To Diagnose or to Characterize?
By Kathryn Craft | May 9, 2024 |
photo adapted / Horia Varlan
Thanks to the 24/7 information kiosk that is the internet, anyone with a smart phone can now become a lay doctor. This can be handy if you wake up in the middle of the night with a stabbing pain and learn that the burst appendix you feared was probably just gas. But for a while now, I’ve been wondering if immediate access to all things medical is always good news for novelists.
Back before it only took a tap of the finger to paste a celebrity photo onto a Pinterest board or borrow a bio from a known sociopath, writers imagined their characters into existence. If that character’s specific story included a mental or physical health challenge, instead of cruising the ’net for a diagnosis, the writer might wonder, If something in a man’s brain made him go blind, how might that test his wife’s assertion that her plastic surgeries were meant to please him? In that story, the husband’s localized headaches and blurred vision might be convincing enough. Consider the law of diminishing returns: these days, a writer can spend hours if not days of their precious writing time googling whether shrapnel from the Vietnam War could migrate slowly through the brain to cause similar damage decades later. (If that sounds oddly specific, um, well, I have no idea why).
I’m not convinced we need to do that.
Prioritizing the protagonist’s character and her story before doing research is still a solid approach. In the May/June issue of Writer’s Digest magazine, author Alyssa Cole spoke about her process creating the lead character for her newest thriller, One of Us Knows, who is the host of a “system”—the group of personalities formed when an individual has dissociative identity disorder. Cole first came up with the basic story idea: “What happens when the main person who is causing trouble is also the one who has to get them out of trouble?” She says, “I didn’t want to read someone’s story and then be like, Oh, let me make a story based on this thing.” Only then did Cole check primary sources to ensure that she was “accurate within reason and respectful.”
Put story first
For my debut novel, I decided that a formal diagnosis for my protagonist would fail to communicate one of the most frustrating realities in treating mental illness: it’s the person who doesn’t think they have a problem that must seek the diagnosis. The words “body dysmorphia” also would have ripped the heart from my story. It was her disordered thinking about her body that kept her butting up against the unwanted consequences that pressured her to change. I chose differently for a major secondary character. Her known cystic fibrosis diagnosis averted any “medical mystery” that might upend focus on the story I wanted to tell, of how two woman of the same age—one with a strong body but a weak spirit, the other with a hearty spirit but a weak body—might influence each other.
Impaired characters who remain undiagnosed are common in literature. Since 1843, when Edgar Allan Poe’s The Tell-Tale Heart was published, it has been critics—not the text of the short story itself—that spoke of the character’s “paranoid schizophrenia.” In Eleanor Oliphant is Completely Fine by Gail Honeyman, the fact that we don’t know why the titular character is so reclusive drives the narrative. We never learn the malady that is stealing the life of enigmatic author Vida Winter in Diane Setterfield’s The Thirteenth Tale, nor does it matter. The character’s choice to entrust the story of her life to another writer is convincing all on its own.
I’d argue that not being able to put a name to a malady invites us to “read” the character more closely for clues. Can’t we simply accept that these characters are the way they are, quirks, limitations, and all, and watch as their authors show the impacts of their condition across the cast of characters?
Or, knowing that answers are out there, is today’s reader not as willing to sit with uncertainty?
Maybe the decision of whether to diagnose or characterize is one of worldview. As someone who has had her share of orthopedic issues in life—causing some to call me “accident prone,” although I prefer the wordier phrase, “so active that odds are she’ll eventually get hurt”—I like to believe that we humans are more than our health issues. Just because all characters with Down Syndrome have certain similarities doesn’t mean they’re bound to act from the same Wikipedia symptom list, or express themselves in the same way or for the same reasons, any more than anyone else would. Even my grandson, who was born with extreme brain abnormalities, has a distinct and indomitable personality. What all characters do have in common is that they are flawed individuals with the potential to be exceptional—and the exceptional characters are often the most interesting. As their creators, it’s up to us to make them so.
Pair diagnosis with characterization
In the very first line of Broken for You by Stephanie Kallos, we learn that protagonist Margaret Hughes has a brain tumor. Because readers seek orientation to a story from its opening, they will easily accept this as fact. The excerpt below is from paragraph two.
Her physician spoke of cisterns, vessels, ventricles, a star. Of cells that had forgotten how to die. It was all so complicated, so difficult to understand, but in all fairness she had no one to blame but herself. She was the one who’d insisted on seeing the images, made him promise that he’d be straightforward, tell her the names of things, explain why she’d been experiencing these headaches, these slips of the tongue, errors in cognition, apparitions.
After delivering this news, Margaret’s doctor suggests she might want to call her ex-husband.
But there was something irritating in Dr. Leising’s tone—as if he didn’t think she should hear his prognosis in the absence of a male shoulder to weep on. As if she couldn’t handle things without the benefit of counsel by some father-by-proxy. Margaret had managed her own affairs nicely for most of her life. She wouldn’t be railroaded, pitied, or bamboozled now. I might look like a nice, diffident old lady, she thought, but I’m not about to be treated like one.
It’s only several pages later, at a café, that she allows his exact diagnosis to set in. It was a very common type of malignant brain tumor: “An ‘astrocytoma’. A slow-growing star.”
Clearly, Kallos did not allow this diagnosis to eclipse Margaret’s characterization. We have a good sense of the steely disposition and agency Margaret will bring to her decisions from here on out. Despite the grim news that she may have as little as two years left to live, Margaret evaluates her options this way: “She could either undergo a lot of treatment and die, sooner or later, or she could undergo no treatment at all and die, sooner or later.”
So, did we readers need the astrocytoma diagnosis? I’d argue no, except for one thing: Margaret wanted it. And in Kallos’s capable hands, Margaret’s “slow-growing star” serves a story function: it foreshadows that there is something hopeful, maybe even beautiful, yet in store for this character.
If you decide not to diagnose, keep in mind that your readers will have Web MD, too, and they aren’t afraid to use it. The armchair doctors in the book clubs I’ve visited for my debut have been more than happy to diagnose my protagonist’s mental health issue, and comparing their thoughts to her characterization has resulted in rousing discussions. I also think the approach I settled on allowed my readers to relate to my protagonist without having to diagnose themselves.
Ask yourself these questions
• How will a firm diagnosis improve your protagonist’s story in a way that characterization alone cannot?
• Do you have a hidden goal of teaching the reader about a certain condition? Think instead of inspiring them to go learn more about the condition in the nonfiction section (or, more likely, WebMD).
• What is your protagonist’s story goal? If it’s healing, how can your plot exhibit their agency in achieving that? If they have some other deeply desired goal, how does the medical condition present a significant obstacle to its attainment?
• Could you characterize the condition itself by giving it a more fanciful name?
• How can you surprise the reader who has experience with this condition? For instance, could the protagonist’s symptoms become a strength instead of the constant trial the reader would expect them to be?
Let’s not allow the internet make characterization into a dying art. Thinking through in advance what story purpose the medical condition in your fiction will play is a mad skill, one I urge you to embrace.
“There are two sides to every story,” the saying goes, but we’re novelists so we know there are more than that. Let’s talk! Do you think that in our information age, readers expect our ailing characters to come with firm diagnoses? In your own reading, is characterization enough—”he simply is this way”—or does not knowing why he’s this way distract you from the story? If this topic relates to a story you’ve written, please share your decision-making process.
Kathryn Craft (she/her) is the author of two novels from Sourcebooks, The Art of Falling and The Far End of Happy. Her forthcoming book, Crafting Story Movement: Techniques to Engage Readers and Drive Your Novel Forward, draws from decades of experience as both a story consultant and a movement specialist/dance critic. Learn more on Kathryn’s website.
[coffee]
Brilliant! I think that as writers we need to understand the medical conditions we include in our characters, but how much detail we share depends on the plot and on the characters themselves. We don’t want to insult potential readers by misrepresenting a condition. Yet we needn’t overburden readers about details that are superfluous. A condition’s impact on the characters (both the primary and secondary)is the more intriguing aspect.
On a similar note, I’ve debated many hours on how to have a central character in my work in progress meet her demise. Any tips?
This is spot-on, Brenda: “ A condition’s impact on the characters is the more intriguing aspect.”
As for the demise of your character, it interests me that you don’t know how. I guess my first question is, MUST she die? If you’re simply following your intuition on this one, maybe comb your manuscript for any clues your subconscious—the source of your intuition—may have laid down. Bad driver? Early daily run? Swimmer? Distracted driver? Adventurous eater? Risk taker? And if you’re thinking murder, an antagonist who knows her habits and interests could easily take advantage of them to hide that fact.
Based on my physical health experiences, getting a firm diagnosis can be a 200k word mystery novel in itself. An equally long sequel would be finding the combination of specialists, treatments and diet to get that protagonist to remission.
WebMD is the worst reference. I know everyone uses it, but it is full of myths and inaccuracies. If you do decide to diagnose your character or just give her all the symptoms, please do further research to avoid perpetuating myths of a condition and to respect those who are actually living it.
Writing about health, I think, is very tricky. I’ve never tried. I guess because I find it so personal and I find most people are incredibly uncomfortable hearing about it. Also, I can’t imagine writing about a condition I didn’t experience myself. The ones I’ve had/have don’t fit the common definitions. I’ve found symptoms and solutions can be as unique as humans.
The way you describe diagnosis and treatment as a mystery Is inspiring and heartbreaking all at once, Ada. And thanks for warning us off WebMD—good to know!
Excellent post, thanks for sharing your thoughts and I totally agree that medical diagnosis has a role to play and should be included when it’s key to the plot, when it’s an issue for the character – essentially, in such cases, the malady (or diagnosed illness) becomes the “antagonist”, i.e. what the MC has to fight against. How far should we go into medical aspects? I honestly don’t know, I guess it depends on the context.
For one thing, you’re right that it should not become so overwhelming that the author stops doing his “characterization” work as you put it—and which I see as “development” of the character, tracing the “arc”…But on the other hand, not doing it enough can be counterproductive. I have a recent example of such a case at one of my readings in my circle of writers. I described a scene in which my MC has a particularly acute episode of fear of heights and overcomes it. To me, that scene was crucial and showed how brave my MC was, able to finally face the most devastating fear she’d ever experienced. For some of my readers, the scene made my MC look weak, a prey to a ridiculous fear of heights, an absurd case of vertigo that obviously they didn’t see as anything earth-shaking. They saw it as a rather irrational, weak reaction and my MC came out looking bad, quite the reverse of how I saw it or far from what my intention was!
So in rewriting the scene, I went to great pains to explain what fear of heights was, and that it’s no joke and I gave a flashback scene of the MC suffering from such episodes as a child…only to be told I’d overdone it, and that all those flashbacks were actually infodump and not needed!
So again, I cut back on the flashbacks and medical descriptions in my third rewrite and hopefully got the balance right this time! Go figure! But it does show how difficult it is to weave in a convincing way medical knowledge without slowing down the pace and yet making your MC’s suffering as believable as possible.
Vertigo is a “ridiculous fear” or a sign of “weakness”? Tell that to Hitchcock. Now, yes, the vertigo in question was a clever way to describe male sexuality and its obsession with mother figures and eroticized lovers, but the opening scene is harrowing with no subtext and though it does reveal a vulnerability it’s hardly evidence of the character being some kind of psychological weakling.
Having been in reading/writing groups early in my career, and having counseled students who’ve received curious feedback from other group members, I’ve come to realize that you have to be able to discern valid criticism from that which is something other than valid. I hope you ultimately got it right to you own satisfaction.
Hi Claude, thanks for demonstrating that achieving the right balance can be tricky. Keep in mind that the answer to this dilemma may come by threading in foreshadowing earlier on in the story. Because that’s difficult for a critique group to assess, their advice can result in overwriting.
For example, when reaching a hotel, the character could say, “Wait—where did the client want to meet?” and his business associate could point straight up and say, “The Limelight. It’s on the roof—the views are supposed to be amazing.” Your character’s reaction—or the excuse he gives, with no explanation—would start creating subtext. Add in a different sort of confrontation with heights along the way, and you will have laid sufficient track for the scene in which he confronts this fear when his desire and the stakes are much higher in the scene you mention.
Ah, Kathryn, great questions in your post. And interesting answers. As a former RN who still reads medical literature, I sometimes do criticize the presentation of a character…not necessarily the way I learn or discover the diagnosis the writer if working from, but how the writer carries that through in the story. My brain doesn’t easily accept miracles when I have attached a diagnosis to a character. But that’s just me. As others indicate here, it is something to consider when deciding to include a diagnosis. We cannot make up cures (unless we are writing a miracle story) yet we don’t want to be writing a medical text. We do need to do research. What you did in you first novel worked well. As a reader drawn to the works of Atul Gawande, Abraham Verghese and others…the presentation of medicine needs to have power and to be accurate. Fiction can be fiction…but miracles on the page might not work. And there are always readers like me who might put the book down if the miracle is simply impossible!
Interesting to add miracles into the discussion, Beth. I bet you could believe if the writer had carefully tended to averting the reader’s disbelief. If you include the unexplainable right on page one, the reader will accept surrealism as evidence of genre, and the writer would have an easier time of convincing the reader.
But you raise another important point here, and that’s that we writers do not know who will be reading our novels—among them lawyers, engineers, snowboarding champions, and doctors—and our novel will be ruined for them if they pick up a factual discrepancy. Thanks for enhancing the discussion!
I feel it can be enriching and important (in some cases) for the writer to know the diagnosis, but not necessarily tell the reader. Not all the time, but sometimes it helps to have that road map.
One point I disagree with, though: “Back before it only took a tap of the finger to paste a celebrity photo onto a Pinterest board or borrow a bio from a known sociopath, writers imagined their characters into existence.” … I’d argue that’s quite unfair to modern writers. Characters were often inspired by existing people, or even existing fictional characters, long before the internet! And modern writers certainly still dream plenty of characters into existence.
Lily I agree with your first paragraph, 100%. Your point that I’m slighting modern writers, who also often base their characters on real people, is fairly presented. To be clearer, I was talking specifically about characterizing characters who suffer from an illness, by way of pointing out that they all have different personalities as opposed to being the sum of their trying symptoms. And I do think the best of published work does characterize well, even when written by doctors such as Abraham Verghese and Robin Cook. Sorry if I was unclear.
Great post, Kathryn. Three thoughts:
From real life: when my wife was suffering symptoms she thought were a reaction to cortisone shots she was getting for a neck condition, a nurse practitioner on a hunch did an ultrasound, and discovered a “complex mass” in Terri’s abdomen. An autopsy revealed she had Stage IV ovarian cancer. That diagnosis was like a visit from Death itself, for the prognosis was alarmingly unfavorable. And that proved true to events–Terri was diagnosed on September 12, on the following January 8, she passed away. No treatments worked, all the news was bad, and that was her “journey” through her illness. As Claude noted above, in this case of this sort the disease becomes a kind of antagonist, and stating it outright serves a clear purpose of revealing to the character what she is up against.
From fiction: A character in my last novel was diagnosed with “schizoaffective disorder,” which her best friend and the narrator describes as “a lot of syllables in search of an explanation.” I didn’t want her mummified in a set of symptoms, but rather prone to anxiety and misperception but also, as events unfold, capable of strength, certainty, and courage.
Finally, sometimes the absence of a diagnosis can amplify the worry over what might be happening — not just for the patient but for their caregivers. Our pup right now seems to be having a relapse of bronchitis he suffered last year, but it’s unclear at the moment. We’re taking him in to the vet tomorrow. But in the meantime, his condition is constantly on my wife’s mind and mine. (Fergus just soldiers on, as dogs often will do unless really sick.)
Hi David, thanks for reading. Terri’s story had a twist right from the beginning—who would have thought that’s the diagnosis she’d be leaving with that day? I’m sorry her fight against her antagonist was such a short one—or, if she was in profound pain, maybe that part was a blessing.
As for your fiction: I LOVE THIS: “a lot of syllables in search of an explanation.” That’s the kind of fanciful language that can humanize medical issues as actors in a story. And “prone to anxiety and misperception” as well as positive traits sounds like a great case study in how to pull off creating a character that comes with a diagnosis.
And the tension of “not knowing” is a wonderful addition to this conversation, thank you!
Kathryn, I am in awe of the human body, mind, soul, how beautifully we’re created (there are no mistakes) and human behavior is endlessly fascinating. I agree that any diagnosis should be in service of character and story. In my novel BOUND, one of the sisters is developmentally delayed (no diagnosis except that her mother contracted an unspecified viral infection during pregnancy) and there are so many unknowns. The story family and the reader have to live with the uncertainty that we’ll never know how she’ll fare in the future. The other sister was burned severely several years prior, but she lives with both the physical and mental scarring. She’s the narrator. One reviewer said among some other very nice things: “The descriptions of the medical procedures were so detailed I wondered if the author had gone through the process of skin grafts personally.” Both these characters’ afflictions are based on my cousins but I had to also do extensive research to get the details right, but they all serve the story. Thank you for reminding us that the story always comes first.
Hi Vijaya, sounds like you have a good grasp on the role of diagnosis as it affects characterization and plot. Thanks for sharing examples from your stories. Re: the skin grafts, I happen to like a fair amount of medical detail when appropriate because it’s an interest of mine (the details about leprosy in Verghese’s The Covenant of Water and Alice McDermott’s Absolution were fascinating), but it just depends on the scenario. I love that your character’s developmental delay was unspecified, because often times, the root cause of such a thing can only be guessed at anyway. When we don’t know, we must learn to accept and do the best we can.
Good post, Kathryn. My two-cents’ worth: illness or medical condition needs to be handled like other aspects of narrative, like setting, explained only to the extent that it informs the story and character, not in such detail that it distracts, confuses, or bores the reader. Plus, a little mystery can add to characterization, without overworking it (what was she really doing in that Brazilian rain forest where she contracted this disease?).
Sorry for the late reply, Christine, but it was for good writerly reasons—went out for cocktails and dinner with the women I meet with to write each week to celebrate the year’s accomplishments! We should all take time to do this.
I like your example about the question raised in the Brazilian rainforest, presumable while contracting a medical condition. Or was she there because of her condition—seeking a natural cure, perhaps? My mind is off an running. And of course like all things, the amount of medical detail depends on the character relating that detail. A doctor or researcher might give more detail, a clueless dad or a harried mom might give less. Character reigns supreme.
I’m inflicting a grim medical diagnosis on my main character to find her joy in life. She will get a late stage breast cancer diagnosis with poor prognosis, as I did, have a quadruple mastectomy, as I did, and kick breast cancer’s butt, as I hopefully will continue to do. My protagonist won’t let shape shape her life. As you may guess, the subtext will critique body image/shaming, especially online/SM. She’ll be mocked for wearing tight clothes that make her rib cage look like her breasts droop to her waist (tentative title: Honey, Does This Dress Make Me Look Flat?). The uncertainty I navigate is how tender and scared a potentially terminal diagnosis leaves (not just) the patient. Friends and families are also devastated (sending you a hug, David). On my blog I playfully listed my 10 best things about not having breasts anymore, but it’s not a fun dance to partner with a deadly diagnosis. Thanks for a great post that the story balance depends on the character; wise words that I’ll put to immediate use in my draft.
I’m glad you found this helpful, Deborah. When in doubt, especially with the protagonist, I turn first to inner conflict. If you explore only her fear, that might be too obvious. But maybe she won’t allow fear to emerge right now because she’s heading into battle and can’t afford to be derailed, sending a signal to loved ones that their tears aren’t helpful right now, which has the effect of leaving her feeling alone with her antagonist at a time when she could really use the hugs that make her feel too vulnerable. I may have that wrong, but you won’t! How can she be feeling both “this” and “that”? This complexity will make her pop, make her more relatable, and more real.
I have several characters who probably have mental disorders. They are undiagnosed, and will likely remain that way. Readers may draw what conclusions they want.
Noelle I love the way you suggest “characters who probably have mental disorders.” Ha! There are days when I think that’s all of us. Who truly know their own mind, or how it works? As a writer, I like this approach, since each of us is a mystery. From my personal experience, the trick is a consistent characterization that won’t confuse the reader—especially if the disordered thinking results in constant inconsistency.