The Sciences

Deconstructing Gawande – why narrative and structure are important

Not Exactly Rocket ScienceBy Ed YongAug 23, 2010 1:00 PM


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According to all sorts of “how-to” sites, one of the most important rules for online writing is to keep it short. Well, try telling that to Atul Gawande and his legion of readers. Known for his superb long-form essays and books, Gawande recently published a masterful piece in the New Yorker about death and dying. I plugged the full text into Word and it weighs in at a monstrous 12,000 words. This is a feature that makes Wired articles look like paragraphs. And yet, its copious length flies by. I read the piece in 20 minutes, with no distractions except for the occasional need to reach for some tissues. I’m not alone in thinking this; the piece was passed all over Twitter, with several people noting how readable it is despite the excessive word count. And bear in mind that all of these people read the piece on screen (and I digested it as a single, scrolling column). How does it succeed? Part of the answer doubtlessly involves the subject and Gawande’s own experience. Death is a topic that is close to our hearts, either through experience or contemplation. There can be few issues that are more guaranteed to stir an emotional reaction in a reader. Gawande also has an inbuilt edge in that he is a doctor first and a writer second. He absolutely knows what he’s talking about and he has years of stories and medical experience to draw from. But I would argue that even these massive advantages do not guarantee a good read. In a similar position, many writers would still struggle to keep a reader’s attention rapt for a 12,000-word magazine article. To me, the secret of Gawande’s piece is its masterful structure. This is a textbook example of how to use narrative to sustain interest, regardless of length. Let’s break it down. The piece is about death and how people deal with dying. It’s an expansive topic and while Gawande covers a large amount of territory, the piece really only has four (maybe even just three) main ideas:

  • Caring for terminally ill patients is a big, neglected and increasingly important issue.

  • Hospices are about much more than just letting people die.

  • Discussions about the end of life are important for terminally ill patients and their loved ones.

  • Doctors need to have these discussions with their patients too.

And that’s it. Four ideas, and the last two could realistically be grouped together. You could write all of that on a PowerPoint slide. This is not to downplay the quality of the article. The piece is readable exactly because it hinges around a small elite set of messages. Each one has stories, statistics and facts that support it, but these are side dishes that are used to flavour a meaty, central ingredient. Cooks risk spoiling a dish if they try to pack in too many textures and flavours; likewise, writers can make their articles unpalatable by pursuing too many tangents or packing in too many ideas. But simplicity is not incompatible with depth. Each of Gawande’s four main concepts could be the subject of a feature article in themselves and, in fact, they are. I’ve tallied up the word counts spent on each one and they’re all the length of a 2-4 page piece in a normal magazine (respectively, they come in at 1700, 2300, 1300 and 2500 words). These four sections are all obviously united by a common theme. But to hang together in a single feature, they need more than that. Gawande achieves this by using the tale of a terminally ill cancer patient, Sara Monopoli, to frame the four topics. It is obvious enough to use real-life stories to illustrate the theme of death and Gawande’s experience gives him plenty to draw from. But his critical move was to use a single story to frame all of the others. We meet Sara three times from her initial diagnosis through a gruelling series of choices and treatments. Each episode provides anchors for the rest of the piece, introducing the key themes while providing an emotional centre. In the brief introduction, we see the events that lead up to a terminal diagnosis and we see this as a problem that affects real people. From there, Gawande segues veers off into his first two topics – the importance of end-of-life care and the role of hospices. We cut back to Sara for a hefty segment in the middle of the piece (and if you haven’t read it, you should probably do so now). We learn that her treatments aren’t working and we hear about the impossibly tough decisions that she and her family have to make. Again, this introduces the importance of discussions between patient and loved ones, and between patient and doctor – the third and fourth core themes of Gawande’s piece. Finally, the ending (of Sara’s story and the feature) is both fitting and inevitable. The whole piece works roughly like this, with word counts attached:

  • Sara’s story – an introduction (1,000), which leads into...

  • The first act – the importance of end-of-life care (1,700) and the role of hospices (2,300)

  • Sara’s story – an interlude (2,600), which dovetails nicely into...

  • The second act – the importance of discussions for loved ones (1,300) and doctors (2,500)

  • Sara’s story – an epilogue (600)

Of course, there’s more to it than this. There’s the skilful storytelling, the deft use of anecdotes and case studies besides Sara’s, the sense of underlying academic rigour, and so on. But all of that hinges upon this brutally efficient structure – without it, the other elements would collapse like a body without a skeleton. I’ve always said that to write well yourself, you need to constantly read good writing. So read this. Photo by Vees //

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