UTMJ • Volume 87, Number 2, March 2010
106
“As a writer, I have been a physician, and as a physician a
writer . . .”
– William Carlos Williams
A
s both an emergency physician and a writer of fiction,
I’m fascinated by the inherent irony of these two
activities. When writing, I use words on a page to cre-
ate lives that readers will hopefully care deeply about, as if they
were hated neighbours or close friends. Meanwhile, in the
Emergency Department I’m faced with real people experienc-
ing real suffering, and sometimes wonder why I don’t care
more.
I became hooked on emergency medicine during a fourth-
year elective at Bellevue Hospital in New York City. It wasn’t the
trauma, the hectic pace, or the blood. For a middle-class kid,
my imagination was captured by patients who on the surface
were so unlike myself. And yet, listening to their stories, I also
discovered how frightening and precariously thin the line was
that separated me from the working poor, the drug abusers
and alcoholics, the homeless. We are often a product of the
choices we’ve made (or our parents and grandparents). A
wrong turn here, a bit of bad luck there, and it’s my dirty feet
stinking up the area around my rusty stretcher as I snore away.
After fourteen years of emergency medicine practice, I firmly
believe that to be an effective and compassionate healer
requires attending to patients’ stories with fascination and
humility. Even if I’m treating two identical acute myocardial
infarctions, the patients experience their situation differently –
fear, denial, acceptance.
From the very beginning of medical school I knew I also
wanted to be a writer. This wasn’t a calculated decision. I
revered books as a child. It wasn’t only the words and the sto-
ries, but how the books looked and smelled, how they sat in my
hand. Writers were my superheroes. They saw the world as it
really was. They were honest and truthful, and because I was
learning that the world didn’t necessarily rotate on honesty
and truthfulness, writers were considered bold and brave. My
allowance was often spent at a bookstore called Oscar’s. Oscar
himself would wink over his bifocals as I made a direct line to
the paperback classics – Verne, Twain, Dickens. Sometimes
he’d disappear into the basement and return with dustier and
cheaper editions that he’d been saving for me. I was shy and
chubby, and later precociously pimpled. My love of books and
literature provided for a secret kinship with this kind, grey-
haired man. At his bookstore my insecurities fell away. I felt
important.
I’d spend hours alone in my bedroom, late into the night,
breathing in the musty smell as I turned the pages. I suffered
from childhood asthma. The wheezing was never serious, and
my parents, children of Eastern Europeans, believed a touch
of brandy or scotch would help me. From my earliest child-
hood, literature became an exhilarating mixture of danger
and intoxication.
My professional career has become a protracted, unsuccess-
ful negotiation between medicine and writing. Each has suf-
fered because of the other. I can’t fit them both, to their fullest
capabilities, into a normal week, or even an abnormal week.
I write slowly and rewrite endlessly. I wish I could write fast,
but I’m a tedious sentence builder. Only by writing can I dis-
cover what I’m writing about. The story emerges out of itself.
I question facets of each layer as it is put down, and in such a
stepwise manner construct a story. To improve and grow as a
writer, I feel the need to devote significant hours. The process
itself is an exploration into unmapped personal territory. I
don’t know what I’ll find, what I’m capable of, unless I con-
stantly challenge myself. Four years in medical school earned
me the right to be called “Doctor.” After a decade and a half
of hard work, I’m still skittish about referring to myself as a
writer.
Much of my precious writing time is compromised by guilt
and doubt. I become defensive, slouch-shouldered, and
racked with shame, especially when writing isn’t going well.
What am I doing wasting hours, or days, being diligently
unproductive? What, exactly, is being accomplished?
Shouldn’t I be attending to one of the many academic articles
begging for my attention? Why am I not in the ED, caring for
suffering patients, being the doctor I was trained to be, mak-
ing some badly needed cash in the process? During particu-
larly bleak periods, my brain whites out, I can’t muster an orig-
inal thought, and the voices turn vicious. What have you writ-
ten? This isn’t paying the bills. Stop being selfish and get out-
side and play with your son.
Without writing, I might be a more accomplished physician,
perhaps closer to the nosebleed heights on the academic lad-
der. Not only is my curriculum vitae lighter, but by cutting my
clinical hours to accommodate writing, my family isn’t in the
financial position it might have been otherwise. I’ve tried to
quit writing many times, but always found myself scribbling,
taking notes, trying to convince myself that I wasn’t writing.
Between my third and fourth year of medical school, I took
a year’s leave of absence to devote solely to writing. I needed
to discover whether I had talent, or at least enough potential
Guilt and Time: My Enemies
Jay Baruch, MD, Brown Medical School
This work was previously published in the literary journal ARS MEDICA
Poetry and Short Stories
UTMJ • Volume 87, Number 2, March 2010
107
Poetry and Short Stories
to hope and dream. During that year I studied writing infor-
mally, began what turned out to be a truly awful novel, and sup-
ported myself as an editorial assistant at a medical publishing
house (how else would a medical student with a BA in English
earn a living?). There, I became acquainted with artists who
worked full-time to support themselves so they could then go
home and do their “real work.” They were working eighty to
ninety hours a week without any promise of critical or financial
success. During my year “off” from medical school, I learned
about self-discipline and the necessity of art as a life-giving
source. Medicine should be approached with similar intensity.
Medicine might be considered an art, but I wasn’t convinced
that it was practised by artists. Most importantly, having
stepped out of the rutted rail that is medical education, my one
year away gave me the courage to approach my medical career
in non-linear terms.
I took another break from medicine a few years after finish-
ing residency. My rewarding medical career allowed less and
less time for writing. Without writing, the practice of medicine
wasn’t as satisfying. It felt like an awful itch that I couldn’t
reach around to scratch. I became restless, impatient, and in
the spirit of honesty, a tad bitter.
Some colleagues made me feel that I was committing pro-
fessional suicide.
What’s more, I hadn’t published a single story. The walls of
my apartment in Brooklyn were papered with rejection slips.
Some rejections came so quickly I suspected the U.S. Postal
Service of vetting my submissions.
In the medical profession, clinical decisions are based on
evidence from statistically sound studies. Applicants to medical
schools are admitted or rejected on the basis of quantitative
measures, though many might seem irrelevant to the skills
expected of excellent doctors. To many people, my decision
smacked of irresponsibility, immaturity, with a whiff of mental
illness. And maybe they were right. It wasn’t rational, support-
ed by sound data. It was an urge. How do you justify an urge in
a field where evidence-based medicine is de rigueur, especially
when I had my own doubts?
I soon distanced myself from many friends and medical col-
leagues. Fortunately, some friends outside of medicine under-
stood completely and reminded me to keep my focus. I must
admit that writing fiction, from within medicine, feels like an
irrational act in a hyper-rational world.
At the same time, during those periods devoted solely to
writing, I discovered that I missed the relevance of medicine,
of engaging with people in immediate and profound ways. My
writing became “writerly,” self-conscious, laced with unde-
served importance. Blessed with all twenty-four hours in the
day to spend, I misused time, became less efficient and effec-
tive. Urgency vanished, not just with time, but with emotion
and imagination. The tension and pressure that can grate on
emergency physicians can nourish a writer. I don’t mean steal-
ing realistic details from this or that patient, trading on the
inherent promise of confidentiality in the Hippocratic Oath,
but the raw stuff that gets kicked up from being a close witness
to the cruelty and beauty of lived lives.
For example, the failed resuscitation of a young man who
died from a blow to the head didn’t bother me as much as
speaking with a family member later and noticing that she was
holding a plastic bag with his bloody shirt and jeans.
Imagining my patient getting dressed, rather than dead on the
s
tretcher, brought tears to my eyes. That evening, I didn’t write
about the nature of the accident, the failed resuscitation, or
the clothes. I wrote about grief as a shell game. Do I really
b
elieve that doctors become hardened over time? Or does the
trigger point for deep sadness keep moving, beyond our con-
trol? And when caught unaware, how do we respond to the
shock of it?
I didn’t aspire to write about medical experiences, and in
the beginning I did my best to avoid any topic that was med-
ical. Part of that reasoning included some resentment, a half-
assed temper tantrum. “I’m going to show you, medicine” – as
I held my breath. Even if I made a conscious decision to block
out that turf for creative use, I couldn’t deny that medicine has
shaped my identity. If I hadn’t become a doctor, I’d have a dif-
ferent set of life experiences. I’d be a different person and a
different writer. Eventually, medical themes, patients, and doc-
tors started appearing in my work.
Quitting medicine isn’t a viable option, nor is taking a doc-
tor job only to pay the bills. I fear becoming one of those mar-
ginalized, out-of-touch doctors; a dot-matrix printer in a white
coat. Since I don’t see myself becoming a “fast” writer, time will
always be my nemesis.
As a student of literature, I’m interested in characters, the
context in which they live out their lives, and the motivations
that drive them. Writers often write characters into corners;
then they must write themselves out. The skilful writer often
discovers something about the story, the characters, and him-
self (or herself) from such a dilemma.
As an emergency physician, I’ve learned that patients are
more than their chief complaint. They have stories to tell.
Their lives have been altered. They may have become unrec-
ognizable to themselves, and they’ve come to the ED because
they lack the specialized knowledge to understand what went
wrong and how to regain their bearings. Illness isn’t the dis-
ease or injury, but the experience of being diseased or injured.
I’ve used my narrative skills to better understand their illness
in the context of their lives, but many times this isn’t possible.
The act of working in an ED can be mentally and physically
demanding. There is constant pressure, perpetual sensory
overload, and the fear that a patient in the waiting room might
have a life-threatening problem. Well-trained, talented emer-
gency physicians make it look easy. But anyone who has tried
to do a pirouette, and looked ridiculous in the process, knows
the sweat and work required to make that spin look effortless.
Circumstances seldom permit narrative penetration, maybe
a scraping of the topsoil. I slide from one chief complaint to
the next, from the “chest pain” to the “headache” to the
G
uilt and Time: My Enemies
UTMJ • Volume 87, Number 2, March 2010
108
Poetry and Short Stories
“bump on my bum.” Sometimes it feels as if I’m riding on a
cushion of air, staying long enough with each patient to estab-
lish a diagnosis or decide on a workup – blood work, radiolog-
ical tests, or simply words of reassurance. I have proximity with
each patient, but not intimacy.
I enjoy writing slowly; it allows me time to know my charac-
ters. Part of the fun and challenge of writing fiction is investing
a story with a particular voice, tone, point of view that is unique
and personal. For me, the hardest part of writing is tapping
into the emotional heart of the story. When I have that, I have
the thread that I can pull through the narrative, and hopeful-
ly, pull the reader along with it. I want to take readers with me
on a trip and return them home at the end. But I want the story
to resonate with them even after the experience of reading it.
My favourite emergency medicine story is Ernest
Hemingway’s “Indian Camp.” The narrator tags along with his
physician father who is called to treat an Indian woman expe-
riencing a difficult labour. Her screams send the village men
off to the outskirts to smoke. An axe injury to the foot forces
the woman’s husband to listen to her agony from the bunk
a
bove. The baby is coming out breach. The boy asks his father
about the screaming, who replies that he doesn’t hear the
screams, the screams aren’t important. Eventually the physi-
cian uses a hunting knife and fishing line to do an emergency
C-section. He’s proud of himself. Until he discovers that the
woman’s husband, unable to bear his wife’s suffering any
longer, had slit his own throat from ear to ear.
I couldn’t be an emergency physician without writing. When
I’m not writing, I become an inadequate version of myself. But
I couldn’t be a writer without emergency medicine either. I
need to get out of myself and take care of patients. Difficulty
with a story, or a paragraph, seems so insignificant when com-
pared with the broken lives of many of my patients. I often feel
guilty that through the disrepair in their lives I often find bal-
ance in mine.
Guilt and Time: My Enemies
Jay Baruch practises emergency medicine and teaches medical ethics at Brown Medical School. His short story collection, Fourteen Stories: Doctors,
Patients and Other Strangers, was published by Kent State University Press.
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