An excerpt from Medicine on Fire: A Narrative Travelogue.

I regret not keeping a diary or journal to write about patient encounters and interactions with peers, residents and attendings, not to mention the sundry characters connected to the academic health center where I trained and practiced. Had I done that, I would have had a lot more material to write about, and my depictions of events probably would have been more accurate.

With a world of rich clinical material in front of you, regardless where you practice, you will regret relying solely on your memory to write about patients and players you will meet along the way. The vignettes will seem fresher and will be more reliable when there is a permanent record of them, and your stories will be less affected by cognitive distortion wrought by time.

But even without the benefit of prompts or a written record, my career memories are very good, and my reconstruction of events is probably not affected by the vagaries of memory that can plague some writers.

I find myself gravitating toward short personal essays incorporating events that have special meaning to me and, I hope, to readers. I want these essays to have a moral or educational component to them, or at least a strong take-home message. My narratives could be considered memoir in that they often integrate material from an important time in my life. As I am typing this essay, for example, a memory from medical school erupts. Here is how the scene unfolds.

I am a fourth-year medical student on a family medicine elective in a community hospital located in a predominantly Black neighborhood. I am seriously dating a girl – she becomes my wife – and I am beginning to wear men’s cologne. I am feeling good about life, making my mark (so I think), a survivor of my junior year of med school and cruising midway through my final year. I want people to notice me. I want to announce myself. I want to make a statement that I have “arrived.” I want people to know I will soon be a doctor. I want to wear cologne.

It is lunchtime in the clinic. My attending has disappeared. I am finishing my charting. The only other person is an elderly Black woman from housekeeping doing some light dusting.

Earlier in the morning, I open the exam room door to examine a young Black male. I do not remember his chief complaint, but I do remember that when I take out my pen flashlight to see if his pupils are equal and reactive, he grabs the pen and flips it around, to shine a light on me. He also reaches for my stethoscope, which is dangling around my neck. He wants to examine me.

His affect is weird, and he brushes aside my questions. He isn’t acting right. Putting it all together, I suspect he is in the midst of a psychotic episode. I excuse myself and inform my attending what is happening. He trusts my judgment – after all, I have completed two psych rotations, and my attending knows that I am going into psychiatry. The young man is sent to the emergency department for further evaluation.

Why do I tell this story? Why does the memory suddenly occur in the fourth paragraph? I have told many stories about my medical training, but never this one. Perhaps the most important question is: is the story accurate?

In Patricia Hampl’s book I Could Tell You Stories, one of her vignettes (“Memory and Imagination”) describes a scene from early childhood in which her father drops her off at her first piano lesson. After providing intricate details of the scene, Hampl reflects, “No memoirist writes for long without experiencing an unsettling disbelief about the reliability of memory, a hunch that memory is not, after all, just memory.” Upon reexamining her own account of the piano lesson, Hampl realizes that, although she tried to give a truthful version of the lesson, not all aspects of her story were accurate or even true. She would have written it differently if she had to do it over.

In narrative medicine, as with life, the truth of the events lies waiting in the details. I wonder how accurate are the details of my story, indeed all my stories? Was the stethoscope loose around my neck, or did I pull it from the pocket of my short white coat? Was it only the patients’ affect that was bizarre, or did I do a full mental status examination and there were other abnormalities I have forgotten? Did my attending really trust my judgment (I would like to believe so), or did he do a cursory evaluation of the patient himself? I simply do not recall. And why, when I have retold some of my stories, have I repeated or written them slightly differently than before? Why does it matter?

The answer is: the truth.

There are very few rules when it comes to writing medical narratives. But one rule that cannot be broken is that narrative medicine writing must be truthful. It may not always be accurate, but any inaccuracies cannot alter the truth. Lee Gutkind, author of Keep it Real: Everything You Need to Know About Researching and Writing Creative Nonfiction, stands firm on this point: “The writer cannot embellish, condense, or otherwise manipulate characters or events in order to make a more compelling story…The writer of creative nonfiction is bound, by an implicit and sometimes explicit contract with the reader, to make sure that the architecture of his story is based on authentic and reasonably verifiable experience.”

Hampl writes, “I did not choose to remember the piano lesson. The experience was simply there.” The same is true of my encounter with the patient: the memory merely trapsed forward, colored by my residual impression of it. But that’s the risk of writing personal narratives without the benefit of transcription or source material: they are prone to inaccuracies. And that’s why I wish I had kept a journal throughout my career – to rely less on my memory and more on a solid footing of events as they actually occurred.

According to Hampl, minor inventions to preserve the story do not necessarily make one a liar; rather, the need to reconstruct pieces of history forces us to admit that “memory is not a warehouse of finished stories, not a gallery of framed pictures.”

However, there is one thing I’ll say that I will always remember about that patient encounter, one undeniable, unshakable truth. The cleaning woman caught my gaze as I moved close to her. She smiled and said, “There’s nothing I like better than a sweet-smelling man.”

Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. He is the author of Every Story Counts: Exploring Contemporary Practice Through Narrative Medicine and Medicine on Fire: A Narrative Travelogue.