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A conversation with Carol Cassella, about her book Gemini which addresses difficult ethical questions about life, death, and medicine.
What was the genesis of Gemini? Did you begin with an idea about a character or plot point? Or something else?
After writing two novels told from a doctor's point of view, I knew it was time to give the patient a chance to speak, so that was the first step in creating Raney. Then I needed to decide what the mystery would hinge upon and I turned to the world of genetics, which is rich with possible storylines.
As a mother of twins, and as a doctor, I've long been interested in how much of our lives is dictated by the genes we land here with—a blueprint over which we have no control. But my identical twins (who share the same DNA and upbringing, but have very different personalities), have also confirmed that who we are and how we respond to events in our lives is far more complex than either nature or nurture can explain.
Once I had those starting points decided, my characters began to emerge and the novel grew into a story that encompassed those elements, but also much more. Truly the most fun part of writing a novel is watching it take on a life of its own as it grows and changes over time.
In your first novel your main character was an anesthesiologist, your own specialty; in Gemini your main character is an intensive care physician. How did you approach writing from the perspective of this specialty? How are the demands of this job different from anesthesiology?
Intensive care medicine and anesthesiology overlap quite a lot—they both focus on acute care situations rather than long term problems, and to do them well you need to love physiology—the mechanics of how the heart, lungs, kidneys, and liver keep us alive. They are both fast-paced patient care settings where things can change very, very quickly, so they tend to attract similar personalities. In fact, many intensivists begin with a residency in anesthesiology before doing a fellowship in intensive care medicine. So Charlotte's work was more familiar to me than, say, a pediatrician's or an oncologist's. On the other hand, it has been years since I worked with patients who were as sick as Raney, and I depended on several ICU experts to get the details I needed. The biggest difference between the two specialties is that in the ICU the patients arrive very, very sick, and the intensivist has to try to turn that ship around. In the operating room, most of the patients arrive reasonably healthy—or at least stable—and our job is to keep them that way.
The title of the novel is the zodiac sign for twins. Why did you choose to highlight that theme?
The title Gemini was suggested to me by an editor, so I can't take full credit. It doesn't fully make sense to the reader until the end of the book, when all the pieces of the mystery come together, but once you see the novel as a whole, the title seems perfect! The Gemini myth of Leda the swan and her twins Castor and Pollux—one mortal and one immortal—plays perfectly into Jake's life, both biologically and metaphorically. But there are other "twin" stories at work in the novel, too: Raney and Charlotte, for all their differences, share similar personalities. They are both gritty, skeptical of the status quo, independent yet loyal to those they love. I imagine they would have been friends if they had been born into more similar circumstances. And in the course of the novel they are both faced with wrenching decisions about how far to go when caring for a terribly ill person they care about. I even saw Eric's life in twin terms—the boy he was before his diagnosis usurped his belief that he could ever live a normal life, and the man he became afterward.
The settings of the novel help define your characters and contribute to the novel's conflicts. Was it important to you to have parts of the novel set in the Olympic Peninsula? Did you base Quentin on a specific place?
If you have visited the Pacific Northwest you know that our natural beauty is unparalleled. (Yes, I am prejudiced!) One day of sunshine here is well worth the ten days of rain that pay for it. It is such a joy to describe our landscape that I can never resist setting parts of my novel within it. But it also reflects much about Gemini's characters and their conflicts—particularly Raney's. The Olympic Peninsula, home to Olympic National Park and the rainforest, is completely unspoiled in areas, but many of the towns and the reservations are struggling with poverty and unemployment. In ways, it is only four hours but ten light years from Seattle. This has a huge affect on Raney's life, of course. What would she have been able to do if she had been born into a more privileged family? How would that have changed the decisions she made?
On a more thematic level, contrasting the natural world of Raney's woods and coast against the highly technical setting of an urban hospital's ICU made a good backdrop for a novel that raises questions about natural death versus using every possible intervention at the end of life.
The novel deals head-on with moral and ethical questions about death and life, and when and how it should be extended by medical means. What prompted you to confront these questions? Do you find your own answers to these questions changing with new experiences from your work or life?
I don't think you can be a doctor in this day and age and not struggle with these questions. We have all seen miracles result from new medical discoveries and interventions—people who are given another chance to hold new grandbabies or hug their spouse. But we have also stood at the bedside of patients tethered to a ventilator, going through a long and drawn out death that none of us would want and which causes the patient's family extraordinary grief. Too often we, the doctors, are to blame, because we weren't strong enough to advise them honestly. And as medicine has become more complex, we need more and more specialists involved with critical patients, each focused on their own organ system rather than the complete picture. Sometimes families hear conflicting messages but no one physician is taking the time to listen closely, answer questions, and help them come to difficult decisions. It isn't that doctors don't care, it's often that a rushed and fractionated healthcare system inadvertently neglects that hand-holding component. I often worry that we have raced forward in inventing medical marvels, but our ethical framework and guidance hasn't had time to catch up.
More critically, though, in the last four years this question has become quite personal because several close friends and family members have become gravely ill or died. Being at someone's bedside as a family member, rather than as a doctor, has had a profound effect on my thoughts about end-of-life care.
As our technological ability to extend the end of life increases, do you think understanding the implications of that ability is as challenging for doctors as it often is for individuals and families?
Absolutely. We are approaching the question from different angles—doctors who are deeply invested in saving lives and becoming skilled in the tools that accomplish that, and families who are mired in grief, remorse, and longing as they struggle with end-of-life decisions. Only fifty years ago, less even, death happened more naturally. There was nothing we could do but console. Now we sometimes have to make very hard decisions, and the outcome of those choices isn't always predictable. Will they lead to a few more days or months of good quality life, or a very uncomfortable, even more tragic death? These conversations are extremely difficult for doctors to initiate. They take time, and need to happen early and frequently, and there is little leeway in the fast-paced healthcare system to support that.
It's critical for doctors to remember, though, that we must not only be shepherds of good health and long life, we must also be shepherds of good deaths. Death is not a failure—it is the natural and inevitable transition we all make at the end of our lives, just as we made the natural transition through birth into the beginning of life.
What sort of research did you do for the novel? Do you research as you write, or beforehand?
The research for Gemini was extensive and broad—maybe that's why my acknowledgments run two and a half pages! But I love that part of writing. Before I begin a novel, I have to know that the topic interests me enough to hold my attention and curiosity for the two or three years it takes to finish it. I spoke to neuroscientists, geneticists, intensivists, medical ethics specialists, forensic specialists, law enforcement officers, lawyers, and protective guardians. Then there's the Internet, which can become a drowning ocean of valuable facts. I usually do several months of research in advance, which gives me the nuts and bolts of the mystery twists, then I augment that with focused research questions as plot points or dialogue need tweaking. I'm sure I still miss some details, but it is really important to me that my novels are grounded in solid science. While I want my novels to be entertaining, I also enjoy translating the fascinating world of medical science into words that anyone can understand and appreciate.
Your books always contain intriguing medical quirks or situations. Have you always been interested in these unusual details? Do you find yourself collecting them, making note of them for future books?
The best part about medicine is the mystery—the challenge of taking a collection of symptoms and physical findings apart and tracing them back to the root problem—hopefully one we can fix. There are so many more mysteries in medicine than confirmed facts that it never gets boring, particularly when they involve all the social and emotional layers that affect our health and wellbeing.
I've been a fiction writer and reader since I was very young (though I didn't fully dive in until my forties), so I tend to walk through the world looking for ideas. If some new and startling fact intrigues or puzzles me, I figure it will intrigue and puzzle readers, too, so I write it down or make a voice memo for later reference. Now if only I could live long enough to use them all. . . . Ah, but that dilemma goes right to the heart of this novel, doesn't it?
Would you describe where and how you like to write? In the mornings or evenings? With music or without? How do you transition from parent or doctor mode to writing mode?
Here is my ideal writing life: Every single morning I get up and put on my soft baggy sweat pants and fleece, make a huge latte, sit in front of the fireplace by the windows and let my imagination spin out on the keyboard for two or three hours before I tackle the less creative tasks of my life, such as email or those dirty dishes. Here's the reality: I leave for the hospital at six and come home too tired to do anything but eat and go to bed, or (on the days I'm not in the operating room) I get pinged with critical meetings or messages about children, the business side of being a novelist, or the business side of medicine, and I'm lucky to get an hour or two somewhere in the day to create a bit of fiction. To compensate I often spend two or three days locked in a room where I do nothing but write.
Unfortunately I need total silence to write, though I love music and find it very inspiring. I usually try to take a break and go for a long walk or run with music, and I always come home with fresh ideas. Movement and exercise are important for generating creative work. It can be difficult to transition from parenting or doctoring to the quieter, inner world from which my stories arise. But that's a problem all of us face, isn't it? I'm so often asked how I balance the different roles in my life, but truthfully I don't know many people—especially women—who aren't constantly juggling all the obligations in their lives.
If there's one thing you'd like readers to take away from Gemini, what would it be? What do you look for in fiction?
A good book needs to linger much longer than the time it takes to read it. I want readers to come away from all my novels with more questions than answers—questions that spark conversations and richer internal thought about issues we all face. In Gemini, I'm hoping to spark a conversation about what, for each of us, constitutes a good and meaningful death. Those answers will be different for everyone, but they are key to another question I'm raising in these pages: What constitutes a meaningful life? How do we approach love and art and work, and our own definition of family, so that our lives are as rich and fulfilling as they can possibly be and we fully appreciate each of the finite days we are granted on this earth?
Unless otherwise stated, this interview was conducted at the time the book was first published, and is reproduced with permission of the publisher. This interview may not be reproduced or reprinted without permission in writing from the copyright holder.
Vanessa Diffenbaugh was born in San Francisco and raised in Chico, California. After studying creative writing and education at Stanford University, Vanessa taught art and writing to youth in low-income communities. To write ... (more)
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