Poetic License

What a Dying Woman Saw

She was clear-eyed and dying
when I knew her, soft breaths feathering
from her chest like distant smoke,
face bleached white as burnt out sky.
Propped in a chair, oxygen prongs pulled
to her neck, she commanded like a queen
for morphine, lobster, a second phone,
her mind still ruling an 80 pound body.
She allowed me to sit at the foot
of her bed like a commoner, let me ask
the details of lineage and disease,
revealed the smothering-fear in her dream.
And on the last morning, when I'd suctioned
dark secretions, she wheezed,
You're a poet, aren't you?
That was before I thought to write
more than a patient's history in a chart,
before I knew what lets us breathe easier,
before their stories engraved me like stone.

Some History

She was nicknamed "Queen Elizabeth" by caregivers who could not tolerate her narcissism, but early in my career I found her more fascinating than hateful, more frightened than imperious. I knew her in the intense intimacy that develops during care for the dying, when ordinary taboos are lifted and closeness grows from conversation, bathing, suctioning, hand-holding and pillow-fluffing. Back then, I was naive and inexperienced enough to think doctors act and patients passively receive.

I even believed my relationship with Elizabeth was like a one-way mirror only I could see through. What I didn't realize was that I, too, was being observed, that she was making judgments -- noticing my strengths, weaknesses and idiosyncrasies.

Elizabeth ran a company that required her to make savvy assessments of her clients. The moment she made her comment, "You're a poet, aren't you?" was one of those dizzying, disorienting instants when you suddenly see yourself in a different way. It was the morning she died. There was no time for discussion, no time to ask her what she meant, but what she said stayed with me. With five words, she changed my view of myself from young doctor to someone who might possess the qualities of a poet, an aspect of myself I might have noticed in the background but had never tried to define or express.

Years later, when I began to write, I thought of Elizabeth regularly. Was her impression correct? Did I have the attributes needed to be a poet (whatever those might be)? If I was a poet, could I be confident in my perceptions? Could I use patients' stories (what the poet Cortney Davis has called "details of flesh") to say something meaningful about issues I felt compelled to address? I realized I had internalized Elizabeth's voice and my patients' voices the way they internalized mine; voices of encouragement, permission, affirmation, voices that speak with the truth and accuracy of a death-bed confession.

Becoming a Poet

I'm not sure when a person becomes a "doctor" or a "poet." Yet both have become parts of who I am and how I create, filtering the world and providing an opportunity to fashion meaning from experience. Right now, my identity is still shaky; if you met me at a party, I would be reluctant to reveal I write poetry. But perhaps you would notice something in my style that would tip you off, something I still don't see. Maybe it would be the lines in my forehead. Maybe it would be the tone of my voice. Maybe you would notice the way my patients' stories have engraved me like stone.

Throughout my career, I have written professional papers, with areas of interest that have included sleep disorders, consultation-liaison psychiatry, psychotherapy, family therapy, and an occasional "personal" piece, one of which was published in "A Piece of My Mind" in JAMA. When my daughter was young, I playfully wrote a number of children's stories for our mutual entertainment. When I told a writer friend about the stories, she invited me to join her writer's group. The group included a number of excellent poets who were also skilled teachers. I hadn't previously recognized the close connection between the condensed style of children's writing and poetry, but the similarities soon became apparent. Since the poets in the group were producing such strong work, I began to model them by writing my own first, very tentative poems.

Participating in a group provides a powerful context for learning, both by allowing one to see the shortcomings in one's own writing and also by recognizing the difficulties in the work of others (always easier to perceive than one's own!). Like most people, I did not read poetry on a regular basis, but other group members shared poems by their favorites (Billy Collins, Stephen Dunn, Dorianne Laux, Sharon Olds and Mary Oliver to name a few), and I was impressed by the strength and accessibility of the poetry.

After a year or two in the writer's group, I had produced a body of work, some of it awful, some of it mediocre, and an occasional piece the group and I felt might be good enough to submit for publication. My first acceptance came from JAMA, and there is nothing like a little publishing success to intensify a poet's enthusiasm. At the same time, my hospital (just like every other hospital) began the shift to a bottom-line focus; teaching opportunities disappeared, and the chores increased.

I could not imagine seeing one more patient in the ICU or shifting to a career that did not include psychotherapy as a major component of my work. After a period of intense deliberation, I decided to leave the department that had been my professional home and family to begin a diversified private practice (an office practice focused on psychotherapy or psychotherapy plus medication, school consultation, nursing home consultation) and to devote a full day each week to poetry.

Taking myself seriously as a poet and writing on a regular basis created a stimulating level of anxiety and raised many questions: Did I have anything to say? What did I actually know? Who besides my wife and friends and family might be interested in what I wrote? Could I master the mysterious craft of poetry?

My solution was to pursue poetry with intense study, practice and passion -- an approach similar to the way we all learn to become doctors. I continued to be a member of the writer's group and also attended a summer workshop during a vacation on Monhegan Island, Maine. The workshop helped answer some of my most important questions about the technical aspects of craft (form, stanzas, line breaks -- all the arcane matters that are so crucial). I also grasped the importance of the old advice to writers: Write what you know about. As a consultation-liaison psychiatrist who participated in almost every area of medical practice, I was confident I could write about the world of doctors and patients.

Every physician learns to be a writer, even if the genre is the H&P and progress note. Our interactions with patients tend to be relatively brief, focused, emotionally charged and multilayered. Our best notes can capture these intense moments as effectively as poems. Sometimes our work with patients over a long period of time might seem more like a short story or novel, but our day-to-day work has the brief flash of power often found in poems. In addition, the clinical orientation of physicians (and especially psychiatrists) is similar to the way Randall Jarrell suggested we orient ourselves to a poem: "You need to read good poetry with an attitude that is a mixture of sharp intelligence and of willing emotional empathy, at once penetrating and generous." In the psychotherapeutic relationship, the skills of a poet are most apparent, since psychotherapy focuses on creating new ways of seeing the world and creating new meanings that often involve helping people change the metaphors that guide their lives. I like to think about psychotherapy and poetry with a line by the German poet Rainer Maria Rilke: "Poetry is the past breaking out in our hearts."

Every doctor carries a black bag filled with stories. Given the opportunity, many physicians will tell these stories with emotional power, dignity and creativity. For example, a number of medical journals now include poetry or columns for personal reflection. Now that people know I write poetry, friends and colleagues will hear a story or witness an event and make a point to tell me, "That would make a great poem." I usually agree. But the key issue for physicians who want to write poetry is the simple decision to actually sit down and write. This takes discipline and perseverance (qualities most doctors possess in abundance), and there is no need for more elaborate equipment than a pen, paper and, perhaps, a computer. While I keep a page of ideas for poems, I rarely write from a moment of inspiration. Most poems develop over the course of 10 to 25 revisions from a long, ragged first draft to the highly condensed final poem. It is in the revision process that the draft is transformed from something almost entirely personal to a creative product that might be meaningful to someone other than the poet.

People sometimes wonder if the events in my poems "really happened." My best response is to quote a few other poets. Emily Dickinson wrote, "When I state myself, as the Representative of the Verse it does not mean me but a supposed person." In the view of James Dickey, "The poet is not trying to tell the truth. He's trying to make it." And Denise Levertov believed, "A poet is someone with a genius for lying and an adoration for the truth."

Writing with other people is an extremely powerful way to learn, and I would urge aspiring poets to find a writer's group or a mentor. Hopefully, you will learn to trust your own voice and develop the discipline required for all good writing.

Remember that poetry is an art form that will not help you earn a living. You will not be able to give up your day job in psychiatry! As John Keats said, "There is no greater Sin after the seven deadly than to flatter oneself into an idea of being a great poet." But if you write poetry regularly, you will enjoy the deep pleasures of poetry. William Carlos Williams, a physician, quipped, "If it ain't a pleasure, it ain't a poem." And if you are concerned about how to integrate poetry and psychiatry, consider an 1888 letter from another physician, Anton Chekhov, to his publisher: "I have two professions and not one. Medicine is my lawful wife and literature is my mistress. When I get tired of one, I spend the night with the other. Though it is irregular, it is less boring this way, and besides, neither of them loses anything through my infidelity."

© CME LLC
6/01

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