When Dr. Rachel Kowalsky (who was showcased in our Writers Conference twice these past few years – as a moderator in the first annual event, and a speaker in the second – sets out to tell a story, she doesn’t reach for memoir or case studies. She reaches for fiction. And in her case, fiction comes ablaze.
Her short story Burn follows Serafina, an emergency medicine resident who bursts into flames every time she feels constrained. It’s an image that is as surreal as it is searing, and it allows Kowalsky to explore the invisible forces that shape medicine, and the people who practice it.
“Burn is a short story about an emergency medicine resident who bursts into flames every time she feels constrained,” Kowalsky explains. “Writing it, I wanted to explore the various constraints and desires that can act on a person during a single ER shift. What holds us back? What makes us burst into flames (metaphorically) at work?”
The choice of fire was deliberate. “I like fire as a metaphor because fire is a sign of something invisible that’s happening—it’s the visible result of an invisible chemical reaction that releases heat. So, it makes the invisible visible. Many people we interact with are ‘on fire’ in some way, especially in the ER. They are angry or afraid or in pain, or something else has sent them off course and landed them in the ER.” For Serafina, the flames arrive suddenly, uncontrollably. “The fire just came over her, as emotions often do.”
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Through Serafina’s combustion, Kowalsky is able to explore the limitations of gender, hospital culture, and medicine itself, along with the desires that often feel out of reach: more resources, more justice, more love. “Serafina wants more of everything—more resources, social justice, love,” she says. “And at the end of the story, she realizes that she just can’t have it. She confronts this truth in the trauma bay… and also at the end of the story, when she realizes, ‘They’ll all just go on burning.’”
This isn’t just a fictional exercise. Kowalsky remembers feeling combustible herself. “Right after the peak of the pandemic had passed, I had some very challenging shifts. Many supply chains had been disrupted, so we would run out of simple things like saline bottles or suture supplies, and at one point there was no liquid amoxicillin in any of the New York City pharmacies. Those shifts felt like wading through the mud, like I was fighting to get things done hour by hour. For me, that’s the definition of moral distress—not being able to do what you want for your patients. I was on fire every shift.”
What kept her going was the team beside her. “Luckily, I love the actual work, and I have an amazing group of colleagues and admin team. That’s what kept me engaged during that time.”
Of all the constraints in her story, gender remains the one she feels most urgently. “I have cared for so many Faiths and Destinys—so many girls on fire—in my work,” she says. “Faith self-harms, something tried by 20% of girls in the USA; in her case because she thinks she is ugly. The expectation to be thin and conventionally beautiful weighs heavily on girls and women.” Destiny, another character, is pregnant and does not want to be. “Her presence in the story is a commentary on the limitations on women’s rights being imposed by the U.S. Supreme Court as well as the simple fact of anatomy—two people have sex, but only one gets pregnant: the one with the uterus.”
For Kowalsky, literature provides a way to tackle subjects that medicine and science cannot. “Literature can express so much more than science can, because it’s not constrained by the realities of the physical world,” she explains. “It can travel forward or back in time, explore hypothetical questions and ‘what if’s,’ and it can inhabit multiple perspectives at once. In this way, it can much more easily access the parts of our humanity and our patients’ humanity that aren’t easily articulated during a case presentation or demonstrated in a collection of test results.”
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That’s why she chose fiction over memoir. “Fiction is my genre. It often feels more genuine than reality to me. Reality is constrained by the rules of the moment—culture, politics, social norms. But in fiction, you can sidestep these constraints by using metaphor, mechanisms of plot, and my favorite—magic realism,” she says. She points to Orwell and O’Connor as examples: “Think about 1984, which is one of the greatest criticisms of totalitarianism ever written, yet never refers to actual people or events. Flannery O’Conner… said it this way: ‘We must give the artist the liberty to make certain rearrangements of nature if these will lead to greater depths of vision.’”
She then brings it closer to home with a scene from Burn. “Serafina cares for a child name Felicidad who is crossing the street with her mother when a car speeds up and hits them. Hopefully, most New Yorkers are not hateful enough to purposely run down a child, so this would be unlikely to happen (though admittedly not impossible). But now think of it as a metaphor. Children get run down all the time as casualties of adult politics, which play out upon the bodies of children via legislation about vaccines, gun control, even free lunch in schools. Some adults do literally step on the gas when there is a vulnerable child in the crosswalk. Rather than write a scientific paper or an Op Ed about this, using fiction, I can simply put Felicidad in the crosswalk and send the same message in a more visceral way.”
Not everyone in Serafina’s world can see her burn. Only her mother, a teacher, and her best friend Liv can. “It highlights the fact that so many people burn in secret, without being seen or supported, and that paying attention to others can be a therapeutic and even transformative act,” Kowalsky says. Of all her relationships, Liv’s is the most profound: “Liv is so tuned in that every time Serafina bursts into flames, she nearly dies of smoke inhalation.”
This, she believes, is a mirror for peer support in medicine. “ER doctors are in a prime position to ‘see’ other ER doctors because we understand the challenges inherent to the work. We need to look out for each other, check in, follow up with each other after tough cases.”
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And then, there is the ER itself: the ever-changing backdrop of Burn. Kowalsky calls it magical. “For me—a Guatemalan American—the ER is straight out of Popul Vuh, which is the Mayan creation epic,” she says. “It’s a crossroads. The ER holds a confluence of people who speak different languages, have different perspectives and traditions, different family compositions, are differently abled, etc. Even the consultants who come down to the ER have their own culture… It’s also a place of intersecting emotions: fear/safety, guilt/redemption, anger/relief.”
In the end, Kowalsky hopes Burn reaches many different kinds of readers. “I hope trainees will feel that their hard work and the challenges they face are ‘seen’ here. I hope women also feel ‘seen’ in this nod to the constraints of gender. I hope patients will feel ‘seen’ in their suffering too,” she says. “The truth is that most clinicians care deeply and are quite affected by the people they care for; we work inside a system of social forces and challenges that can stand in the way of spending sufficient time or solving every problem that confronts us. But the humanity is there, even if it’s hard to see.”
“Through writing this story, I think I worked out for myself that we have to be creative and flexible and play the hand we’re dealt. We have to do our best in spite of whatever gets thrown at us—the covid pandemic, whatever’s next.”
In Burn, Dr. Rachel Kowalsky takes what is often hidden in medicine; (the constraints, the injustices, the quiet humanity) and makes it visible. Like fire itself, her story illuminates what we might otherwise miss.
She does not have a book out yet, but you can follow her on her website.
Those shifts felt like wading through the mud, like I was fighting to get things done hour by hour. For me, that’s the definition of moral distress—not being able to do what you want for your patients. I was on fire every shift.
