Conversations: Danielle Ofri, MD

 

SYNOPSIS

 
 

Emily speaks with physician-author Danielle Ofri about the science of writing, the art of medicine, and the imperative of recognizing stories as a tool for healing.

 
 
 

LISTEN

 
 
 
 
 
 
 

GUEST

 
 

Danielle Ofri MD, PhD is one of the foremost voices in the medical world today. She’s a primary care internist at Bellevue Hospital and clinical professor of medicine at NYU, as well as founder/editor-in-chief of Bellevue Literary Review, and her writing appears in The New Yorker, the New York Times, as well as in The Lancet, and NEJM. She’s given several TED talks and performed at The Moth. Ofri is the author of six books; her latest is When We Do Harm: A Doctor Confronts Medical Error.

 
 
 

RESOURCES

 

Mentioned in this episode:

 
 
 

CREDITS

 

Hosted by Emily Silverman

Produced by Emily Silverman and Sam Osborn

Edited and mixed by Sam Osborn

Assistant produced by Carly Besser

Original theme music by Yosef Munro, with additional music by Blue Dot Sessions

The Nocturnists is made possible by the California Medical Association 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 Danielle Ofri, 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
You're listening to The Nocturnists: Conversations. I'm Emily Silverman. Today's guest needs very little introduction. Her name is Danielle Ofri. She has an MD, a PhD, and is one of the foremost voices in the medical world today. She's a primary care internist at Bellevue Hospital, Clinical Professor of Medicine at NYU, and founder and editor-in-chief of the Bellevue Literary Review. Her writing appears in The New Yorker, The New York Times, The Lancet, the New England Journal of Medicine. She's given several TED talks. She's performed at The Moth, and she's the author of six books, latest of which is called When We Do Harm: a Doctor Confronts Medical Error.

In today's conversation, Danielle and I rewind the clock a bit. She tells us about her humble beginnings as a locum tenens doctor, roving around the central US and Central America. She walks us through her journey, which took her very much off the beaten trail, which is admirable in my opinion, and as you can tell from her bio, led to an incredibly rich writing life. I was especially excited to hear Danielle talk about BLR, the Bellevue Literary Review, where anybody can submit their writing. We talked about what she's looking for in writing these days, how she mentors writers, and what she thinks about the future of physician-storytelling. Before we chatted, I asked Danielle to read an excerpt from an essay she published in the journal Academic Medicine back in 2015. It's called "Storytelling and Medicine: the Passion and the Peril." Here's Danielle.

Danielle Ofri
So much of medicine is about stories—the ones we hear, the ones we tell, the ones we participate in—that it is no accident that doctors and nurses are attracted to stories. The rising popularity of literary sections of medical journals is illustrative. These stories often have much more in common with what we actually do and how we actually live our lives as caregivers than does the latest randomized controlled trial, no matter how clinically relevant the data are.

The attraction and desire go beyond stories that tell of life and medicine. Great works of literature have an intrinsic appeal to medical professionals, even when they are not about medicine. The sense of story and character is so much a part of our lives as caregivers.

Now, one could argue that any human being who lives and breathes would find resonance in story and character. And as a writer, I can't dispute this—and I certainly would not want to—but I would suggest that doctors and nurses spend much more of their lives immersed in story and narrative than the average working person does. For readers married to accountants, how many exciting stories does your spouse bring home at the end of the day? There just is not as much drama in net asset dispersion and fixed-cost derivatives.

It is the stories in our work that provide meaning to much of our daily lives. Over the course of our careers, we accumulate hundreds, thousands of stories—stories of our patients, stories of our colleagues, stories of life in the hospital, stories that we play a role in, myths and legends that circulate the wards as slyly and efficaciously as MRSA. After a while, these stories can sometimes weigh on us, feel like they are overflowing, and we are suddenly gripped by a desperate desire to tell someone, to share these stories. The recipient could be a spouse, a student, a coworker, or a hapless fellow traveler on the subway.

The impulse to tell a story is innate in the human race. We in medicine are particularly drawn to stories because these are what our patients bring to us. We hold our patients' stories—their words, their voices, their facial expressions, their fears, their needs, their trust. It is like cupping a butterfly in your palm, the physical tension of clenched fingers in a disconcerting balance against the requisite gentleness to protect the fragile creature.

We are part of these stories, as they are part of us. No matter how efficient medicine becomes, no matter how computerized, automated, algorithmed, wirelessed, evidence based or "QA'ed" it becomes, medicine will always boil down to one caregiver with one patient, in one room, with one story.

Emily Silverman
Thank you so much, Danielle, for that reading and for being here with me this morning.

Danielle Ofri
Thanks. It's so nice to be here.

Emily Silverman
So, I'm really excited to chat with you about medicine and writing and your career. But before we get to the writing and creativity piece of this, tell me about your scientific and clinical life. You have an MD and a PhD. How did you land in the sciences?

Danielle Ofri
Well, it's funny. I come from a family of teachers. There's not a single doctor to be found, or nurse or anyone. But as a kid, I loved my dog. I thought I'd become a veterinarian. That was what I was doing. And then when I got to high school, people who liked science were going to become doctors. And so I just followed the pack. And I knew nothing about what doctors actually do. But that's what you do. And so I went to McGill, knowing nothing about it, and ended up in a British education system with 100% science. And there, if you like science, you're going to become a scientist. Right? Physicians—that was just for, like, technicians. So I ended up in this sort of confusion. Well, what do I do? And then I heard about, oh, there are these MD-PhD programs where you can do both, and they pay for your tuition. And then I'll figure it out the other end. So I did an MD-PhD. program, more driven by indecision.

And so I was going to go into neurology, because I was doing neuroscience research. And, for neurology, you need to do a one-year medicine internship. So I started there. And I immediately fell in love with my patients' stories. And I even remember the patient, Mr. Feliciano, who converted me. And he was a gentleman with endocarditis. He needed weeks of IV antibiotics—wasn't able to do it at home. And me, as the intern, I had to go in every single day; listen to his heart and lungs, do the EKG, draw his labs. And every day—and this was a long time—we were just chatting, and I learned about his life, and where he had grown up. And it was so interesting, and intriguing, that I just stayed on in general medicine. When I ended up getting a job, I opted for a hybrid inpatient-outpatient medicine, and eventually stuck with mainly outpatient medicine. And I just love the long-term relationship with patients because I get to be witness, and part of their stories, over a year, sometimes even decades.

Emily Silverman
Tell us about the PhD in pharmacology. Was it a difficult decision to abandon a life in the lab? Or did the stories suck you in so much that it wasn't too hard to say goodbye to your pharmacology life?

Danielle Ofri
It was a difficult decision. My PhD advisor was an organic chemist by training and his lab was a biochemistry lab. And it was so exciting. We were working on opioid receptors. He was one of the discoverers of opioid receptors: that we have an endogenous receptor for what seems like a plant-based compound. In fact, he coined the term "endorphin". (It's a contraction for endogenous morphine.) Dr. Eric Simon, and he really engendered in us this sense of curiosity, and high index of suspicion for everything. Don't take anything at face value: figure it out, dig into it. And it was so liberating, because medical school is so hierarchical, and all of medicine is. But science is, like, just the playground of "bring the work and you can do it", whether you're the lab tech or the senior scientist.

And so it was hard, and all through my clinical career, I'd have lunch with Eric, and he always sort of lamented that I never stayed in science. But I recognized that both science and medicine are more than full-time jobs. The idea that you can do both is just an illusion. And I knew that I couldn't do science 150% of the time, as one needs to be. So it was best just to put it aside completely. But I've retained the high index of suspicion for everything. And it gave me great training, you know, "trust, but verify" for, really, any new drug that comes out, new treatment, a new political idea. You know, not 'til you see the data, it doesn't count.

Emily Silverman
I'm really interested in this experience of going to Canada and being educated through the British system, and then coming back to the United States, where you did your internal medicine residency, I believe, at NYU, at Bellevue. Can you speak a little bit to the culture clash or similarities and differences between the British system and the American system? How did that come up for you, when you were switching back and forth?

Danielle Ofri
So the British system, which I was completely naive to, is a strict separation of arts and sciences. So, I was a physiology major. You weren't just a bio major. My American colleagues were, you know, bio majors. Here, you could be a biochemistry, microbiology, anatomy major, physiology ... I mean, it really was so highly-spliced. And you really did that, all the way. And so it was really fun, in that you got to delve very deeply, but there were no arts—unless you wanted to.

But luckily, in my first year, a departing senior—it was an acquaintance of mine—said, "you know, if you don't take a course with Professor Ruth Weiss, you will have wasted your education at McGill." So, I was intrigued: "What, pray tell, does Professor Ruth Weiss teach?" And she taught Yiddish literature. Something I didn't even know existed. I mean, to me, Yiddish was you know, schlep, schlemiel, and that's it. But, you know, this was not advice to take lightly. So I took one of her classes and I completely fell in love. You know, the stories of Shalom Aleichem, and I.B. Singer, and I.J. Singer and Peretz; it was this whole world that I really didn't know much about.

And, from there, I took Russian literature, and then Russian history. And I kept getting one step more, and more, and more, into the humanities through this recommendation. And I took several courses with Dr. Weiss. And she even let me take a graduate course. I was this random physiology student in her graduate literature classes. But, again, digging into the story was so fascinating. Also, because the stories are so impacted by the politics and history of the time, they don't exist in a vacuum. And I found that so exciting, and sort of a...if I can give you a postscript from many years later...

So, there's a publication called Publishers Weekly, which is the trade journal for the publishing industry. And when you publish a book, it's, you know, it's reviewed there so libraries and bookstores know what to buy. And so when one of my books was,...I was in there. You know, my editor sends me the link; I saw it. But one of the poets we published in BLR got the physical magazine, and she saw my book, so she tore it out. She mailed it to me at Bellevue; it was so kind of her. It took weeks to show up. And I get it at Bellevue in my clinic. I open it up, and I'm like, "yeah, I've seen this before," but I unfold the page. And there's my book, and Dr. Ruth Weiss's book on the same page. And so I tracked her down. And I wanted to thank her for giving this random science student just a peek into the world of literature and stories.

Emily Silverman
So tell us a little bit about your path to writing. Did you have a writing life and a reading life before the recommendations? Or did that blossom in Ruth's class? Or how did you come to be a writer?

Danielle Ofri
Well, I always loved to read as a kid, and I loved to write. I wrote about my dog, you know, in first grade. But once I got into medical school, there wasn't a lot of time, as you well know, for just about anything, other than sleeping and breathing. Even that—not a lot of time for that. But that exposure with Dr. Weiss was really my first chance to go in-depth, and really just dig into it in a way that felt more elemental. And, because of the MD-PhD program, I ended up spending 10 years in training, between medical school, the PhD, residency, and my years overlapped with the peak of the AIDS epidemic in New York City. It was a pretty intense, and many times very bleak, time. Our patients were largely our age, and they were dying brutal, protracted, just awful deaths. And we just... we were saturated by death, and I remember being overwhelmed, and I'd never thought about taking a break.

But a combination, I think, of two things: One is of just feeling drained. And the second was having a childhood, a camp friend of mine, die of a sudden cardiac arrest. He had IHSS. And he was, we were, 27. And he died instantly. And, it was quite a shock. And I was in residency at the time; I'd never taken a moment to stop. And I realized that I needed to get away from all of this. And so I heard about, from a resident, about something called locum tenens—something I knew nothing about—but locum tenens is temp work for doctors. And unbeknownst to me, that outside of the big cities (where doctors are a dime a dozen), there's a huge doctor shortage in small town, rural America. And most places while they're trying to hire, need to cover their spots, and they use temp doctors.

So I signed up for some locum temp agencies. And they'd find me a gig, you know, in a small town in New Mexico, and I'd work for a month or two. And then when the money ran out, I traveled to Central and South America, because I wanted to learn Spanish. (That's where most of my patients were from.) And then when the money ran out, I called collect from Oaxaca: "What do you got next?" I'd end up in New Hampshire. And it was during those times, that I began to write down some of the stories of residency. And I remember thinking at the time, during residency, that these stories were very singular, that I'd never be this close to such intensity ever again. I was well aware of that. And also, well aware of how historic the HIV moment was. And I told myself, I should be writing this down. But, you know, I had no time; who had time? And I think, also, it felt too close to the emotional bone to write the things down at the time. And we were writing it down, you know, platelet counts and spleen sizes, but not anything about the patient stories.

So when I went to these locum tenens jobs, which are generally in small towns, and when you come from Manhattan and go to a small town, there's nothing to do. I mean, no thing at all. So I had a lot of time on my hands. I cancelled my medical journals, got a few novels, got a laptop, and began just writing down the stories of my patients. And I took these with me when I traveled in Central America, working on them. Not with any idea to write a book or become a writer, but I needed to have a place to put these stories. And I kind of cringe from the word "closure", because I don't think there's any such thing as closure, but you do need to put them somewhere. If they live inside you, as these sort of open wounds, it's very hard to move forward. Yet, you don't want to, you know, close them away, and then they disappear from your consciousness.

And so I feel like by writing them down, I kind of can tuck them in this sort of left lower quadrant abscess, you know. But it's a soft-walled abscess, not a necrotic abscess, because it's still there. A little bit seeps out and reminds you of what it is that we do. It keeps you grounded. And yes, every so often, you know, it ruptures: you get sort of the peritonitis of emotional overload. But it was a way to sort of, just, put these stories somewhere.

When I got back to Bellevue, and I always knew I wanted to come back to Bellevue, there was an economic crisis and a hiring freeze. And then when the freeze unfroze, they only had a 60% position open, which never dawned on me to take a part-time position, but that's what they had. I had a couple of loans to pay off, so I took it. And so on one of my afternoons off, I picked up a writing brochure off the street—one of those little yellow Gotham Writers' Workshop on Second Avenue—and started taking a writing class. And it's my first experience of working on a story, to sort of hone it as a piece of writing, and began sending it out to little literary journals whose readerships are probably smaller than my medical school class. And then I started taking one-on-one classes. And then I remember my writing teacher saying that she missed her subway stop reading one of my stories. You know, that means it's time to get an agent.

So I tried to get an agent, and I sent out my stories to many agents, and one finally took me. We submitted this collection of writings. And I am proud to say it was rejected by, I don't know, eighteen of New York City's finest publishing houses. You know, people say things like, "Oh, write a novel first," or some, like, crazy thing that just, you know, couldn't happen. And then one day, I got a call from the director of Beacon Press in Boston, who read one of my stories, and she said, you know, "Do you have a book?" and I said, "As a matter of fact, I do." And I FedExed my manuscript, and Beacon Press took the book, and then we've been publishing together ever since.

Emily Silverman
I didn't know any of this backstory, and I just love it. It's almost like a Jack Kerouac kind of vibe: backpacking around New Mexico and Central and South America, and then taking locums positions back in the States, and running out of money. And it's just such an unconventional narrative for a physician, because I feel so many physicians get on the conveyor belt and it's, like, very rigid and having to go to the next step and the next step... but, as a young person, you seemed fairly loose. Even this idea of taking time off to do locums. A lot of young physicians could never contemplate that because it doesn't fit into the script of what a physician is supposed to do. So, was that easy for you? Just to be this kind of, like, freewheeling...?

Danielle Ofri
Not at all. I'm as anal retentive as the next, you know, medical student, and the idea of getting off the path... I mean, listen, I went to college a year early because I was so gung ho. I did the MD-PhD program. You know, I was going to become a chief, and all these things. So the idea of getting off the track was terrifying. And I had no template for it. And I remember all my advisors in my residency program said locums was a terrible idea: "You'll lose your medical skills, you'll never get back into academic medicine." That's a quote from one advisor, who is still a colleague of mine today. You'll never, you know, get back to your position, you'll forget all your medicine.

And then I was talking to a social worker, not at all involved in medicine. And she said, "You know, I think they're jealous." And when she said that, it kind of like snapped me, like, maybe they're right. But I think one thing I've learned, and what I try to tell my students when I advise them, is to be open to serendipity. I mean, the advice about Professor Ruth Weiss' class at McGill; that was a serendipitous thing. Even applying to McGill, because of their late application deadline. I wouldn't have picked it out if I had planned things. Doing the MD-PhD; doing locum tenens; being open. And there are a thousand roads to Rome. And we think there's only one way to go. That's one thing that we in medicine can recognize. We are so fortunate: we have a job that will always be there. Illness never goes out of style. There's always jobs for doctors and nurses. And that's a really fortunate place to be. So go ahead and try something different. You can always get a job. You got a stethoscope? That is all you need.

Emily Silverman
What you said about the social worker sitting down with you and saying, "You know, I think they're jealous." It's such an interesting one, because I recently made the decision myself, the difficult decision to take a radical sabbatical and step back from my full-time clinical position. So I'm definitely in that space right now—floating in the void of "Am I going to be able to go back?" And... "Do I want to go back, and how do I want to go back?" But I've noticed that when I talk to other physicians about this decision that I made, the initial reaction is, "Well, that's gonna be really hard for you. You may not be able to go back," and so on and so forth. But then the longer the conversation goes on, more questions come up. And then finally, what I often end up hearing is, like, "Well, how did you do it?" And "Maybe I could do it too." And so, I do think that there might be something underneath this where... You know, obviously it's a privileged position to be able to step back; not everybody's able to do that financially. But if you are able to, there's a lot of people I think, who are afraid to.

Danielle Ofri
Also guilt. You know we're trained to be responsible for every last aspect of our patients' care. And so leaving one potassium unchecked, or one "T" uncrossed or one "I" undotted... It's very hard for us to do that. But you know what? The world will not collapse, you know, if Doctor X or Nurse Y steps back and I think, you know, over time, at least in my time in medicine, it's gotten more intense. So one would think as you get more along in your career gets easier, but I think it's actually getting harder, because of the nature of medicine. And more and more is being packed in. I hate to say that we're being exploited. But there is, to some degree... I think the health care system is built on the fact that medical professionals are professional, and we don't go in it for the money. The fact that it's, you know, a decently paid job is certainly wonderful. But no one... There's easier ways to make a living than getting, you know, puked on your shoes.

But we are professional; we don't leave 'til everything is done. And the system really takes advantage of that. And recognize that it's going to—it's going to function; it's going to hold together, because Dr. Y on Saturday is so worried about her patient's breast biopsy, they will log in on Saturday to check the results, and call the patient, and make sure their patient gets the oncology appointment. We do that all the time. Nurse Z is not going to leave her shift, if the coverage nurse hasn't come in. And so, it's become all the more intense, I think. Harder to step away. But in fact, it's it's really eating away. And such... this type of thing is really corrosive to the spirit of committed people. So I agree that some way to step back is really important, and to not be afraid. And you will always find a job. Maybe not the one you want. But there are jobs for doctors and nurses everywhere. You will have no trouble getting a job when you need it.

Emily Silverman
I want to talk more later about how healthcare has changed over the last decade or two. But before we get there, I want to come back to writing. And in the excerpt that you read, you talked about why doctors write. This impulse, this sense of having an accumulation of stories and needing a place to put them. I don't know... I'm just thinking about myself as someone who's always loved to write and tell stories. And it hasn't always even been writing. Like, I remember when I was 13. My friend Rebecca had a Bat Mitzvah in Israel. And I went with her to Israel and I had this little video camera. And I constantly was just recording everything. Boring stuff, interesting stuff, whatever it was, I just had this urge to... to capture, to document. And it felt to me like if I didn't do that, that something bad would happen to me. It's kind of like my friend Dave once said to me: for him, writing is like possession. He writes to be free.

Danielle Ofri
I feel like it's the way to sort. That, you know, I come home from a day in clinic and my brain is a jumble. And I want to sort things out somehow. And because in real time things happen too quickly. You can't rewind the tape. You can't look at it from another angle, or think or suppose or wonder or just feel it. But writing, and revising, are much slower. In fact, for me, I'm a rabid reviser. I really struggle on the blank page to get it down. But I love revising, which makes me enjoy editing a lot. But I feel, you know, I often cite, and I think in the article we read the excerpt from, I always bring up the story "Misery" by Anton Chekhov.

And of course, Chekhov was a famous physician-writer. But in his story, Chekhov writes about Iona, a sledge driver, a taxi driver. And he's doing the night shift somewhere in Vladivostok at around holiday time, and his horse-drawn carriage is taking laughing party-goers to and from their parties. And with each customer, he tries to start a conversation. His young son has died that weekend and he wants to tell someone. But no one takes up his conversational gambit. Right? They're just too preoccupied or too drunk or too happy. And the whole night goes by; he's never told his story. And he finishes his shift. He brings the horse back to the barn. He parks the sleigh, and he's brushing his horse. And he tells the story to his horse. And the horse listens, patient; doesn't answer back, of course. But it's enough to have told the story. You don't need to get a response.

And I think the telling of the story is so important. Publishing is different; getting feedback or comments. But just getting it down on the page is a way to sort of wrestle the story inside of you, that is just writhing around. It's a way to, just to, grapple with what we do every day, which is both amazing, sometimes horrifying. But it's also so interesting. We have the most amazing job. And if you're curious, and I think most of us are, you just want to know: Well, what makes this person tick? What makes her physiology go? What makes her life go? How did you come to this country? Tell me about yourself. It's so interesting, and it never ceases to be so.

Emily Silverman
Do you think that there is something, though, about having the story be received? And that could be just read by a friend, or that could be published for a million people. That's like the closing of the loop. Because, I hear this a lot sometimes where people say, it's important to write, get it on the page; publishing isn't important, the story can just exist on your computer, and it can still be beautiful. And I think, there's a really good reason to say this, because we really, I think, as writers sometimes have to grapple with our egos and, you know, wanting things like fame and recognition, and really trying to strip that away from the creative process as much as possible. But at the same time, sometimes I do feel like if I get the story out on the page, and it's just on my computer, and nobody ever sees it, there's something that feels incomplete. And there's a part of me that does want to have that warm energy from the other side: reacting and receiving and responding.

Danielle Ofri
No doubt, no doubt. And getting a response is really... It can be an amazing thing, because you then touch a nerve for someone else. That they've been there; and that you can offer comfort to someone is really meaningful. And sometimes I'm surprised when I'll get kind of a...someone says that, you know, "this made a difference for me." It's like being a physician, that you're treating someone and you help someone feel better, which is of course the name of the game.

So there is a part of that, that sort of conversation. And sometimes, you know, it's... it can just be sending the story to a friend. You know, people ask all the time, which stories can you or can't you tell? And obviously, these are the patient's stories. So the first thing is, can you get the patient's permission? Right? I mean, and sometimes that's possible, and sometimes you're years, or decades, or oceans later, and that's not possible. And so we try to, you know, hide identities and change details. But even beyond that, I always ask myself, if the patient read this, would they feel that this was a respectful rendering of their story? And does it come from a place where there is a larger lesson or point, as opposed to just, well, this is a cool war story.

You know, most of my patients at Bellevue... It's a variety, but many people are immigrants or don't speak English. But there's a small core of the poor, starving artist that also comes to me, who maybe grew up in Westchester, but now live in, you know, some garret somewhere and they're making a living as a slam poet, which is a very penurious living. So I had one such poet, and he was always broke. And so I always spotted him medical care. You know, he would come and not pay, we'd do things by phone. And, and, you know, he told me everything. I knew all his STIs—everything, trust me. And so one day, he calls me and says, you know, I just got back from Italy, and I have the worst headache of my life and the light's killing my eyes. And, of course, my radar goes off; this could be meningitis. I said, "Listen, you gotta come in." "No, I have no money." I'm, like, "This is... you must come in." I said "Alright, listen, come during the lunch break of the clerk, and I'll just bring you in the back. We won't register, but I need to lay eyes on you."

So I sneak this guy in the back door. He's got dark glasses on; his eyes are bloodshot; he's looking cringey. And I said, "Listen, I can't rule out meningitis. You've got to go to the ER and get a spinal tap, an LP." Fortunately, he goes. So the ER doctor calls me that night. His tap is negative. He said, "Oh, but you know he's doing cocaine." I was like, "What?! He didn't tell me that." This guy who tells me everything... I mean, literally. And I was so angry that he had not... he left out this clear detail that would have changed how I felt, you know, and I'm staying up late and sneaking care for him. And so, I wrote the story, because the experience of being lied to by a patient was a really, you know, I thought, interesting topic. It hit me in a certain way. I thought it could be a teaching material. But then I thought, this is a guy who might read it. And whether or not my patients can read The New York Times or not is not really relevant. But if he read it, I think he would be hurt. I think it wouldn't serve him well. And for that reason, it stays under the bed. And so my advice is: You can write whatever you want, but whether you publish is a different interrogation. As to, will it serve the patient? Will it harm the patient, if you think, in any way? And, of course, it's subjective, but if the patient would be harmed or hurt or insulted, it stays under the bed.

Emily Silverman
Yeah, I think that's a really great story to encapsulate that decision-making. Sometimes it can be really hard to know: Where does the patient's story end and the doctor story begin? And I heard a memoirist addressing this issue in an interview once, because she had a really difficult childhood life with a sibling who, I think, was abused by one of the parents. And every night, she said, the door would close and this would happen on the other side of the door, and she was in the living room, and she could hear it, and obviously really upsetting. And somebody said to her, "Well, how could you possibly write about this? This isn't your story to tell; this is your sibling's story to tell." And the way that she put it was: "What happened on his side of the door was his story to tell. But what happened on my side of the door, was my story to tell." I don't know if that analogy can apply to medicine, but I thought it was another interesting way to look at it.

Danielle Ofri
Abraham Verghese, who is one of the best doctor-writers out there, once wrote a piece for the Annals of Internal Medicine called "What Doctors Can Learn from Novelists". And...it's a great piece about how we pick up voice and character. But also he pointed out that once a patient tells a story in your office or at the bedside, you are a character in that story. You know, whether you want to be or not, you are. Now of course, there is a power differential. And the patient's coming to you not as an equal or as a, you know, a journalism interview. They're telling their stories, so it's not yours to grab. So you do have to consider that. And whether it's permission or seeing how you slant the story, you're not coming at the story as equal partners. And we have to recognize that.

Emily Silverman
I want to talk a minute about craft. So you mentioned finding this pamphlet—this Gotham Writers' Group. What was your experience of going into a writing group, or a writing class, learning about frameworks for writing.... Just like we learned in medicine, like, here's a framework for chest pain, and writing, it's like, well, is this first person? Is this third person? What is the psychological distance between the narrator and the character and the author? And all of these tools that we have to look at writing.... What was it like to dive into that world? And how did your writing change?

Danielle Ofri
Well, I loved it, because someone's giving you the tools. And it's like getting the tools of medicine or the tools of science. You know, you have a scientific question. Well, here's how you set up a scientific experiment. "Wo Ho! Now I can do that." And so, I really love craft and loved learning it. You know, no one wakes up, you know, as James Joyce, except James Joyce; the rest of us have to work at it. And so the writing classes really gave me the tools, and they were so practical. It's like people say, "Well, how do you learn how to draw? Are you a great artist?" Well, you know, you learn techniques for drawing, and they're out there. And you practice.

So I found it revelatory. And it really allowed me to apply sort of a scientific approach of: How are we doing with our verbs and our adjectives? And how are we doing with suspense and character? Not that it replaces whatever the artistry is, but it definitely aids that a lot. So I found that I had so much to learn. Like you do from every attending you have in your medical training, you learn something else. Every writing teacher, every editor.... Because I work with different editors now, and editors at The New Yorker... it's a very different experience than The New York Times. Versus my editor for my books. It's just a very different... and from each of them, it's like my attending and I learned so much. So, it really was empowering.

Emily Silverman
I've been learning a bit about craft as well, and it strikes me that medicine is more of an art than we think. But potentially, writing is more of a science than we think. And I know the author George Saunders sometimes talks about how he has a prior life as an engineer, and how that science-engineer brain...he brings that to bear in his writing a lot.

Danielle Ofri
When I read The God of Small Things by Arundhati Roy, I was so impressed by structure of the book that I outlined it. And then I realized that she was an architect by training, and no accident, because that architectural mindset of how you fit pieces together; it was miraculous. And so I think it's not accidental that writers may benefit from other kinds of careers.

Emily Silverman
You wrote an op-ed in The New York Times that I have bookmarked, and that I've returned to again and again, and again, and I know that you said you don't like the word "exploit". The title of the piece is "The Business of Health Care Depends on Exploiting Doctors and Nurses". And I know that the authors don't always pick the title.

Danielle Ofri
The authors never pick the title. Let's be clear on that, especially for the newspapers.

Emily Silverman
But it's one of my favorite pieces I've ever read, because it gets back to what you were saying earlier, which is that physicians and nurses are professional; they're altruistic; they're self-sacrificing; and how the system really depends on that. And you talked a little bit about how medicine has changed over the last decade or two. It's gotten much more complex. Now we have so much more medical knowledge; we have a much more dysfunctional healthcare system. We have the electronic health record, there's prior auths, you know. I guess my question to you is: Having been in this biz now for a while, how are you seeing the arc of it? Is it getting harder? Is it getting worse? How are you thinking about this problem of physician burnout? Or moral distress (or whatever label you want to use)? Are you optimistic or pessimistic about the future of a clinical life?

Danielle Ofri
So I'll say: all of the above. And that may sound like a cop-out. But, yes, it is getting harder. But it's also getting easier, right? There are some things that have gotten much harder. And the administrative burdens really, really, have built up. Our tools for treating patients have improved. Tele-medicine, which was, you know, a crazy nightmare in the middle of COVID has turned out to be this miraculous addition to our armamentarium. I'm working on a piece now about, you know,... Patients—some like it better, some don't; where there's data, whether it's better or worse. But you know, what we rarely talk about is that it gave physicians agency. Rescheduling patients with a telephone visit or a video visit is much easier, and suddenly I had a little bit of time, you know, to work things out and gave some flexibility.

So, yes...so it is both. I mean, I do think that it has built up to a point where I think...maybe when I wrote the piece, I didn't accuse the system of actively exploiting this. Now I think I might rephrase that. I think there is an act of exploitation. I think the corporatization of healthcare has really recognized that there's this one fully elastic, unexpendable resource, and that is the professionalism of medical workers. And if COVID didn't show that, I don't know what did. But, you know, we could not have survived COVID with just our structures of medicine. It relied on the individuals who stepped up to the plate, in every way, shape and form. And paradoxically, while it was one of the most difficult times of medicine, it was also the most inspirational times. They kind of let the inmates run the asylum. And we got to run it and do things that you couldn't do for years and years. Now, you could do it overnight. And, hey hey! It can work, and the place didn't fall apart. And so there's something very emboldening about that. And I think that we built up this reservoir of goodwill and power in our voices—the recognition that the work that we do is really meaningful.

But I think that also gives us both the power and the responsibility to speak up about it, that we have this voice, and that when we call our politicians to say, "Hey, I'm a doctor, and I'm treating patients and here is what is going on." It gives you a different amount of currency, and we should use it. And when I talk to people about how do we frame our activism, I can think of really two great ways to frame it, that's meaningful to all the stakeholders. And the first one is patient safety. Right? I didn't talk about doctor burnout. I don't think they really care, to be perfectly honest. But patient safety, medical errors, lawsuits, people do care about. Everyone—from insurers to hospital administrators, to government—cares about that. And so, if you can frame what's going on in a patient-safety lens, people do listen. So when crap comes up at my hospital, I file a patient safety report, even if it's not, like, oh, it wasn't a medication error. But a stupidity in the EMR, that makes me likely to make a mistake, I make a report and make some administrator follow up on that.

And the second lens is patient satisfaction. And I don't think that health care systems have this, some like glowing angelic...they truly care. But it matters in terms of money now, and so they do care now—for whatever reason—and that is a way to frame things. That some of the things that we're doing—patient satisfaction, you know—most places will put in the nice coffee machine and graham crackers and valet parking. But what patients really will feel satisfied by is enough nurses on the wards. Or, they have to wait so long for their doctor—enough time with their doctor. Those things. If we frame those as patient safety and patient satisfaction, I think they do have a chance of being heard.

Emily Silverman
I want to talk about BLR, the Bellevue Literary Review. What is it? How did you get involved in it? And what is it like to, not just be an author yourself, but be a steward for other writers?

Danielle Ofri
So Bellevue Literary Review started in the Fall of 2001. When I came back from my locum tenens and I started back as an academic physician, I really wanted some way to incorporate the writing I'd been doing about patients into my daily medical practice. And so, when you have students and interns, they hand in their H&Ps (the history and physical). So that's the very standard presentation of illness: history of present illness, past medical, past surgical; it's a very rote way of going. And once you've read 5, or 10, or 50, or 60, they all kind of sound the same, and I was just going a little crazy with boredom. So I said, "Hey, listen, guys, for one of your write ups, please just ditch the H&P format. Just ask them: What's it like to have diabetes? Or, when your doctor told you had emphysema, what did it feel like?" And so I started getting these really amazing stories from the medical students.

And at the same time, we got a new Chair of Medicine who, on the in-patient service, was requiring a thousand-word essay of medical students... right... You'd think that, like, the heavens,... like the sky fell down! A thousand words, oh my God! ... you know. But for medical students, it's a lot. But it could be about anything, as long as it's inspired by a patient, it could be philosophy, pathophysiology, ethics, anything. And so he was accumulating his own pile of essays. And the student colleague said, "You guys ought to get together." And so we thought about: Huh, maybe we should make, like, this, like, student in-house journal. We'll, like, photocopy and staple it. But as we talked, we recognized that there's really a universal fear and vulnerability about our bodies and health care. I mean, you can get through life and never need a roofer, maybe, or an accountant, but you'll never escape the healthcare system. And I think the pandemic certainly pointed that out: that we're all vulnerable. And all the power we have in terms of money, you know, career skills, all that could just fade away when you're the person in the gown in the room. And I truly believe—I think this is not original—that the sort of plane of vulnerability, that creativity comes from, has a lot in common with the vulnerability that we feel about illness and our bodies and our minds. And so we decided to form a literary journal.

And so we took out a two-line call for submissions: poetry, fiction, nonfiction, and we were swamped. We got a thousand submissions so quickly, and recognized that we really had touched a nerve. And it was a few doctors and nurses, but mainly just ordinary people and writers. And so we started publishing twice a year, a literary magazine, based in Bellevue, and sort of logistically living within NYU's Division of Medical Humanities. And this was really fun. We did this for nineteen years. And then, in March 2020, when the pandemic hit, the hospital said, you know, we're getting rid of everything that's not operations. You gotta go. And I'm thinking, "Can we do this another time? ...Kind of busy in our day job..." But that, you know, the rule from on high... We had three months to get out. And, because things were so uncertain at the time, nobody wanted to take us on, to make a commitment.

So we decided to incorporate as a nonprofit. And so we broke out, and became a 501(c)3 independent nonprofit literary arts organization. Again, not something I'd any plans in my life to be doing. But now I run a nonprofit. And it's been amazing. I think you kind of don't know how much a shoe pinches till you take it off. But suddenly, we're completely free. There's no one who you can offend, except your readers. It's been two years now. We have a board, we have editors, and we've started fundraising. And it's really exciting to see the journal grow into a full arts organization. So we now have a full spectrum of events about the intersection of healthcare and the arts. And we can collaborate with dance organizations, film and art and music; really do whatever we want.

And stewarding other writers is so exciting. I mean, there's nothing more gratifying than, like, bringing a piece that's part of the way there, and getting it all the way over the finish line. I remember a piece we pulled out of the slush pile. This was a couple years ago. And it was a piece a young woman wrote about being on spring break in Fort Lauderdale, right? And this was at the disco, in the 70s. Bee Gees playing; lights flashing. She's trying to pick up this guy, they're dancing, and her artificial leg falls off on the dance floor. And, so she's on her hands and knees going on the bottom of the dance floor trying to find her leg. Bee Gees still going; her date hasn't noticed; he's dancing; the lights going. And she's going through the beer trying to find her leg. I was so taken by the story, but it was really not quite ready. And we started working together and I said "Listen, you know, I don't know you. But if you want to work on this, we got to really dig deep, if you want to do that." And we did maybe fifty rounds of revision, and it became this amazing story. She eventually made it into a full book, a memoir. And that's like...it's like seeing your kids grow up and be, you know, get a job and become successful. So, it's really fun. It's less risky, because it's not your work. So you don't feel your imposter syndrome. You don't feel like you're, you know, baring your soul. You're just helping someone else shine, which is just so much fun.

Emily Silverman
Physicians and nurses and other health care workers have been writing for a long time. It's a long tradition. You mentioned Chekov, and we have William Carlos Williams and a lot of other physician-writers that have come up in the past. It's a long tradition. I'm wondering, what are you excited to read these days?

Danielle Ofri
Well, it's funny because one of the exciting things about the literary journal is the slush pile. We get 4,000 submissions a year and you never know what you'll find. And it's amazing that fresh stuff does come up. And sometimes it's a poem. When someone just teases out one little strand of emotion and holds it up to the light and rotates it around to find some new angle. Sometimes it's fiction. You know, we call fiction the great lie that tells the truth, and sometimes fiction is the most powerful way to bring a nonfiction experience to light.

So, one of the things that's very hard as an editor is reading the very standard illness narrative. Here's what happened when I got sick with cancer, or when my mother had dementia. And there's a very big difference between a moving experience and a moving piece of writing. And, of course, that's where craft comes in. And of course, I always feel terrible rejecting someone's nonfiction piece about a very moving experience, but the writing isn't yet moving. So I'm really most intrigued when people find a different angle, when you can kind of shift the camera. You don't have to start at step one; you could start at step ten, and flash back and forward. If you ever look at the book Atonement. Take an Ian McEwan novel, you know. He'll spend 500 pages on a ten minute experience, and then a paragraph on a century, you know, and it feels completely normal because we experience life like that.

And so watching writers play with structure, but still stay within, kind of, classical story format. We're not much more experimental, I don't really like gimmicky writing. But I think even within the traditional story, or essay format, you can be very creative. So I'm excited when people use different ways of bringing the same thing to the table, because then it's not the same. You're right. The first day in anatomy lab, it is the same...but it's also, it's...it's not the same. When someone brings a different way of imagining something that feels fresh. And I'm always amazed at how there's always another way to do it.

Emily Silverman
To close out for our listeners, our audience of healthcare workers, what advice would you have for them? Maybe some of them have never written before and want to start, or maybe some of them are seasoned writers trying to get their work off the ground? What words of advice would you have for them, and trying to enrich their writing life?

Danielle Ofri
Well, I would certainly advise them to take a writing class or get a writing teacher. I can't stress how much craft plays a role. And I think we assume, "Oh, we just can write." But it's like any other skill. No ballet dancer gets up there without having taken ballet classes. And the same with most writers, other than, you know, the few. And even those writers, they had editors who helped them. So really do that, and use the same amount of rigor that you would for any other skill, like your medical career. You wouldn't just, you know, drop into a renal transplant without having all this training.

The second thing is to read widely. One wonderful course I took at the Gotham Writers' Workshop was "Fiction Reading for Writers". To take great novels, but look at them for craft that you can beg borrow and steal. There are great ways that people do it. I saw... reading The New Yorker, their fiction, reading their nonfiction, and they... "How do they do that; how do they get me to like, come right in? Where's that turn point?" And then borrow that. One of the critiques I find often in manuscripts that I read that are not at the top levels, that I feel the author's hand. I can see the thesaurus that they're paging through. I can see the way they structure it to make it look more artsy. The magic has to be invisible, but the work has to happen on the other side.

And I guess the third thing is just to pay really close attention all around you. Stories are in front of you, around you, both in your work, outside of work. Put your phone down, look around, see what's there and let your mind wander. You know, don't keep yourself plugged in 24/7. And, if you ever read biographies of creative people, they always talk about some point when they were kids in the summer, staring at the sky, or having just open-ended time, which is really hard to do in today's society. But I really recommend not filling in every free moment, and try to let your mind just go, and chill, and see where it wanders to. That's a great help.

Emily Silverman
I have been speaking to Danielle Ofri, MD, PhD, writer, editor of the Bellevue Literary Review, and all-around amazing dynamo, and now, friend. Thank you so much for coming on to The Nocturnists podcast to discuss your writing life.

Danielle Ofri
Well, thank you so much. It's been a pleasure.

 
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