Interview with Vincent Lam

Interview by Jason McBride, Toronto Life
April, 2006

In "The Best Medicine," in our March issue, doctor and writer Vincent Lam reveals how to make the medical system work for you. Here, he talks to Jason McBride about juggling his two professions; what kinds of choices we make in our health care; his first book of fiction, Bloodletting & Miraculous Cures; and the inevitability of an influenza pandemic.

First of all, how old are you?
I'm 31.

When you were younger, what did you want to be first: a doctor or a writer?
A writer. But in the midst of wanting to be a writer, I felt it would be a very good thing to have a job. Because all the writers I admired had also done things in the world. I thought that was a really important thing to do. My thought process, very simplistically, went like this: "Well, I should choose a job where I can learn about people, and what would be perfect? Well, I could be a doctor."

How old were you when you thought this?
14 or 15. I had very little appreciation for how incredibly tough it would be to become a doctor.

Were you writing when you were a teenager?
"Writing." And then, after I finished my medical school residency, I carved out some time to sit back and do it again.

How could you possibly carve out that time? I assume your days are jam-packed. Do you work full time?
I do. Actually, I'm working a little less right now. Not because of writing, but because I have a son. While I was writing the book, I was working a full-time emergency medicine schedule. But, emergency medicine is very focused. The way the work is structured, you go there and you work very hard. And you're very busy. But once you're done, you leave, and your responsibility has ended. So you can customize the time a bit more. It's possible to work one day less per month or three more days this week and not work the next week. That's not really possible in most types of medicine, where there is an ongoing suite of responsibilities that you must attend to every day, regardless of whether or not you see a patient. In other medicine, the absolute maximum you can work is basically 24 hours a day, seven days a week. Certainly, as a resident, I was putting in 150-hour weeks. That was just what you did. But not every hour was intense. I would be sitting there, waiting for tests to come back, or staring at an X-ray box, under incredible stress, but ultimately not doing anything. I'd be miserable and exhausted, but I wasn't doing anything. So the limitation was just the amount of hours that exist. In emergency medicine, frankly, the limitation is your psychological exhaustion. That limit kicks in quicker.

What's the average limit?
Most of the people who have a sustained career in emergency medicine work 15 to 16 shifts a month, a shift being anywhere from six to 12 hours. Hospitals where it's very intense will have shorter shifts. Places where the pace is a bit slower can have 12 hour shifts. The hours don't tell the whole story. I've worked in places that have 12 hour shifts, and I would finish work feeling refreshed, relaxed, as though I'd had a walk in the park. At my place, Toronto East General, I finish an eight-hour shift and I'm completely exhausted. I just have to lie down.

I can't imagine you run home and crack open the laptop.
I usually write before I go to the hospital. My routine, before I had a son, was to write and then go to the hospital. Now, my routine is to stumble from one thing to the next and try to get something done.

How long did you work on Bloodletting & Miraculous Cures?
Two years.

And during that time, what was a typical day like for you?
The ideal day was to wake up around 8 a.m. and write from breakfast until two or three in the afternoon. Then, I'd either go the hospital or, if I didn't have a shift, do other things.

I imagine a lot of the book is autobiographical?
There's one story that's autobiographical, called "A Long Migration," about my grandfather. The rest, not really. I know they sound like interesting or notable events—or at least I hope they do—but actually, they're pretty common. Cardiac arrest on the floor, heart attacks...

Alcoholic doctors?
I've heard of those (laughs). It's part of the legend. I can't say I have cared for many alcoholic doctors.

When you're working at the hospital, do you ever think, "This would be a great story"—or are you so focused on what you're doing that such thoughts don't occur to you?
Usually, I feel a certain emotional tension in a particular situation, and I think, "Gee, this conflict I'm feeling would work well in a story." That's what occurs to me, rather than the actual event. There are two very important problems with writing about things that happen in the hospital. One is that a lot of the events that happen in real life are so ridiculous you couldn't write about them. People would say, don't make up stuff, that's so silly. The other issue is that the events often don't make sense the way we see them. Something we see may have psychological and emotional parameters that only make sense if you have a certain amount of technical knowledge. If you sit down to write about them, it wouldn't actually work. I'm also mindful of patient confidentiality. I try to genericize the medical events because, ultimately, they're just a stage and the drama grows out of a larger conflict.

I can think of maybe three doctor-writers in the history of literature. You'd think, given the fact that it's such a site of drama, more doctors would come out of medicine. Did you look to those doctor-writers for inspiration?
I can't say I was primarily influenced by doctor-writers when writing this. I was influenced by the writers I love—Peter Carey, Margaret Atwood, Hemingway, the list could go on and on. And there are many writers whose books I love who probably exert some subconscious influence, but who have an entirely different style than mine: José Saramago, Gabriel García Márquez. One of the reasons there are some doctor-writers out there—and I agree with you, probably not enough—is that the two things are really similar on some levels. They're both exercises in storytelling. What happens to you, as a doctor, is that someone comes to you and tells you the beginning of the story. What they're hoping you'll do is tell them the end of the story.

A happy ending?
Yes. But even if you can't make it a happy ending, I think people perceive an immense amount of value in being told what the end of the story is. Ultimately, you have to understand how the human mind navigates from fear to understanding to hope. You need to do that as a doctor. It's the same thing a writer does, but a doctor does it as a personal interaction, and a writer has to conjure it on the page.

In my limited experience, a lot of doctors aren't very great storytellers.
Well, the problem is, we've become a very technological society. Before we had that technology, doctors had to be great storytellers, because they had little else to offer people. People loved their doctors, because they could tell them what was going to happen, or they could give the impression of a human narrative. Now, we can do incredible things, things we could never have dreamed of 50 years ago. We've become so engrossed in that. And it happens on both sides. People expect the cure, the pill, the operation, the treatment. And doctors have this really rigorous process by which they're held intellectually accountable, so that they do things that are scientifically supported, that are technically right, and have demonstrated benefit. So, on both sides, we pay great attention to these technical issues. They are incredibly important; I don't mean to diminish the importance of using technology and science to our advantage. But the art is in danger of being waylaid. People may think, I don't care if my doctor tells me a story or not, I just want my doctor to do the right thing. And the doctor may think the same thing. They may think, what does this person care if I've explained this to them properly or not? Because I'm doing the absolutely right, medically-based, evidence-supported whatever. But all the science, all the technological knowledge, exists as a detached truth. It holds true in large groups in their generalized circumstances. Whether or not it's applicable to an individual person who's facing a human dilemma, well, that's tough. And that's why there are doctors. I think it would be a shame if we lose the art of it.

Did you have the linked story structure in mind from the beginning—or was it something that grew organically?
I had the arc of it in mind—in the sense that I did set out to write a book of integrated short stories. However, the specific way each story linked changed throughout the writing. I'm a child of the word-processor generation, so I would literally try different combinations. I would do a find-and-replace and change characters' names. At various points, there were more characters.

Is there one character in the book who's especially close to your heart?
They would be upset if I chose one. All of them experience things I've experienced emotionally. So I would not say, honestly, that I had a favourite character. They all can say things I have been tempted to say, but have never said. So they are all very dear to me. "The Best Medicine" is obviously very thorough and helpful, but I wonder if there was anything you couldn't include because of space reasons.
That piece has to do with how individuals access health care. And I think one issue that is very tough for us to confront, as a society, is the definition of goals in health care. What I mean is this: right now, everyone is talking about waiting times. I'm not saying that's not a valid issue. But no one has ever said, well, is reducing waiting times the most important improvement we can make to our health care system? Or is it reducing infant mortality? Or is it increasing life expectancy? You can put forth any of those goals, and if any of those goals acquired public interest, it would have the potential to be an important, societally recognized goal. But I think it's a mistake to not recognize, as a society, that we always have a trade-off between goals. The right thing to do is not an absolute in the health care system. The right thing is a function of what we want in our health care system—as a society. And the fact is, resources are not unlimited. If we want to choose one thing, we are implicitly not choosing others. So in the forum of public debate and discourse, we need to be able to examine conflicting priorities. And consciously set goals we feel are priority within society and our health care system. Some people would say "The public system can do what it want, let me just pay for what I want, that won't affect any one else." The reality is, it doesn't work out that way. If you let people pay for what they want, then the people who provide services will be less available to provide services in a public forum. If many people pay for "what they want," this undermines the popular and political will to support the public system. That discussion can go on and on. No choice is neutral, but we are very hesitant to discuss these problems in the public forum. What's more valuable? Should we shorten waiting times so that everyone gets their hips a month sooner, or should we pay for more meningococcal vaccine so that more kids don't get meningitis? Who wants to tackle that? I'm not saying there's an easy answer, but hidden in our goal-setting is a very random process. And it shouldn't be that way; considering our priorities should be an explicit process.

You write that, in the Family Health Network system, a family doctor gets paid a flat fee of $107.28 a year for each patient. That seems very low.
It is.

So how many doctors participate in this program?
The numbers are changing every week, driven by market forces. Doctors choose the program if it makes sense for them. People are opting into it, but if it doesn't make sense, people will opt out of it. But it is a low number. I think the revamp of the payment system is better than it used to be. But it vastly under-rewards family doctors. There is a huge discrepancy between the value of services provided and the monetary compensation provided to family doctors, in comparison with specialists. And, arguably, compared with myself as an emergency doctor.

And that discrepancy arises from what?
Two things. Historically, family doctors are very nice people. And sometimes, the nicest people aren't the best negotiators. There are also simply many more family doctors. So, if there are fewer ophthalmologists, you can pay them astronomically. It doesn't affect the budget that much. When you have thousands and thousands of family doctors, if you want to pay them in a fair and reasonable way, the impact on the budget is correspondingly high.

But there is a shortage of family doctors.
We're getting into a circular discussion here (laughs).

At what point did you decide to go into emergency medicine? You're a nice guy; why didn't you become a family doctor?
I always thought I'd be a family doctor. Then I went to the emergency department, and thought, wow, this is amazing. A huge variety of things come through the doors. I thought, these guys can treat heart attacks, set broken bones, sew up cuts, resuscitate people at the point of death. And I thought, this is the classic stuff, this is what everyone imagines when they think of a doctor. I was hooked. At the time, I had no idea how much better it would work out for my writing career. I just thought, hey, this is great. I didn't think about scheduling issues or time management. Emergency medicine is very addictive. It's exhausting, but it's exciting and stimulating. It's an absolutely terrible and absolutely wonderful thing to do.

Do you think as you get older that addiction might lessen and you'll want to open a family practice?
The classic route, in decades gone by, is that people would work in emergency for some time and then burn out. Then they would go and do something else—whether it's family medicine or retraining in some other specialty. That was more possible at a time when there was actually less you could do in emergency medicine. You could work in emergency medicine with a smaller repertoire of skills and knowledge. There wasn't that much to know. So you could go into it without having to make a big professional commitment. People were more likely to do it en route to something else. That's changed in several respects; it's no longer possible to just dabble. It's become a fairly complex specialty that requires a very broad range of knowledge and or sophisticated and up-to-date skills. As a result, people who do it have to make a faily concerted professional commitment to it. So the career path of emergency medicine is changing. People are doing it longer. As well, I know a number of fantastic emergency physicians who were once fantastic family doctors. And I'm convinced they were absolutely brilliant in both capacities, but market forces made it completely insensible for them to continue doing family medicine. It goes both ways.

If the book became a best-seller, would you give up practising medicine?
No, I love practising medicine. If I have a tough day writing, it's just great to get out of the house, see some patients. Writing is very satisfying, but it's also very introspective. All the frustrations are quite internal. It's a very different process when someone comes to see me at the hospital with their single problem, and I try to do my best to make their single problem better. I love that. Maybe when I'm 85 years old I won't be practising emergency medicine, but right now, I don't foresee the end of it.

You also write that Ontario's health information systems are shockingly archaic. Why is this, and are the systems likely to change?
Some if it justifiably has to do with the protection of privacy of information. That has inherently slowed the integration of health information systems. But also, the economies of health care systems are strange. In most companies, you can justify a capital expenditure if you can demonstrate that the expenditure is going to increase efficiency, reduce costs and improve delivery time. No company wants to spend money unnecessarily, but that becomes a justifiable expense. Health care systems are different, because they don't necessarily make more money by providing a greater number of services within a certain time frame. I do believe health care should not be a for-profit system. The management of budgets within many hospitals—and within the provincial health care system as a whole—does not necessarily take into account how any particular expenditure is going to affect other parts of the budget. So, for example, it may be that the health records department has a certain budget. It's hard for them to unilaterally say, we need to spend $10 million digitizing all of our health records. Because, ultimately, that doesn't help them as a department—it simply means they come in over budget. It may deliver huge efficiencies to the lab services department because lab results can be retrieved more quickly and tasks don't have to be duplicated? It also may increase, fractionally, the delivery time of services everywhere in the hospital, but that still doesn't help the health records department. But these things are happening. Everyone recognizes that, in an age where you can find any piece of trivial information about anything on the Internet, you should be able to get someone's CT scan on-line, from a hospital two blocks away, when they had that CT scan three days ago. You can't necessarily do it, but everyone recognizes you should be able to do it. It's not that this process isn't happening, but there is a lag time.

You're writing a guide on surviving an influenza pandemic. Will this be written in the same way as "The Best Medicine"—in layperson terms?

And you think such a pandemic is inevitable?
Yes. The circumstances, however, of a catastrophic, societally disastrous pandemic are hard to predict. Is a pandemic inevitable? Yes. What will that mean? It could mean a huge range of different things, some relatively minor, some more disruptive. The challenge in planning for a pandemic is to be able to accept that; to be able to say we understand a great deal about the concepts and epidemiological forces at work in an influenza pandemic, and yet also acknowledge there are a great deal of specific characteristics of a pandemic that simply cannot be known until it's here. And that's a very tough planning exercise that, inherently, cannot be perfect. But only in acknowledging those realities can we actually plan in a meaningful way. The book is going to do two things. One, it's going to give people some sense of perspective so that people can place media coverage and small pieces of information in a broader context. Two, it's going to give people practical advice about what they can do in their personal lives to improve their chances of being least affected by a pandemic. No one can make any guarantees about anything when it comes to a pandemic—either at the planning or individual level. I would be lying if I wrote a book that said, "Read this book and you will survive any possible influenza outbreak." That would simply be irresponsible and untrue. But I do think there are important things people can do in their own lives which optimize their chances of not having ill health effects or their lives disrupted.

Well, I'm glad you're writing that. Maybe you can write something next about how to survive climate change.
Drive less (laughs).

How do young doctors in Canada (including yourself) see the future of the profession?
It's great. Medicine is very demanding; it's a tough field to be in. Most doctors accept that. Like everyone else, we have complaints to voice, things we want, things we're happy with, things we're not happy with. Medicine needs to have voices, and those voices need to exist at a policy level and at a cultural level. Because the practice of medicine is very closely intertwined with issues of governance, budgets and social agendas, as well as issues of human drama, loss and hope. We're right there. I think it's a big mistake, and an incredibly huge loss, if doctors simply resign themselves to being technicians. We can deliver unique, added value to society by using our perspective to say something. And to say something in cultural terms as well as in terms of decision-making. I think that more and more young doctors are becoming aware of that potential.

© Toronto Life 2006