Sometimes I envy the real journalists. I imagine them marching forthrightly into the hospital, the clinic, the doctor’s office, declaring themselves as members of the press. They are welcomed—or they are treated with suspicion. They are given the run of the place—or they are fenced in by restrictions. But their identity, loyalties and job responsibilities are clear.

My identity is not always clear, nor my loyalties, nor even my job. Well, let’s be honest. Most of the time my identity is perfectly clear—and it isn’t “journalist.” The “good stories” I see in the medical world—the crisis moments, the fascinating, terrifying times when disaster is just averted or the unforgettable crises when something goes irretrievably wrong—most of these I see because I am a doctor. When patients show fear or colleagues admit uncertainty, when families implode or doctors explode, I’m present not by virtue of a press credential but by right of medical license.

When I stumbled into medical journalism back in medical school, I made naive mistakes and upset people without meaning to: I literally told tales out of school, and many of my classmates felt that in criticizing my medical education, I was devaluing theirs. I had underestimated the power of the press—I hadn’t expected male medical students to pore over an article in a women’s magazine and trace the identity of my thinly veiled characters, taking offense at my humor. I’d worried about protecting the confidentiality of patients, but not of my peers.

I didn’t really know the rules of reportage. I had no training as a journalist, and I found myself working with an editor who wanted to blur boundaries: Why not conflate a couple of stories as if they’d happened one after another? It was only when this editor suggested gently that my story would be much stronger if a patient actually died that I pulled myself together and began to set some rules: This is fact. That is fiction.

Now, in magazine articles or essays, I sometimes change identifying details and include notes telling readers that names and identifiers have been changed. But the truth is that a lot of medicine is in identifying details, which means there are a lot of great stories I just can’t use. Occasionally, I do show a family something I’ve written, assuring them that if they don’t want it published, it won’t be. I once wrote an essay about taking care of an infant who had needed a liver transplant. I changed her name, but she was the only child at our health center with this genetic disease and the only one with transplant scars on her abdomen and someone else’s liver keeping her alive. Anyone at the health center could easily identify her. So I showed the essay to her mother; her only request was that I use her daughter’s name and give her a copy. She was proud of her daughter’s progress and her family’s heroism.

That particular situation worked out perfectly well, but it suggests all kinds of constraints on what stories I can tell, which details I can use, and what tone I can take. And I tell myself that real journalists are free of these conflicts and constraints but, in truth, I know that journalists do not necessarily breathe only the heady air of pure freedom and objectivity. Everyone brings to the job a complex mix of prejudice and experience and the desire to tell a good story, along with a set of standards. But if I can write only about heroic families and children who make good progress, and if I write about them knowing that I’m going to seek approval of parents, my writing is limited and changed, and not necessarily in a good professional direction.

But when people let you into their lives because you are a doctor, you can’t turn around and say, “Oh, by the way, I’m also a journalist. Can I use what you said or did or what just happened to you?” Neither can you just go ahead and write about them in ways that are at all recognizable. To do this would be to betray professional trust and violate some pretty old oaths and to act like a creep. So I save those “good stories” for fiction, in which I can change every identifying detail, conflate unrelated anecdotes, and even kill off a patient to make a stronger story.

When I pursue medical stories that don’t arise out of my personal experiences, I often get access easily—into an operating room to watch a procedure, for example. Or maybe a doctor will open up to me because we’ve made common cause around iniquities of HMO paperwork or the vicissitudes of residency. I know, however, that certain professional promises are understood—I’m not out to axe the profession. I don’t believe that the story will always be better if the patient dies, if the doctor is incompetent, if the hospital is understaffed, or if the drug is dangerous.

As a medical student, I wrote in the somewhat obnoxious tones of the wiseass novice who saw clearly the hypocrisies, pomposities and peculiarities of her elders. Back then, my stock in trade was my outraged sensitivity, my ability to look at the medical profession with an outsider’s eye. But that’s long gone; I am as hypocritical and pompous and peculiar as any other elder.

My loyalties are divided. Most of the time I’m a doctor. And practicing medicine takes up great quantities of mental space with information and anxieties and the trailing threads of so many different lives. Maybe I could argue that much of the time I’m also a writer—I write fiction, after all, and I write about knitting and food and rearing children—since writing also shapes my sensibilities and perceptions. But most of the time I can’t say that I’m a medical journalist or, at least, a reputable medical journalist, since that designation carries a specific conscious and conscientious identity. It’s an identity I inhabit at times, as an act of will, carefully hedged round with rules and regulations tailored to my peculiar circumstances.

And that isn’t all bad. One of the more useful aspects of training in psychiatry is that they teach you to identify your reactions to a patient and use those reactions diagnostically: Does talking to this person leave you feeling happy and energetic or dull and sad? Instead of ignoring your subjectivity, you identify it and incorporate it into your professional persona. My goal as a medical journalist is to recognize and incorporate the complexities of my professional subjectivity, to use my sense of identification, my accumulated experience, and my privileges of access, to tell slightly different stories, or to tell stories slightly differently.

Perri Klass, M.D., is assistant professor of pediatrics at Boston University School of Medicine and medical director of Reach Out and Read. Her articles have been published in The New York Times Magazine, Vogue and Esquire, and she writes regularly for Parenting and Knitter’s Magazine. Her most recent book is “Love and Modern Medicine” (Houghton Mifflin, 2001).

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