t have a hometown where I blend in and become invisible, no different than the rest of the populace, where my roots are and where generations of my family has lived. Some people have that and I am envious, because it is a rich heritage and so accessible.
But perhaps I have a perspective that is different, even advantageous. In my previous books, when writing about Johnson City or El Paso, I had people say to me that they had lived in these places all their lives and they had stopped seeing certain things or they did not register, and they loved that I had seen and brought it to life for them.
The book’s success has been wonderful to see – it has been slow and steady, a case of the tortoise nipping the hare. But then that has been the story of my life. Honestly, my day-to-day life has not changed substantially and I hope it doesn’t – I love my work, my family, and I have lots of things that engage me and never enough time.
What I have so enjoyed with this book’s reception is the word-of-mouth that has gone with the book, the lovely feeling of one reader telling another, ‘You must read this!’ I always wanted to write that kind of book, and have that kind of success, the sense that you are contributing to the discourse in middle America, a discourse that begins at a book club in a living room and then spreads.
What is the nobility of suffering? How does it vary from culture to culture?
I’m not sure there is much nobility in suffering. Perhaps it is just something we say to make it bearable.
Some cultures are more resigned to suffering, feel it is part of the human condition perhaps, and can be accepting – sometimes to the point of passivity. In other places – here for example in the States – there is an expectation that medicine will provide a cure, mandate a cure even. People don’t want pain, they don’t want suffering and they resist it and sometimes that will to live helps to bring about a cure. Often though it results in unreasonable expenditures and suffering at the end of life.
‘Imagine the suffering of patients,’ you’ve said… Is this not only the key to being a great doctor, but perhaps a great writer? And maybe, just maybe, a key to being a great human being?
I think the key to being a good physician, something we all aspire to, is to understand how the illness feels from the patient’s perspective. Sometimes that is hard – how do we ask a 27-year- old medical student to imagine the suffering of someone felled in their fifties with cancer that is incurable?
But the trying, the willingness to engage with the patient, to see yourself in them – to see your own vulnerability, your own variety of fear, your need for reassurance – that goes a long way. I love the quote by Frances Peabody, an ancient quote now, ‘the secret of the care of the patient is in caring for the patient.’
Training as a Writer
In 1990, while practicing medicine, you decided to attend the Iowa Writers’ Workshop and obtain a degree in Fine Arts. What led you to go back to school – particularly for creative writing – while you were in the middle of a successful career as a doctor?
At the time I was living in Johnson City, Tennessee, working at a small medical school as an internist and infectious diseases specialist. Between ’85 and ’90, we began to see many HIV-infected persons at a time when the pundits said AIDS was a big-city disease, and we’d never see it in our small communities. Soon we had close to 100 patients in a town of 50,000, a mystery I explained in My Own Country. It was an intense, sad, heartbreaking period because we had no real therapy and lots of prejudice and hatred, but also lots of courage and heroism.
Not having anything by way of medicine to offer my patients, I began to visit with them at times in their homes. That is when I found that even when I had nothing to offer, I had everything to offer: It was the distinction between healing and curing (and the cure was what all of us in Western medicine were obsessed with). I realized that I could heal when I could not cure, meaning that my presence, my interest and support, could help the patient and the family come to terms with the illness, come to terms with death. But by the fifth year of this practice, with little in the way of help, I was getting burned out.
If I wanted to stay in the war against AIDS – and I did – I needed to pace myself, to take a break. I had been writing short stories and essays as a way of keeping sane during those intense days. So I decided I would apply to the Iowa Writers’ Workshop, send in my two stories, and if they took me, I would go. If they didn’t take me, I was still determined to take a break and support my family by working in emergency rooms.
Well, Iowa took me, and I wound up cashing in my 401K plan and giving up my tenured position to drive out there with my wife and two young children. As I look back, I think it was a very selfish thing to put my family through, but it was an act of self-preservation, too – I felt I would implode if I didn’t take a break. In Iowa, I worked in the University HIV clinic once a week. Other than that and the workshop that met weekly, my time was gloriously free to read and write.
Given my background, this was precious time – I didn’t think I would ever get time like that again (and I haven’t) – so I worked very hard for the year and a half it took me to finish. The bills piled up, and when I was done, I needed to get a regular job again, which is how I landed up in El Paso at Texas Tech’s teaching hospital there. I chose a place well off the main academic trail because I thought that my nights and weekends would be mine, no grants to write. That turned out to be true and my first two books were written there.
I’d love to hear more about your decision to cash in your retirement plan, give up a tenured position, and move your family halfway across the country to go to ‘writing school’… That’s quite a roll of the dice. How did you know that was destiny calling and not a siren’s song?
It wasn’t really a roll of the dice in the sense of gambling on monetary success from writing. God no! It was1989, and I felt overwhelmed by the numbers of patients with HIV we were taking care of with limited resources. We had no treatment in that day. It was poignant, painful but somehow very meaningful to me.
But I knew that if I wanted to keep working with AIDS the rest of my life, I needed to pace myself, take a sabbatical of some sort. I had been writing short stories all through those days, using fiction to capture and explain and understand the things I was seeing. I decided to apply to Iowa, send in my two stories, and I told myself if they took me I would go. Two stories – that’s how they decide. They took me and I went! What that did was force me to take myself seriously as a writer.
I wasn’t gambling my livelihood – I knew that I would be back in medicine, that being an internist, a teacher of medical students, is my passion and my identity and what I love to do. But I had taken to heart the lessons my patients in Tennessee had taught me, those young man my age who were dying, and that is that life is short, and the opportunity fleeting, and there are times when you must chase your passions, your dreams. Only time will tell if you were right or wrong, but at least you tried.
You describe first knowing you wanted to be a physician when you read Of Human Bondage when you were 12. When did you first realize that writing was going to be a part of your career in medicine?
I had always enjoyed writing and reading – if I had grown up in the west, I might have been aware of the possibility of a career as a journalist or writer. But growing up in Africa, the very idea of a career related to writing was nonexistent. I went into medicine out of love for that field.
But when I was an intern and resident, I began writing largely for my pleasure. Later, when I was working as an internist and infectious diseases specialist, I was soon in the heart of the HIV epidemic (the subject of my first book My Own Country). I wrote short stories and essays, as a way of keeping sane during those intense days.
As I published a few of those, I decided I would apply to the Iowa Writers Workshop, send in my two stories, and if they took me, I would go. Well, Iowa took me and that was the start of my taking my writing very seriously.