Saturday, January 21, 2012


I have been reflecting on the issue of patient confidentiality in medical writing.  Cases shared for educational or research purposes are de-identified.  The standard approach is to use initials, not names, and change characteristic features, such as age or gender, if they are not directly relevant to the clinical question.

What about fiction set in clinical environments, in which patients and doctors are characters?  All characters bear some connection to the writer’s personal experience.  They are usually designed to feel “real”, in order to make their stories believable and to communicate some element of human truth.  How can a writer achieve this effect without making characters who are too “real”, traceable to the individuals on whom they are based?

Fiction is preceded by the caveat: any relation to actual persons living or dead is purely coincidental.  However, can we say this with confidence when our characters are influenced by actual persons and intentionally crafted to behave like them? 

Is there a higher standard for coincidence when the writer is also a doctor?  Medical professionals have privileged access to the lives of others and a unique perspective on the human condition.  This exposure can enhance our writing and give our novels insight.  However, much of our human contact occurs in confidence, in the context of private doctor-patient relationships.    Patients who tell us of their personal struggles and tragedies do so for therapeutic purposes, not to become the basis for fictional depictions of struggle and tragedy.

In some cases, we know which patients of ours inspired which characters.  If we are successful at de-identification in our writing, we are the only ones who can draw the connection.  In other cases, the link is obscure even to us.  Characters come into being without conscious attribution to someone we know.  They are composites of our experiences, the essence of many people rolled into one.

It is difficult to tell exactly how others will respond to or interpret our work.  I do try to imagine how my patients would feel reading my writing.  Would they see themselves in a universal sense, in the way that any readers identify with characters who are like them?  Or would they feel used, their personal details stolen or taken advantage of, because they see themselves in an individual sense?

If I suspect that a character or a particular scene would cause offense to a patient or family member, I change it.  Yes, I could exercise my freedom of speech and write whatever I want.  But I also take my professional obligations and privileges seriously.  I aim for my clinical and literary lives to complement each other, not conflict.  And even though my sharing of experiences is not for educational purposes, there is an intention to create something positive.

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