Medical Narratives

I arrived in the hospital's neo-natal intensive care unit that night just after 7 p.m. I found a chair where I could see the baby. The parents arrived. The mother began crying. I opened my notebook and discreetly jotted down some notes.

And then I waited for this child - a newborn who never really had a chance - to die.

During my long career in the newspaper business, I'd seen dead bodies from my time on the police beat. Car wrecks, homicides and fires. But I'd never witnessed death, never been there to watch that moment when there's life and then... nothing.

Tonight, I was venturing into new territory.

That's what happens when a reporter steps into the medical world to write narrative stories. It's one thing to report about the latest medical breakthrough, profile the new hospital wing or find an authority to discuss the disease of the week.

Stories about the men and women who work in the medical world, and those who use it, are something else altogether. You, the writer, bring the reader in close, letting them experience the emotion and drama, and the heartbreaks and the miracles. From a pure story-telling standpoint, nothing comes close to the potential of the medical world. It's a remarkable place, one that makes readers think and feel. Within this world they see the range of humanity - hope and fear, science and faith, brilliance and doubt.

Pulling off a narrative story in the medical world requires a different kind of story thinking and reporting, one that many reporters are unaware of.

Start with trying to understand the world

Reporters who enter this world without realizing that it has its own rules, mores and values do so at their own peril. Approach this world as if you're covering city hall or the school beat, and you'll never get to the heart of the story and the people.

The men and women who work in this world are wired differently from the rest of us, certainly differently from writers. They don't spend a lot of time thinking philosophically. Thank God they're that way. That allows them to do what they must do, see the things that make the rest of us turn away.

That means, though, that tapping into their feelings and motivations is difficult. Those are parts of themselves they keep under lock and key. It's going to be your job to open the vault. Some of the most difficult interviews of my career involved doctors. It wasn't that they were evasive, but that I was asking them to plumb a part of themselves typically off limits.

So how do you do it?

First, narrative reporting in the medical field takes time, something the professionals who inhabit this world have little to spare. That means you're going to have to work around their schedules, getting a few minutes here and there. I interviewed a neurosurgeon many times at 7 p.m. getting a cup of coffee with her in the hospital cafeteria, begging for some of her time, before she headed home. I had a better chance of winning the lottery than in carving 45 minutes out of her daily schedule for a casual, sit-down interview.

All this means that you better know why you're there. What's this story about? What emotional center are you looking for? Don't answer that you want to "do something" about cancer or heart surgery or the burn unit. The word "something" means you haven't thought out the story. You're going to be dealing with smart, sometimes impatient people who want to get to the point. Time is precious. You better be able to come up with something better than "Well, it sounds like an interesting story."

So answer those questions before you enter the narrative world. You won't have all the answers. That's what reporting is all about. But you will have a plan. And one of the best ways to start planning is to focus early on the theme.

What is this story really about? Not what it's about on the surface. Not what's going to appear on the editor's budget. But what's the emotional meaning of the story? Figuring that out - and it's something you have to ponder alone - will be your road map for the rest of the trip. That theme will help you report more efficiently. If it builds on the theme, then it goes in your notebook.

Take a look at Part 3 of my series on Sam Lightner, a boy with a severely deformed face. Part 3 deals with the surgery and the two primary doctors who operated on Sam. Read the story, see what details I include about Dr. John Mulliken, and how they relate to the theme that drives Part 3 - doctors taking a risk. The details - photographs of his pets and the fact he's never been married and has no kids - reveal Mulliken's character and make him come alive.

The medical world is full of obstacles. HIPAA regulations, patient waivers, getting the doctors and nurses and hospital administration to buy off on letting you into their world will drive you nuts. Getting around those barriers is going to take some work. Don't give up.

When I proposed spending months on the neo-natal unit, I enlisted the help of a unit supervisor. She set up a meeting with hospital administrators, where I pitched the idea. Once they gave the OK, I went to each shift change for a week to introduce myself to the nurses, explain my idea and tell them why I wanted to do it. I took questions, explained how I worked and how they could help me. I gave each nurse a choice of opting out. I wanted the nurses to feel at ease with me in the unit.

The most essential ingredients

At all times, make this your mantra: Respect. And I mean for everyone: receptionist, cleaning crew, nurses, technicians, doctors, patients and family members. Remember that you are an intrusion. There is much at stake in the medical world. Your story isn't a priority.

Admit your ignorance. You didn't go to medical or nursing school. Ask the "dumb" question, and make sure you understand the answer, so you can explain it to your readers in a way they'll get it.

Be prepared to be changed. You'll soon understand why a doctor doesn't wear her heart on her sleeve. The night I watched that baby die, I was a parent, father and reporter. At times, I was deeply moved as I watched the parents grieve as life ebbed away. And yet I also realized that what I was witnessing would make a "great" scene in my story.

I stayed up late when I got home. Just thinking. Delve deeply into this world, and you'll find yourself doing the same thing.

And finally - above all - remember this: Medical narratives aren't about medicine and technology. They're about people. Write about the people. Always. Once you understand that foundation of storytelling, you'll be able to start applying story craft. The craft allows you to take the information -- the emotion and vision -- and express it so your audience can grasp the story.

Let's break down the elements that must go into a story.

CHARACTER: In dramatic narratives, the character is the central organizing point of the story. Something happens to the character and everything emerges from action.

But don't limit yourself to thinking that a character must be a living, breathing person. A character can be a disease. Or a place. When I wrote my story, "Level 3: Life on the Neo-natal Unit," I quickly conceived that the unit itself was a character, and that everyone else that walked in those doors-- patients, doctors, nurses, parents and babies - was a minor character.

In the "Boy in the Mask" series, the lead character is Sam. But study each day of the four-part series, and you'll see that near the end of each part, I introduce a new character who hands the story off to another character.

Tim Campbell sees Sam, intervenes, and enlists Jennifer Marler in Boston. She pulls in John Mulliken, who leads the operation. And the story ends with Sam signing up for school.

Some short pieces will have but one character.

Whatever the case, you must choose a character. Remember, you're not writing a term paper about neo-natal units, or surgeons. You're writing a story about a nurse in the unit, or a specific doctor.

STORY ARC: Something must happen. A story is not about treading water, no matter how descriptive your words. A story is not a still-life painting.

If the story is interesting, readers will read. If it's boring, they stop. It's that simple. Give a reader a character and a story arc and they'll hang with you.

ACTION: A story is made up of action. Action plays out the story arc. Action is a specific sequence of events that arouse emotions in the reader. Action can be dramatic: A shooting, a patient's heart stopping and alarms sounding in the ICU.

Action can be quiet: Two parents sitting in chairs, alone, weighing the doctor's advice to turn off the machines that are keeping their child alive. Action is something the reader can see and feel. They are there, and that allows them to become emotionally invested in the story.

Don't tell me someone is brave or nervous. Show the action and let the reader see it play out. But, as you can see, the action must be meaningful. Do you want to show a nurse getting a cup of coffee and going to the break room? No.

But what if she goes there after a child dies? Yes.

The point is this: Stories are about choices. Your choices. Early in your reporting, ask yourself these questions: Who is the character? Does the character face external or internal conflict?

A doctor in the OR faces an external conflict: She must find the cancer and cut it out of the brain. A parent in the waiting room faces an internal conflict: She must sit there and battle fear and doubt.

QUOTES: What can I say but this: Don't be seduced by them.

DIALOGUE: This is a far more effective way of letting the reader know the facts and the meaning of what they're reading. Dialogue reveals character and parts of the story arc and allows the reader the wonderful experience of being in the moment.

Take a look at this section of my story. Sam has come to Boston with his parents to meet John Mulliken. They are in an examination room, and Mulliken is looking at Sam's face for the first time.

"Sam. I'm Dr. Mulliken. Nice to see you."

Mulliken boosted himself back onto the exam table. He scooted up next to Sam as if he were the boy's grandfather. He put his hand on Sam's knee.

"What bothers you the most?" he asked. "If you had one thing you wanted, what would that be?"

Sam shrugged. He stared at his hands, folded in his lap.

"Should I give you some choices?" Mulliken asked. "Some multiple choices?" Sam responded with a barely perceptible nod.

"Our goal will be to make you look as symmetrical as possible, to balance out your face," he said. "A Picasso is a great painting, but no one wants to walk around with one for a face. We have many things to talk about: Making your ear smaller, the tongue movement, the eye. The neck's pretty good."

He put his arm around Sam's shoulder. "What do you want, Sam?" he asked quietly as if there were no one but them in the room.

Sam bowed his head and stared at his hands.

"Well, you're really down to the choice of two things," Mulliken said. "We can focus on the face or the ear, but we can't do both at the same time. If we get the face smaller, the ear will look bigger. Frankly, I just don't know. The face is tough, very tough. Lord, I just can't imagine..."

Sam raised his head. He looked deeply into Mulliken's face with his one good eye.

"I want to fit in," he said in his raspy whisper. "I want to look better."

Mulliken nodded, his features softening. He pulled the boy a little closer. "I can understand, Sam."

SCENES: Stories are told in scenes. What you read above is a scene. There is a beginning, middle and end. The scene is the stage where the writer shows what's happening, where the action is played out. A scene is told in continuous time, real time and is narrowly focused. A story is made up of a series of scenes.

TRANSITIONS: These are the glue that holds the scenes together. These are the gaps in your story where you can slip in the facts, the back story and history. Move along quickly and get back to the scene. The most dramatic action in a story takes place in a scene, and it gets the most space.

ENDINGS: Sad to say, they get short shrift. We spend so much time crafting perfect ledes, that we forget that the ending is what readers remember. The ending must wrap up loose ends and resonate with readers.

Tom Hallman Jr., a reporter at The Oregonian, has won every major writing award, including the 2001 Pulitzer Prize for Feature Writing.

Photo credit: Scott and Justine fromwyo via Flickr