Conversations: Suzanne Koven, MD
Synopsis
Emily talks to Dr. Suzanne Koven, author of Letter to a Young Female Physician: Notes from a Medical Life. Dr. Koven graduated from medical school in the eighties at a time when there were so few women in her residency program that she had to write up her own maternity leave policy. Her memoir is a testament to how, while some things have changed for the better for women in medical education, much of the culture remains the same.
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Guest
Dr. Suzanne Koven has practiced primary care internal medicine at Massachusetts General Hospital in Boston for over 30 years. In 2019 she was named inaugural Writer in Residence at Mass General. Her essays, articles, blogs, and reviews have appeared in The Boston Globe, The New England Journal of Medicine, The Lancet, The New Yorker.com, Psychology Today, The L.A. Review of Books, The Virginia Quarterly, STAT, and other publications.
Credits
Hosted by Emily Silverman.
Produced by Emily Silverman and Adelaide Papazoglou.
Edited and mixed by Jon Oliver.
Recorded in San Francisco by audio engineer Jon Oliver and at Ugly Duck Studios in Brighton by Ian Bouslough.
Original Theme by Yosef Munro. Other music by Blue Dot Sessions.
This episode of The Nocturnists is sponsored by Fabled.
The Nocturnists is made possible by the California Medical Association, the Patrick J. McGovern Foundation, and people like you who have donated through our website and Patreon page.
Transcript
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The Nocturnists: Conversations
Emily in Conversation with Suzanne Koven, MD
Episode Transcript
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Emily Silverman
I'm Emily Silverman, and you're listening to The Nocturnists: Conversations. Women have been excluded from the practice of medicine for much of the profession's existence. But fast forward a couple of centuries, and now women make up more than half of medical students in the United States. So, can we say that the culture of medicine is finally shifted to be warm and welcoming and supportive of female physicians? Not quite. My guest today, Dr. Suzanne Koven, graduated from medical school in the 80s, at a time when there were so few women in her residency program that she was asked to write up her own maternity leave policy. Her memoir is a testament to how some things have changed for women in medicine, while others have remained the same. Today, Dr. Koven is a primary care physician and the inaugural Writer-in-Residence at the Massachusetts General Hospital. Before we spoke, I asked her to read an excerpt from her new book, Letter to a Young Female Physician: Notes from a Medical Life. Here is Suzanne.
Suzanne Koven
Early on, I believed that displaying medical knowledge - the more obscure, the better - would make me worthy. That belief was a useful spur to learning, but ultimately provided only superficial comfort. During my first year clinical skills course, and oncologist asked me to identify a rash. "Mycosis fungoides," I blurted out, since it was one of the few rashes whose name I knew, and the only one associated with cancer. My answer turned out to be correct, causing three jaws to drop at once: the oncologist's, the patient's, and my own. But the glow of validation lasted barely the rest of the day. A little further on in training, I thought that competence meant knowing how to do things. I eagerly performed lumbar punctures, and inserted central lines, and applied for specialty training in Gastroenterology, a field in which I had little interest, thinking that I could endoscope my way to self-confidence. My first few years in practice, I was sure that being a good doctor meant curing people. I felt buoyed by every clear chest X-ray, every normalized blood pressure. Unfortunately, the converse was also true. I took cancer recurrences personally. When the emergency room paged to alert me that one of my patients had arrived there, I assumed that some error on my part must have precipitated the crisis. Now, late in my clinical career, I understand that I've been neither so weak nor so powerful. Sometimes, even after I studied my hardest, and tried my best, people got sick and died anyway. How I wish I could spare you years of self-flagellation and transport you directly to this state of humility. I now understand that I should have spent less time worrying about being a fraud, and more time appreciating about myself some of the things my patients appreciate most about me. My large inventory of jokes. My knack for knowing when to butt in, and when to shut up. My hugs. Every clinician has her or his own personal armamentarium, as therapeutic as any drug. My dear young colleague, you are not a fraud. You are a flawed and unique human being, with excellent training and an admirable sense of purpose. Your training and sense of purpose will serve you well. Your humanity will serve your patients even better.
Emily Silverman
Thank you for reading that. As you know, I loved this memoir. Thank you for sharing it with me a little bit early. I was feeling very special to have a sneak preview. And I wanted to open up this conversation by talking about the doctor "origin story". You talk about how you really struggle to pin down just one narrative, and you say, "Origin myths are meant to be revisited and revised again and again." What did you mean by that? And, tell us how you think about the doctor "origin story".
Suzanne Koven
When you write your essay for medical school, you have, by necessity, a very well-crafted and coherent narrative. And also, by necessity, it's probably not entirely true. And that was certainly the case with me. What I wrote in my medical school essay, some 40 years ago, was that I'd studied literature and that now it made perfect sense for me to apply all I'd learned about human nature (reading novels) to clinical medicine. That turned out to be true later on, but it wasn't true at the time. What was true at the time is that I graduated from college as an English major, and I got my first job as the assistant to the Assistant Editor of a magazine that nobody read. I lasted that first summer, and then I panicked. I didn't know what to do next. I wanted a clear path forward, and I enrolled in pre-med courses. But the origin story for me goes back further than that, because my dad was a doctor and I loved visiting his office. He was a solo practitioner of Orthopedic Surgery. I loved helping him with the plaster casts, and developing X rays, and big vats of chemicals, and so forth. But I, as a child back then, as a girl back then, I couldn't really articulate for myself the idea that I would want to be a doctor, because I wasn't male. And I wasn't good at science, nor even particularly interested in science. So the whole thing was on the back burner for me, until after I graduated from college. Of course, I said none of this in my med school application essay.
Emily Silverman
Yeah, there was one part where you said, "What felt at the time like a shameful truth - that I was propelled less toward medicine than away from boredom." And then there was also another sentence that said, "I wanted to be close to my father, and I wanted to witness at close range, the freedom of men." And you also talk about how your relationship to medicine evolved over time. You said, "It was an arranged marriage, but in time, I fell in love." So, tell us a little bit about that. In what way was it an arranged marriage? And in what way did you fall in love?
Suzanne Koven
Well, it was an arranged marriage in the sense that I didn't approach it with the idea that I was in love with medicine; that a doctor was the only thing I was ever meant to be. And, it's also complicated, because at the same time, I think I did feel rather passionately about it, because I intuited that the part of it that I would love... the part of it I would be good at... would be interacting with patients; hearing their stories. We didn't talk about narrative then. We didn't talk about narrative medicine then; we didn't talk about the role of storytelling in medicine. I never heard any of those words, in all of medical school or residency. And yet, I knew that that's where I belonged. So, the format of my medical school was fairly traditional: two years in the lecture halls, and then moving out into the clinic and the hospital. The first two years, I really... I just held my breath the entire time. I did what I had to do. It all felt terribly unnatural to me. And then, when I started seeing patients, it was as if I exhaled, and I thought, Ah, this is who I am. But of course, that wasn't the end of the road. And, to be honest, even at this very late stage of my career, I feel myself still evolving.
Emily Silverman
Pretty early on in your book, you have an essay that's dedicated to books and reading. And I was laughing as I was reading this chapter, because you talk about how, in some ways, reading was an act. You said, "My paper writing technique was to find a theme, flip through the book, find quotes and stick them together with a thin mortar of my own prose." And I related to that so strongly; I had never heard anybody articulate it.
Suzanne Koven
it would make for a very neat story to say that I had little aptitude or interest in science. However, I was a perfectly wonderful student of the humanities, and a precocious reader and writer, who happened to find herself in medicine later on. But, that's not true. I was not an avid reader, or a confident reader. And it took me a really long time to come to that, as well. And if I would want readers to take away one thing from this book, it's that, if we're lucky, life is long. And I was, in many ways, a terribly late bloomer. I came to reading late; I came to medicine late. I got my MFA in my 50s; publishing my first book in my 60s. Particularly since there are so many incredible, young, clinician writers (including you), some of our colleagues may feel that they really need to, kind of, rush, but you don't need to rush. You'll know when the time is right, and you'll evolve into it, if it was meant to be. And if it's what you really want to do.
Emily Silverman
Yeah, in that same vein, just thinking about, like: Am I okay; am I a fraud? Am I not? Like, these are thoughts that come up a lot - in doctors in general, but I think in women in particular. And, you say in your book that both women and men have "impostor syndrome", but women don't just perseverate on our inadequacies, we denigrate our strengths. Tell me a little bit more about that.
Suzanne Koven
I was just in a session with a group of women residents the other day, and I made the comment that "imposter syndrome"... One of the tricky things about it is that you know you have it, and you know other people say they have it, but you don't really believe other people when they say they have it, or you don't believe they're justified in having it." Because, almost by definition, if you think you're an imposter, you think no one else is an impostor, by comparison. And I think, in medicine, young doctors-in-training (both male and female), worry about: Will I remember enough? Will I know enough? Will I do the right thing for a patient? Will I be technically competent? I think that's pretty much equal across the board. What I find, is that when a woman receives a compliment, about the way they interact with a patient, the way they communicate, that they're particularly caring, or empathic, that we sort of brush that off and say, "Well, yeah, but that's the baseline." Anybody can do that. Except, that's not true. Anybody can't do that. And, if you ask patients: "What do you want a future doctor to perfect?", they don't say, "Oh, I wish they knew more facts." They say, "I wish they communicated better. I wish they listened better." And these are deep skills and hard won.
Emily Silverman
So, where do we learn that this doesn't have value, or that this is the baseline? Is this a message that we internalize from the culture? Or is this something that comes from within? Or, how did we get here?
Suzanne Koven
My insight into how "imposter syndrome" works was enriched immensely by the response I received to the initial essay I wrote, by the same name: "Letter to A Young Female Physician" in the New England Journal of Medicine, back in 2017. And I received so many messages from women, and particularly women of color, or women who were physicians in highly patriarchal countries, who saw this entirely as internalized sexism and racism. That, if you've been told your whole life that you are second rate in some way, then how could you not, at some level, believe that?
Emily Silverman
My favorite chapter in the book was the one about dieting. And one of the quotes that I took away from that chapter was, "It took me years to figure out that my impulse to diet had more to do with shame. Specifically, shame about desire." And, I just thought that was such an interesting connection. I was wondering if you'd be willing to expand on that a little bit. And, specifically, what does that have to do with gender, if anything?
Suzanne Koven
Oh, it has everything to do with gender. I think it's not an uncommon story that a young girl, particularly at the time of puberty, maybe particularly if she's smart and verbal, gets the feeling simultaneously that she shouldn't take up too much space - physically, and in other ways as well. It's easier to act on the sense of taking up too much physical space. I'm 13 years old, and I've crossed the threshold over 100 pounds. I remember distinctly that this was very shameful to weigh more than 100 pounds. And I was just feeling uncomfortable, and that maybe I was too loud... and my hair was too curly... and maybe I talked too much in class. But there was an answer, which was to diet. So I went on my first diet: calorie-counting. I had a little paper calorie counter that I bought at the local candy store,, and I devised a diet for myself: 450 calories a day. That seems sensible. And, you know, that was the answer. Of course, it wasn't the answer. And yet, I went back to that solution, again and again, and again, and again, over decades. Of course, I got fancier, and more creative, as time went on. And, in fact, I got so fancy and creative that, in middle age, I decided for a brief period to become a diet doctor. Because that was, sort of like, the ultimate sneaky way to feed this obsession. I could actually trot it out into the open. But, as someone once said, "You can never get enough of what you didn't want in the first place." I don't think, really, I wanted to be smaller. I just wanted it to be okay not to be smaller. And it took a few decades to figure out that I could give myself that permission.
Emily Silverman
Yeah, I love that connection between desire and shame, and dieting. And I just found that chapter to be really, really... just vulnerable. And, thank you for telling us that part of your story.
Suzanne Koven
Yeah. Yeah, I mean, it's no coincidence that while I was hatching my 450-calorie diet plan, I was also begging my mother to let me get my hair straightened chemically, and obsessing over whether my handwriting was neat enough. And all these other ways to somehow rein myself in, because I was afraid of what I would become untethered. And that is... Talk about internalized messages... Believe me, that wasn't coming from within. Listen, I don't..., I don't want to give the impression that all these demons are entirely driven out. Even at this late stage of my life. I still have some of these thoughts. But, at least I've developed the reflex to question them. If I find myself thinking: Life's pretty good, and I wrote this book, and I love my medical practice, and I have a wonderful family and friends... but if I just could lose like maybe 15 pounds, I know something's up. Because, here's the thing. If I have that thought in the afternoon, and I didn't have it in the morning, it seems very likely that it's not about the 15 pounds. It's that the 15 pounds is a very poor translation for feelings of discomfort. Except, it's the language I started speaking when I was 12, and I've never fully unlearned it. I also had some really conflicted ideas about the sexism in my residency program. And there was a lot of sexism. I remembered that, well, there were just about as many women as men, but then I look at a photograph of our residency class. And there weren't; we were in the minority. There was no maternity leave policy. When I got pregnant, I was told that I should go to HR and write one. I got pre-eclampsia with my pregnancy, because it occurred to no one, including me, that maybe a pregnant woman shouldn't be on her feet for 12-16 hours at a time. And, yet, I never allowed myself to think, "Wow, this is a really sexist environment, and I'm a second-class citizen here." Except it was more complicated than that. A few months ago, I got together with an old residency mate of mine, who is Black, and I was asking him about his experience of racism at the time, and comparing it to my experience of sexism. And, I made the comment to him that I don't know how I could have been so infatuated with a system that seemed to have so little regard for me. And he said, "No, you're wrong. They loved you. And they loved me too, because we were stars. And we made everybody feel good, and look good. And, yet, there was a part of us that knew that it wouldn't take much for our star to fall. And that's why we felt we needed to be so perfect." And, when he said that, it really kind of blew my mind. Because I thought of all the times I bought into this "marine mentality", and "Yes, Sir, give me another," and, "Yes, I'll take that extra admission," and "Yes, I'll work that extra shift." And, I was high on that, because of the approval it would bring me. And yet, when he said that, I realized it was that I was so afraid that if I didn't do that, I would become nothing in their eyes.
Emily Silverman
Yeah, I think one of the most powerful lines in the entire book is "Perhaps the reason I didn't rebel against the culture of my medical training, was that I loved it." And you use the word "infatuation", and I just really related to that.
Suzanne Koven
Yeah...
Emily Silverman
You went to Johns Hopkins for your residency. I went to Johns Hopkins for medical school, and so I've been with the Osler Marines.
Suzanne Koven
Well, think about it. How could you not, at some level, love something that you're doing for 110 hours a week, for 18,000 bucks a year? You have to love it, in some way, to survive. You couldn't survive, if part of you didn't love part of it. The part of it that I loved, I think, honestly, was very connected to my dad, who by the way, even though he was an Orthopedic Surgeon, was the most un-macho of guys. In his free time, he was a painter and a self-taught scholar of James Joyce. But, the whole: Marines and we're in the trenches together and we're tough and we can handle anything... I loved that. I loved it. And, the fact that it was, in many ways, incompatible with being female - most notably, when I developed pre-eclampsia, which is really dangerous to mother and baby. I never thought of it that way. I never thought of it as a conflict, until many years later. Really, until I wrote this book, I never thought, "Wow, that was kind of messed up."
Emily Silverman
Yeah, you said there was a list of unspoken rules: Do not complain; do not ask for help; do not acknowledge exhaustion, hunger, thirst; display a calm demeanor, even during emergencies; maintain an empathetic, but distant relationship; do not cry. Etc, etc. I just felt that so strongly, when I was there and, to an extent, continue to feel that in medical culture at large. And I just wanted to share an anecdote with you briefly, from medical school, when I was on my Surgery rotation. I was in the operating room with a bunch of Surgical residents, and they were all men, and they were all tall, and they were all big, and they were all strong. And I was there: a young woman, a medical student. And they were all talking and joking about who in the Surgical residency had the biggest DSI? And, DSI this, and could it be this person? Or this person? Who has the biggest DSI? Blah, blah, blah. And over the course of the conversation, I used context clues to infer that they were talking about a dick-sucking index. In other words, they were talking about, who is the biggest suck-up.
Suzanne Koven
Right.
Emily Silverman
And, at one point, during the conversation, they turned to me and they said, "Hey, med student, "Do you know what DSI means?" And I said, "Dick-sucking index." And they started laughing. They thought it was hilarious. And I had this wave of emotion that was really confusing. Because, on the one hand, I felt kind of humiliated. But on the other hand, I felt kind of like a bad-ass. Like, I had said it, and it had surprised them.
Suzanne Koven
Right.
Emily Silverman
And then at the end of the day, the Surgical residents left the room, and one of them turned around, and he was, like, "See you tomorrow," or something. And it was the first time that they had acknowledged me.
Suzanne Koven
Yeah.
Emily Silverman
And it was so seductive, and I felt like finally I was in the club. But obviously, this is not healthy. And so - I just wanted to share that anecdote with you to give an example of how this continues to manifest.
Suzanne Koven
Yeah, I totally get this. And a big revelation for me recently, and I guess it saddens me, is that so much of my experience, 30...35...40 years ago, is still relevant; is still current. When I asked you to take a look at a draft of this book, and I asked a few other young physicians, physicians-in-training, I kind of held my breath a little bit. I thought, "Well, what if I sound like one of those old fogies talking about when giants walked the earth?" in that I had a terrible fear that I would hear, "Okay, Boomer." And yet, what I hear over and over again, is that none of this has changed. Well, maternity leave policies probably are better. And, in some ways, it may even be worse now. I've been looking into some statistics about women in medicine, and the good news is, there are more of us than ever. We now, as of a couple of years ago, constitute the majority of students entering medical school; are now women, by slight majority. We're the majority in several residency programs. In some specialties, the vast majority - OB GYN particularly. And yet the bad news is pretty much everything else, in terms of pay gap, in terms of the kind of harassment that you are describing. And that is harassment, what you experienced. And then harassment more serious, even than that. I ask myself, "If there are more of us, and if society at large is supposed to be more diverse, and more enlightened, than it was back in the 80s, why aren't things better?" So, there is this sense of progress without progress, that I find heartbreaking and fascinating. I think what you're describing in your anecdote about that Operating Room, it really epitomizes something that I felt so often early in my career, which is that in order to thrive and survive, I need to be one of the boys. And yet, I'm not one of the boys. I don't like this kind of humor. This isn't who I am. And yet, if I say, even to myself, "This isn't who I am," then I'm excluded from the circle. I think the answer is more women need to be in the circle. The attending surgeon needs to be a woman; the Chief of Surgery needs to be a woman; the president of the hospital needs to be a woman. We will never achieve full culture change in medicine, and address things like harassment and pay equity, until we have women in positions of power. There was a tweet just the other day; I forgot who sent it. I think I can quote it almost directly. It said... this was a female physician writing... "In 1993, when I was eight, 43%, of entering medical students were women. How come none of them are my bosses?" Great question. I think part of the answer has to do with the realities of childbearing and child care, and the realities of sexism generally.
Emily Silverman
I want to pivot a little bit back to something you said earlier in the conversation, which was when you were a medical student and a resident, nobody was talking about storytelling and narrative and things like that. Yet, you had this intuitive sense of the power of the narrative, and you give an anecdote of a patient named Albert Blake. And you say, "Decades after I first knocked on the door to his hospital room, I understand that Albert Blake agreed to tell his story again, and again, not to pass the time, but to survive." Tell me a little bit about your evolving relationship to storytelling and medicine, and how you've seen it blossom as a topic that is actually relevant and acceptable to talk about.
Suzanne Koven
In internship, my favorite part was the part everybody else hated, which was clinic. I didn't particularly like being in the ICU. I much preferred being in clinic, and having patients I had seen in the hospital come in fully dressed, showing their kids' prom pictures and stuff like that. I loved that. I think I was in my forties, when I started sneaking over to Harvard Square after work, to take night courses in writing. And I started to think about whether I might bring that passion fully into my medical life. The first step, which was about 12 years ago, was facilitating a reading group at the hospital once a month. And that blossomed into reading and writing workshops, and mentoring hospital staff interested in writing, and ultimately becoming the first writer-in-residence of the hospital. So now, at this stage in my career, my role as writer-in-residence is a much bigger part of my job than my clinical role, which is something I never could have foreseen; never could have planned. It simply evolved step by step.
Emily Silverman
I love the part in your book where you have psychiatrist and medical historian, Abraham Nussbaum, who is paraphrasing Foucault. And he says, "Foucault described the moment when physicians combined dissection with clinical practice as the "great break" in the history of Western medicine. Instead of seeing themselves as people designated by society to attend to those who are suffering, they began to think of themselves as scientists." There's also another quote where you say, jokingly, to your friends, "I'm just a therapist who does pap smears," and there's also some comparisons to being a priest, being a rabbi. What is a doctor? Are we scientists? Are we therapists? Are we spiritual guides? Are we data-entry specialists, which it seems like we are now, increasingly. Is that too much to ask of one person? And I've been wondering, like, should we outsource some of the more scientific pieces of it to pharmacists and technicians? And should we really retain a claim over the more relationship-building and spiritual piece of it? Or, do we claim the more medical and technical and pharmaceutical parts of it, and we just outsource the relationship to people like therapists and spiritual leaders?
Suzanne Koven
Yeah, It's such a great question, and something I think about a lot too. I don't think it's too much to ask, except for the data-entry part. I would never outsource the spiritual and relationship piece of it. And, in fact, I always feel I'm doing my best work as a doctor, when I'm just on the edge of my role. And the horizon that I'm approaching is the relationship, the spiritual. I do know that... if it doesn't sound too highfalutin to say it... that what we are is healers. And what is essential to being a healer, is probably not data-entry; is probably not to have at your fingertips every potential drug interaction. Those certainly... Somebody needs to know that. But what is essential to healing, is the ability to understand, and to form relationship. Somebody is in trouble. They are frightened. They've seen a whole bunch of consultants; they've had a whole bunch of tests. And then you, who know them, meet with them; process everything; sit with them over it. And they say, "I feel so much better." And, that's the kind of the work on the edge.
Emily Silverman
I agree with you, I don't want to see that part of the job outsourced, at all. I guess what I feel sometimes is that it's already happening. For example, I'm a hospitalist, and there are moments where I know what a patient really needs is a 60-minute family meeting. But it's physically impossible for me to do that work, with every patient that's under my care. And I think that might be driving a lot of the moral distress that's behind this epidemic of burnout that we're experiencing as physicians. And there is data to suggest that burnout has a stronger impact on women.
Suzanne Koven
The reality is we have less time with our patients than doctors did in previous generations. That's just the math of it. And to your point about how you have to outsource some of it, that may be okay. And it may even be, for certain doctors, their preference. For example, if somebody is an ophthalmologist, and what they love doing is cataract surgery, one after the other, all day long, that's wonderful. It's great. We need those people. And there's room in medicine for people who would rather do that than, for example, to do what I do. But, if there's a mismatch between what you feel your true role is as a healer, and what you're being asked to do, that's where the moral dissonance comes in. I think so much of burnout has to do with feeling that you are operating against your own values. I wrote a piece about this in the New England Journal a few years ago. I called it "The Doctor's New Dilemma." And the way I framed it was, if you open the door to a deeper interaction with the patient, you'll fall behind. You'll get stressed out; you'll get burned out. If you don't open the door, then you have a more existential sort of a crisis. And that is an even more direct route to burnout. And I think many of us find ourselves at the kinds of crossroads that you're describing. Should I attend that one hour family meeting? Which I know I'd be great at, I know the patient and their family would love, I know would be tremendously therapeutic for this patient, I know would nourish my soul... Or should I outsource it? Do all the other things that I have to do, and not get home at 10 o'clock... There was a study, just a few months ago, that showed that female Primary Care physicians spend two and a half minutes more per patient, on average, than our male colleagues. And you think, "Well, two and a half minutes. I mean, that's not such a big deal." Well, over the course of a day, it's 15%, which is 15% income gap. Or 15% staying later? It turns out that what we're talking about in those two and a half minutes is what I loved about intern clinic: the prom pictures, the people stuff. So, do we give that up? Or do we not give that up? Or do we make women in charge of more stuff, and hope that things will change such that we don't have to give that up. That we can operate in a system where we spend enough time with patients, and still don't get penalized for it in our paychecks?
Emily Silverman
I like that one.
Suzanne Koven
Yeah.
Emily Silverman
I think that's a great place to end. Everybody, pick up Letter to a Young Female Physician: Notes from a Medical Life. This is a really, really, powerful memoir, from Dr. Suzanne Koven. I thoroughly enjoyed reading the book. I thoroughly enjoyed our conversation. And I want to thank you so much for bringing your stories to The Nocturnists.
Suzanne Koven
Thank you so much, Emily, for all you do for stories in medicine.