Author Interview

A Conversation with Carol Cassella, Author of Oxygen

1. How did you come to write this book? How much of the story is drawn from your own experience as a physician?


I’ve been a closet writer my whole life, so maybe the more intriguing question is why it took me so long to finish my first novel! But even when I’m not writing, I’m thinking like a writer. I have a tiresome habit of internally narrating the world around me, both at home and inside the operating room, and I knew for years that I wanted to weave that narration into a fictional story that reflected some of the truths and questions I come across in my work as a physician.

The opening paragraphs of Oxygen are drawn directly from thoughts I’ve had in the operating room. I’ve put thousands of people to sleep, but it’s still a remarkable thing to witness and control. It keeps me acutely aware of the narrow line between life and death. I have never been through anything like the experiences that Marie undergoes in the novel, but I have faced some scary moments in the operating room every anesthesiologist has. It really is every doctor's greatest fear to harm a patient are trying to help. But what you learn from those moments can make you a better doctor.

For me, the greatest privilege of being a physician is getting to meet people I would never intersect with in my nonworking life. The gamut runs from prisoners to billionaires who, for at least a limited period of time, trust me with their life. It constantly reminds me that we are all vulnerable, all afraid of the same things.

2. Anesthesiology and writing are two very different pursuits. Do you find similarities in the focus required for each, or do they satisfy two distinct parts of your personality and intellect?

Odd as it seems, I do see similarities between anesthesiology and writing. On a practical level both require meticulous attention to detail. At their best, a good novel and a successful anesthetic should appear smooth and uncomplicated, but those results only arise from hours and hours of planning and fine tuning.

I also see similarities between medicine and fiction writing on an emotional level. You achieve better results if you listen closely to what people tell you about themselves and watch for meanings below the surface. That may not seem obvious about anesthesia, but when I interview a patient I'm listening for clues to their psychological state as much as symptoms of physical disease. If I can understand my patient’s fear or anxiety, I might be able to make the surgical experience easier. I try to do the same thing when I write fiction—look for the story behind the story; uncover and examine what my characters are afraid of, or searching for, or in love with.

There is plenty of opportunity to be creative in the operating room. Every human being responds differently to medications and every surgery requires a different combination of drugs and techniques to keep a patient safe and comfortable. But writing is definitely a richer and more personal creative drive. I’ve asked myself if I could give up either medicine or writing. I hope I never have to make that choice. I love being a doctor. I love being able to take people through a frightening experience, which surgery often is, and bring them out safely on the other side. But I need to write. I need to keep trying to translate my experience of living into a story.

3. In describing Marie’s specialty, you write “anesthesia was the antithesis of the complete, personally involved physician I had idealized to myself…. It came as an unexpected, almost uncomfortable surprise to me when I discovered the immediate gratification of my specialty.” Do Marie’s reasons for choosing anesthesiology echo your own?

Marie is not an autobiographical character, but her thoughts about anesthesia very closely reflect my own. I practiced internal medicine for three years before I became an anesthesiologist, and I loved getting to know my patients over a longer time frame. That part of it was great. But the administrative tasks and time pressures of internal medicine were frustrating. This was in the earlier days of HMOs, and I never felt that I had adequate time to listen to patients, because there were always so many more waiting to be seen freezing in their little paper gowns!

On a personal front, I was about to begin my own family and I wanted to work part time so that I could be at home some with my children. I didn't think I could do that in internal medicine, so I began to explore changing specialties. I’d never done a rotation in anesthesiology during medical school, and I was genuinely surprised to learn how involved and challenging the work can be. Even though we don’t spend as many days with our patients as an internist, we are with them at a critical and emotionally stressful time. The procedural part of anesthesia is also very rewarding. It feels great to figure out the best way to relieve someone’s pain.

4. Your description of the practice of medicine has a wonderful authenticity, but so do your descriptions of Marie’s concern for Jolene’s mother and Marie’s relationship with her niece. How does being a mother inform your writing?

Being a mother informs everything that I do. My children are the center of my life. But even with a clear focal point, it gets tricky to balance career and family, and I struggle with the perpetual guilt most working mothers feel. That said, my kids and husband are enormously supportive and helpful, and I think my children have learned good lessons from seeing both their parents pull together to make a home.

In Oxygen, Marie feels that her chance at motherhood may have been sacrificed for her career. Her sister Lori has chosen to be a stay-at-home mother, and never discovered the challenge and self-sufficiency that a career can give a woman. In some ways these two characters reflect two halves of my own life: the doctor I might have been if I had not had children, and the mother I might have been if I had not become a doctor. I’ve been lucky enough to blend both in my life. But ultimately I believe it's our relationships that matter most, and that’s one of the themes I’ve tried to explore in this novel. Certainly being a mother is where I've learned that lesson most intimately. In a day filled with the chaos of four young children, it's easy to be overwhelmed by the work of just getting from breakfast to bedtime. But when you look back months or years later, you recognize that it was the small things in each of those days that means so very much. So corny, but so true!

5. Marie is hit especially hard by Jolene’s death. It takes a toll on her personally, but also professionally; she is unable to treat another young child when she is called to his case. How do doctors grapple with the experience of losing a patient? How do you separate those experiences from your personal life?

It's very difficult to cope with losing a patient, especially if there is any question that the death could have been avoided or delayed. I've had the experience of telling family members that the person they love has died, and found myself crying along with them. In Marie's case this loss is compounded by questions of negligence, and the lingering pain in her own family’s history. Her professional defenses break down and make it impossible for her to distance herself from the death and move on.

Marie tells Lori that she used to worry about how she would buffer herself from the pain of illness and death once she became a doctor. Years later she realized that emotional walls had gone up involuntarily, beyond her control. I wonder if that isn’t the real battle for a doctor. Human beings have a remarkable capacity to adapt, and as a physician that can mean you even adapt to grief and suffering, forgetting that it’s a brand-new experience for the patient and their family. So rather than consciously distancing ourselves from difficult emotions, I think we may need to consciously remind ourselves to be very present in that experience with our patients.

In the circumstances of the novel, Marie feels a deep need to face Bobbie, and ask for forgiveness. This is something we are only lately addressing in medicine: the place for hospitals and doctors to tell patients and families we’re sorry things didn’t turn out as expected. I think silence may be one unfortunate consequence of litigation. But we’re learning that an apology can bring relief and sometimes lower the legal costs. For the physician, the most important person to forgive may be oneself. That can be critical to recovering and regaining the confidence needed to help other patients in the future.

6. You have a remarkable talent for capturing the rhythm of a hospital and the routines of calls and breaks and procedures. Was it hard to bring them to life so vividly?

The hospital scenes (working in the operating room, taking call, bantering with the nurses and technicians and other doctors) were some of the easier sections of the novel to write. I just lifted examples right out of my actual working life and tweaked the characters and stories to better match the purposes of the scenes.

I don’t currently work as many hours as Marie does, but I used to. I know many doctors who work extraordinary hours, late into their careers. It can get fatiguing, and that fatigue can go home with you and affect your relationships and creativity, and certainly your health. The hospital can become your whole life—your social community and point of connection with the rest of the world. In Marie’s case this leaves her feeling abandoned and friendless when her career implodes.

I also tried to write these scenes realistically to show the mundane aspects of hospital life as well as the dramatic. Unlike the medical stories in movies or TV, doctors really don’t spend every moment in the middle of a tragedy or medical miracle!

7. In a few places in the book you mention the shortage of anesthesiologists, and it turns out that Joe was hired for lack of a better option. Does the shortage really exist? If so, why?

There is currently a shortage of anesthesiologists in the United States, and that's projected to persist for a number of years into the future. There are a lot of reasons for this, but some of it can be traced back to the 1990s when concerns about an oversupply led to a downsizing of anesthesia residency training slots, and fewer doctors choosing to specialize in anesthesia.

So much for forecasts! In truth, the volume of surgery has increased, and we have an aging population that needs more operations. Also, a greater than expected number of anesthesiologists have retired or chosen to work part-time. I suppose I have to blame myself for some of the shortage in that case.

8. In the final pages of the book, you write that Marie and her peers were “engulfed in a healthcare machine that has outstripped our individual competence with its monstrous ambition and complexity.” Do you feel that the “healthcare machine” that manufactured the circumstances of Jolene’s death is more at fault than Joe? How has it evolved into something that compromises rather than enables patient care?

Medicine in America today is indeed complex and sophisticated, and its evolution has been exponential in the last fifty years. In the most extreme cases of medical intervention, I sometimes wonder if our technical capacity to diagnose illness and extend lives may have outpaced our medical moral wisdom. Technology allows us to do so much for patients. But technology has exploded both the costs and the capacity to do harm. As in any complex system, if you trace a bad outcome back to its roots you’ll usually find that there were many small mistakes that added up to one catastrophe. That’s certainly what happened to Jolene; Joe’s actions were only one factor. Was Joe also a victim? I think so. The decision to hire him arose from economic pressures in the healthcare industry that are very real. In fact, all the elements of this story have happened, I just brought them together in this fictional situation.

We do many things very, very well in hospitals today, and we are focusing on medical errors and trying to eliminate them. Anesthesia is actually one of the specialties that has significantly lowered rates of complications and errors in the last decade. But the insurance and healthcare delivery systems we depend on work better for some population groups than others. Despite having the most expensive healthcare system in the world, some regions of this country are actually seeing life expectancy go down. I don’t have the answers for how to fix that, but I want to raise the questions. We need to be asking why, from both a scientific and a moral perspective.

9. The book sensitively portrays the other side of the malpractice lawsuits that have become common. Was it important to you to portray the complexity that is frequently lost in media coverage?

A medical malpractice suit is painful for everyone involved, the physician as well as the patient and their family. I’ve never been involved in a malpractice case, but I know doctors who have been emotionally devastated by the experience, even when they were found completely innocent.

In Oxygen, both Bobbie and Marie find themselves isolated and wounded by the lawsuit. Marie feels driven to attempt some personal contact with Bobbie; to try to resolve their mutual despair on an emotional level that the legal system can’t possibly address. Of course, that’s completely taboo while they’re sitting on opposite sides of a malpractice suit.

Medical litigation has its place, and wronged patients need an avenue for monetary compensation. But I think we sometimes expect legal action and money to achieve an unattainable peace, and both sides of a malpractice suit may end up losing.

10. We have an ongoing fondness for stories like Oxygen or television shows such as Grey’s Anatomy and ER. Why do you think medical dramas play such a large part in pop culture?

Almost everyone winds up in the role of a patient at some point, and sometimes the medical experts surrounding you can seem like the wizards behind the curtain. But of course, we aren’t wizards. We’re just people, and eventually we have to be patients ourselves.

To be a patient, particularly a surgical patient, is to lose control. You hand over your clothes and slip into a teeny tiny little hospital gown with no underwear, and give permission to near strangers to knock you unconscious and cut you open. That’s a pretty vulnerable position! I think we’re drawn to fictionalized versions of these stories because we want to see what happens on the other side of the magic curtain—look inside the lives of the people to whom we give up control.

When I was in medical school we would take a break from the library to watch Saint Elsewhere. It gave us a sense that what we were studying so hard to become was worthwhile; it dangled a romanticized version of the lives we wanted live. One thing I've discovered is that the day-to-day life of a physician is not nearly as exciting as what you see on television. We aren’t all beautiful, and we definitely don't have all those love affairs!

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