Ruth Levy Guyer: I'd like to ask you several things––about your work as a physician, about your writing life, and your life in public service––particularly the work you do for the literacy program Reach Out and Read. I also want to ask you about writing in the context of your family––You wrote a book with your mother and another book to your son. I am happy to start this conversation wherever you want. Or perhaps I should start by asking whether you have ever stepped back and said,“I am a juggler.”

Perri Klass: I don't really think of myself as a juggler, partly because it requires real skill and grace, and partly because I guess as a juggler, you would be setting yourself challenges for the sake of challenges––can I handle four balls, can I handle five, can I handle knives...I think of myself as someone with a relatively short attention span, who likes to do several things at once, and also, in the context of medicine as a generalist––someone who is content to know a little bit about many things, always acknowledging that for any given medical question, there will be someone who knows a great deal more.

RG: But you clearly know so much about so many topics...and that shows up in your writing and I'm sure in your practice (although I am not one of your patients!). Your talk at Haverford (April 7) is titled "Doctors as Writers, Doctors as Readers, Doctors as Characters." For our far-flung alums, can you say a bit about this talk and about the role that narrative medicine plays in enriching doctors' and patients' understanding of their own experiences and in fostering good relations between them.

PK: I didn't set out to think about the connections between writing and medicine, but since they have been two of the major intellectual engagements of my own adult life, I have naturally given a fair amount of thought to the overlaps and the contrasts. So that's part of what I want to talk about--how medical education shapes you as a story-teller and a writer––and it really does!––and how it also changes the way you hear stories and the way you read. As far as narrative medicine, which can mean different things in different contexts, I think that there is a great deal to be gained by increased understanding of the ways in which patients come to you with stories of what is happening to them––as they understand it––and the ways you create a medical narrative––as you understand it––and the ways that you can work together to arrive at narrative and medical understanding.

RG: I've always thought that the medical chart should include not just the doctor's assessment of the patient's condition but also the patient's assessment as well as assessments by the nurses, family members and others. In other words, the "story on the chart" should be several stories. And only with all of the stories there can one get a real grasp of what's going on. One of the people who talks and writes about narrative medicine says it is the capacity to "recognize, absorb, metabolize, and interpret" stories of illness and be moved by them. Her definition is actually quite biologically based but also includes the emotional component of the reaction. When you are writing, do any of these things go into your thinking or are they simply "what happens" as a result of your work?

PK: All of those things can contribute to writing about medicine--and to the personal reactions you are writing about. And it's always an interesting question when you are looking at medical narratives––and medical charts––how to figure out when is the time to include more and more information and more and more perspectives––and when is the time to focus down, maybe to come back to the patient and what the patient knows and says and feels, leaving aside all the interpretations that have been offered by family members and observers...and in fact, that's a process we also all go through when we write: when to expand, when to trim down...

RG: What motivates you to take a medical story and write it as fiction instead of in a direct way as an essay? For example, how did The Mystery of Breathing end up as a novel instead of a "case history?"

PK: Well, that isn't always easy to answer––some of these processes are pretty mysterious. But The Mystery of Breathing is a good example, because I had it both ways––I did write about the experience which touched off that novel first of all in memoir form, in an essay that was originally published in the NY Times Book Review, and is in my book, Baby Doctor. When I was an intern, I had a crazy person after me, who sent anonymous letters about me, accusing me of all kinds of turpitude (I had plagiarized my articles, I had faked my way through medical school and was notorious for ruining other people's experiments, I had altered my resume, I was a terrible doctor and a danger to patients), to many people in the publishing world and in the medical world. It was quite elaborate, and went on for a long time––lots of letters, including letters with what were supposed to be the "original" versions of the articles I had plagiarized (though never with a date or a source so they could be traced).

RG: Wow. Where's that person now? I hope s/he is locked up somewhere. I've never written fiction (at least I don't think I have!) so I'm curious whether you feel some sort of liberation when you write fiction that you don't feel when you write nonfiction. Obviously the characters can become whoever you want them to in fiction (although, of course, they have to be true to life) but clearly the "facts" of the medicine must be wholly accurate in both forms.

PK: Oh, they never caught the person. But the crazy stuff stopped, and it stopped after I published that initial essay in the Times about the weird experience of being accused of plagiarism––so my own narrative, that I constructed, was that my enemy was frustrated and infuriated to see me telling the story...but anyway, when I made it into a novel, The Mystery of Breathing, it was in some ways liberating, though oddly, what ended up happening was that I found myself at times in sympathy with my villain, and at times out of sympathy with my protagonist. That is, I think that when I initially sat down to make it into a novel, I meant it as a story of the terrible thing that happens to this heroic and blameless doctor, who lives only to help children...but it was a much more interesting story if she wasn't so saintly, if she was someone who might engender a certain amount of resentment, a certain amount of eagerness to see her get what she "deserved"...

RG: I read that book a number of years ago and I have to say that you succeeded in making at least one reader (me!) less sympathetic with the doctor than she would have expected. As for saintly doctors, do you find that contemporary medicine is making saintliness harder than it should be? So much of medicine today is affected by the marketplace. Yet what most patients want and what many doctors yearn for is a relationship. Patients want to know that the doctor cares not just for but about them. Do you think there is hope that medicine will return to a more interpersonal enterprise? How would that happen?

PK: I think there will have to be real consumer pressure––which so far there has not been––to make some market-driven customer-driven changes in the ways that doctors get reimbursed. Nobody reimburses us for time spent talking to patients or listening to patients or calling people up to go over test results––and it's not that doctors don't want to do this, it's that all the pressures go in the other direction. We get yelled at for not being "productive" when "productivity" means seeing patients as fast as you can, which means no time for relationships. That's what's rewarded. I think there ARE consumer-driven changes in medicine––look at some of the changes in obstetrics and gynecology. I thought that when the news stories hit about "concierge medicine," there might be a consumer response to say, hey, why can't we have that kind of care, we pay all this money––but instead, you hear doctors griping about the system, and patients griping about care, but they don't seem to connect.

RG: We've been talking about concierge medicine in my class this semester. I think it's a new name for the old form of medicine, which did involve a relationship, and of course the concierge practices add onto that the requirement of big bucks! It definitely subverts the concept of justice in the distribution of medical resources. You say that you don't get compensated for developing relationships, yet the work you and other pediatricians do with Reach Out and Read seems to be to look at the child (and parents) and think about the whole person and what it means to be literate and to love reading and learning. What is the process that you use to engage a reluctant child or parent in this when reading is not something on the family's radar screen?

PK: Well, first I would just like to say that most of us who go into medicine––certainly, who go into primary care––do it for the pleasure of relationships and connections, and we tend to resent bitterly all the pressures that take that away. And of course, we look for ways to build those connections, and to do it efficiently in a busy clinic day. Reach Out and Read is about looking at the whole child, and understanding that body and mind grow together, and that part of helping parents rear a healthy happy child is about language and learning and school readiness--and that many of the terrible discrepancies in our society go back to early childhood opportunities and development. By bringing up books and reading in the context of health care––alongside other issues which parents know are very important, like nutrition, like immunizations and disease prevention, you can make this suggestion earlier than might otherwise have been the case––and of course, we give a book!

RG: I wanted to ask you about your memoir with your mother, your letters to your son, and also I wanted to see what else you thought I should have asked you. But I also promised to "release" you to your patients and students, so let me just ask if you'd like to say anything else.

PK: I guess I would like to say that the combination of writing and medicine has meant, for me at least, a lot of wonderful and complicated and unpredictable opportunities to look at stories and turn them inside out and approach them in different ways and use them to understand the world, to understand myself, sometimes even to treat patients...

RG: Perri. Thank you SO much for this conversation, for all of your wonderful writing, and for the wonderful example you set for people through your writing and your work.

PK: Thank you for this great conversation––and for the opportunity to come talk with students!