How is a writer like a surgeon?

Note: I’m taking a short break this week, so I’ll be republishing a few posts from earlier in this blog’s run. This post originally appeared, in a slightly different form, on July 22, 2015. 

The late E.L. Doctorow belonged to a select group of writers, including Toni Morrison, who were editors before they were novelists. When asked how his former vocation had influenced his work, he said:

Editing taught me how to break books down and put them back together. You learn values—the value of tension, of keeping tension on the page and how that’s done, and you learn how to spot self-indulgence, how you don’t need it. You learn how to become very free and easy about moving things around, which a reader would never do. A reader sees a printed book and that’s it. But when you see a manuscript as an editor, you say, Well this is chapter twenty, but it should be chapter three. You’re at ease in the book the way a surgeon is at ease in a human chest, with all the blood and guts and everything. You’re familiar with the material and you can toss it around and say dirty things to the nurse.

Doctorow—who had the word “doctor” right there in his name—wasn’t the first author to draw a comparison between writing and medicine, and in particular to surgery, which has a lot of metaphorical affinities with the art of fiction. It’s half trade school and half priesthood, with a vast body of written and unwritten knowledge, and as Atul Gawande has pointed out, even the most experienced practitioners can benefit from the use of checklists. What draws most artists to the analogy, though, is the surgeon’s perceived detachment and lack of sentimentality, and the idea that it’s a quality that can be acquired with sufficient training and experience. The director Peter Greenaway put it well:

I always think that if you deal with extremely emotional, even melodramatic, subject matter, as I constantly do, the best way to handle those situations is at a sufficient remove. It’s like a doctor and a nurse and a casualty situation. You can’t help the patient and you can’t help yourself by emoting.

And the primary difference, aside from the stakes involved, is that the novelist is constantly asked, like the surgeon in the famous brainteaser, to operate on his or her own child.

Closely allied to the concept of surgical detachment is that of a particular intuition, the kind that comes after craft has been internalized to the point where it no longer needs to be consciously remembered. As Wilfred Trotter wrote: “The second thing to be striven for [by a doctor] is intuition. This sounds an impossibility, for who can control that small quiet monitor? But intuition is only inference from experience stored and not actively recalled.” Intuition is really a way of reaching a conclusion after skipping over the intermediate steps that rational thought requires—or what Robert Graves calls proleptic thinking—and it evolved as a survival response to situations where time is at a premium. Both surgeons and artists are called upon to exercise uncanny precision at moments of the highest tension, and the greater the stress, the greater the exactitude required. As John Ruskin puts it:

There is but one question ultimately to be asked respecting every line you draw: Is it right or wrong? If right, it most assuredly is not a “free” line, but an intensely continent, restrained and considered line; and the action of the hand in laying it is just as decisive, and just as “free” as the hand of a first-rate surgeon in a critical incision.

Surgeons, of course, are as human as anybody else. In an opinion piece published last year in the New York Times, the writer and cardiologist Sandeep Jauhar argued that the widespread use of surgical report cards has had a negative impact on patient care: skilled surgeons who are aggressive about treating risky cases are penalized, or even stripped of their operating privileges, while surgeons who play it safe by avoiding very sick patients maintain high ratings. It isn’t hard to draw a comparison to fiction, where a writer who consistently takes big risks can end up with less of a career than one who sticks to proven material. (As an unnamed surgeon quoted by Jahuar says: “The so-called best surgeons are only doing the most straightforward cases.”) And while it may seem like a stretch to compare a patient of flesh and blood to the fictional men and women on which a writer operates, the stakes are at least analogous. Every project represents a life, or a substantial part of one: it’s an investment of effort drawn from the finite, and nonrenewable, pool of time that we’ve all been granted. When a novelist is faced with saving a manuscript, it’s not just a stack of pages, but a year of one’s existence that might feel like a loss if the operation isn’t successful. Any story is a slice of mortality, distilled to a physical form that runs the risk of disappearing without a trace if we can’t preserve it. And our detachment here is precious, even essential, because the life we’ve been asked to save is our own.