By: Carol EH Scott-Conner, MD, PhD
WHY WRITE?
If you keep a journal, you are familiar with the process of putting words
to an event. Writing down what happened allows you to place the event into a
kind of context, externalize it, reflect upon its significance, and maybe
remove some of the heat of emotion from it. This brief article deals with the
logistics of transforming those journal entries into published creative fiction
or nonfiction.
WHY SHARE YOUR STORIES?
Think back to those early years when you, as a young person, began to
formulate life goals and when you first heard the vocation (in the truest sense
of calling) that led you to surgery. Perhaps you were influenced by a life
event, an encounter with a charismatic surgeon, a family member in the
business, or maybe your goals were shaped by things you read. By books and
stories. Stories capture the imagination by tapping into a cultural heritage
that goes back to the days when our distant ancestors gathered around the fireside
to tell tales. Physicians who write for a wider audience dare to share their
own stories with the public.
We work in a time of severe fiscal and administrative constraints. Much
of our time and energy is spent dealing with these issues. It can become
joyless. Somewhere along the line, patients became consumers, and physicians
and other members of the healing professions became providers. Creative writing
is a way for you to renew your own passion and to communicate the passion – the
drive that keeps us in our careers – to the next generation of potential
surgeons and to outsiders.
START BY KEEPING A JOURNAL
Any writer needs material. Fortunately, as surgeons we are surrounded
by the deepest mysteries of life and death. We routinely encounter people in
crises, and are able to observe a great range of humanity up close and person.
It is no accident that some of our greatest writers, such as Checkhov, were
physicians.
The best place to start is simply to keep a journal. There is no
pressure to ever share what you have written with a broader audience, but if –
at some future date – you wish to do so, you will have material.
If you have never kept a journal, I recommend the “Morning Pages”
approach described by Julia Cameron. She suggests that you begin every day by
writing three pages of anything you wish. Three pages – no more, no less. I
have been doing this for about 14 years. I spend about 30 minutes at the start
of each day with a cup of coffee and my journal. I write one or two significant
events that I recall from the day before, or I write down my dreams, or I write
down some possible solutions for writing projects that I am stuck on. Sometimes
I can only finish one or two pages before I have to go to the OR. In that case,
I finish my three pages at the end of the day.
Over the course of the day, I might make a note or two of something
that caught my eye or captured my imagination. Let’s say, for example, that
when I shook hands with a patient’s husband after surgery, I was struck by how
strong and warm and blunt his hand was, and that (like many farmers) he had
lost the terminal part of a finger or two. I might note down simply “farmer’s
hands.” The next day, I might journal for a page or two or even all three about
how that hand felt and about all the hands over the years, all the family
members (husbands, primarily nowadays) I’ve spoken with, all those
interactions.
Or, on my bike ride home, I might catch a glimpse of migrating white
pelicans in flight. That becomes something to note down, and write about the
next day.
Why not just write about it when it happens? First of all, usually
there isn’t time. Second, the delay allows reflection, and you have a topic or
topics in mind when you sit down to write. You aren’t simply facing a blank
page with a fuzzy mind and a cup of coffee in hand.
Over time, material accumulates and the habit of writing becomes
engrained. Maybe you will start to get the urge to share your experiences with
a broader audience. The material that
follows deals with various aspects of creative writing for publication.
FINDING YOUR GENRE: FICTION
VERSUS NONFICTION VERSUS POETRY
About twenty years ago I started to get inquiries from male colleagues
(most of my colleagues, in those days, were men) who had daughters – “my
daughter is thinking of going into surgery. What can I give her to read?” and
when I tried to come up with a list, I realized that the very few books
available at that time written by female surgeons, mostly memoirs, although
very true were largely written from a place of bitterness and struggle. There
was very little I could come up with at that time that conveyed the sense of
joy and vocation that I would want to pass along. So I set out to write.
I began thinking I would write a memoir. So, let’s start with memoir as
an exemplar of creative nonfiction. Creative nonfiction is a term used to apply
to the general body of writing the truth, in which the writer uses some or all
of the techniques of fiction. The one thing that is not allowed is trampling on
the facts. Memoir is particularly tricky. The inevitable editing that has to
occur – simply winnowing down the events of a lifetime into a handful worthy of
inclusion – is of necessity subjective. Memoir says, here is the truth, as best
I remember it. It is a window into a period of time, a way of life. A memoir
that is perceived as self-serving is self-defeating. Memoir needs to tackle the
difficult issues – it is the tension between the narrator and the world that
brings it to life. Think back to the hardest times in your professional life
and ask yourself if you are willing to bring these to the page.
Ask yourself also if you have kept good enough records (or have access
to good enough records) to accurately reconstruct what happened. Ask how you
will incorporate patient-specific details. How will you portray administrative
struggles? How will you deal with family issues? Add to that the difficulty in
reconstructing the past, in the absence of accurate records, and you may start
to see the appeal of fiction.
Creative nonfiction for surgeons goes much farther than memoir,
however. It encompasses a spectrum ranging from essays such as “A Piece of
My Mind” in JAMA that explore the humane aspects of the practice of
medicine through pieces that explain various aspects of medicine and healthcare
for the public. There is an almost insatiable appetite for this kind of material,
and it forms an easy segue from the writing you have already done in your
professional life to the creative writing realm.
Let’s talk specifically about “A Piece of My Mind.” It’s one of the
first things I turn to when each new issue of JAMA arrives. The vast majority
of these pieces are clinical vignettes and feature a physician and a patient –
sometimes the physician is the patient. The guidelines specify that the piece
must be nonfiction. Information can be withheld, but nothing can be changed. The
permission of the patient is required, if the case is in any way identifiable.
The piece must be short – the word limit is 1800. Increasingly, in this kind of
writing, the consent of the patient or family (and the opportunity to review
the piece of writing) is required. Most of the time, consent is readily granted
and leads to a new dimension in the patient-surgeon relationship.
Physicians are sometimes driven to write after they experience the
health care system themselves, either as a patient or as the close relative of
a patient. Often the experience is a negative one. The thing that distinguishes
the best of these pieces of writing is a sense of distance, a dispassionate
objectivity that can only come with time. Indeed, one medical literary journal
noted that this was the single largest failure they noted in rejected pieces.
Fiction affords greater latitude. The first thing to understand about
fiction (and it took me a while to get this basic point) is that it has a
structure. Much of what we encounter in the course of our work as a surgeon is
simply anecdote. Something happens. Fiction needs a protagonist, and the
protagonist must have a goal. Something intervenes to thwart attainment of this
objective, and there is conflict with resolution. Often the protagonist emerges
changed in some way. So for the typical clinical encounter, the protagonist
might be a patient, a surgeon, a trainee, a family member. The possibilities
are endless.
Simply taking a clinical vignette and changing various aspects to make
the patient unrecognizable is not enough to make something fiction. And this
gets me to a key point. If you are really serious about creative writing, you
would do well to take advantage of opportunities around you to learn the craft.
Poetry is a thing apart. Poetry, more than other forms, demands
attention to the shape (form) as well as the content. My experience as editor-in-chief of our
literary journal, The Examined
Life, has convinced me that writing poetry for publication requires
specialized skills and knowledge which I do not possess. Writing poetry for
yourself, of course, is another issue. I included some references at the end
that may be helpful, but the remainder of this short article with deal
exclusively with prose, especially in expanding upon some of the key issues in
writing for publication.
LEARNING YOUR CRAFT
I come from Iowa City, the home of the famous “Writers Workshop” – now, I’m not part of
the workshop and I haven’t studied there (it’s an extremely competitive MFA
program). But I subscribe to the philosophy
behind the name. Workshop implies a place where things are made; and part of
the philosophy is that writing is a craft, and that aspects of the craft can be
learned, taught, and practiced. Studying these aspects of craft allow you to
express yourself far more effectively.
As surgical educators, we know that some trainees come to surgical
residency with a greater degree of eye-hand coordination and learn operative
skills faster than others, but none of us would expect a raw trainee to go into
the operating room and perform an appendectomy without study and practice.
Similarly, we need to lay to rest the myth of the born-writer, who sits
alone in a room and is visited by a creative muse. The words just flow, and you
either have it or you don’t. Just as we all learned how to operate, how to
perform scientific experiments, so too creative writing is a set of skills to
be studied.
How do you get started? It’s not that different from the search for a
collaborator with specific expertise when you embark upon a research project.
All universities have creative writing programs. An increasing number of
medical schools incorporate creative writing into the curriculum for the
medical students. Once you start asking around, you are likely to find a core
group of physician-authors at your own institution. There may even be a
literary journal, either on-line or print, at your college of medicine. For
sure, there’s a good chance your university has one. At the University of Iowa
there are at least three. The University hosts the prestigious Iowa Review, a
well-established literary journal. The College of Medicine hosts the new The
Examined Life Journal (of which I am the editor-in-chief), now putting together
its fourth issue. And there is at least one student-run journal at the
University.
Writing conferences such as the Iowa Summer Writing Festival provide a
variety of short courses and the opportunity to interact with fellow-writers,
most of whom are not physicians. There are, in addition, specialized
conferences designed for medical writers, such as The Examined Life Conference
held at the University of Iowa Carver College of Medicine.
How do you work with the material at hand? Obviously, respect for
confidentiality and feelings of patients and colleagues must rule. This is why
I went the fiction route! It’s not enough just to change the names. Remember,
you aren’t writing a case report. The part that we as physicians may find most
compelling - the medical details of the case - really matter the least. What
matters is the interaction between individuals. How people change.
Use a writing group (preferably non-physicians) or writing courses to
“workshop” your writing. Get your piece as good as you can get it, and then let
your group have at it. Take careful notes! Notice what they found
incomprehensible (jargon!) or what fascinates them. Correct the jargon (I had a
group get hung up on “laparotomy pad” for several minutes) and expand upon the
fascination. For example, several years ago I wrote a short story called “The
Sound of Thunder,” about an unsuccessful resuscitation. Initially I thought it
was about the tension between a surgical resident (who wanted to go all out and
take a dying elderly patient to the OR) and an attending who decides otherwise.
I live in a rural area so I often mix bits of nature into my stories - I threw
in a snapping turtle (“once they bite, only the sound of thunder makes them let
go.”)
The piece was triggered by an actual event, but I drew on a lifetime of
these decisions to invent a composite resuscitation scenario that was pure
fiction. Protecting the patient was the easiest thing in the world, because the
medical details of the scenario (although they had to be true to life) mattered
the very least. When I shared this story in a writing workshop, the non-physicians
in the group liked the medical details, but they were fascinated by another
aspect - how do you go home at night after a day like that? How do you interact
with your spouse? What do you say? (Read
the completed piece here.)
There are a variety of excellent books out there for the neophyte (or
even the experienced) writer. I particularly recommend Robin Hemley’s Turning
Life into Fiction. At heart, all writers are magpies and thieves,
picking up bright jewels from the sidewalk, stitching them together into some
kind of narrative. All writers deal with issues of disclosure and respect for
that which should not be written. For the nonmedical writer, it may be issues related
to family or friends. For us, it is patients.
WRITING THE SHORT STORY
For many medical writers, a short story starts with a clinical
anecdote. This problem also occurs with beginning fiction writers who are not
physicians. The problem is that an anecdote is not a story. A story has a
structure, but an anecdote is just something interesting, bizarre, or amusing
that happened. Many of the tales we tell our friends are really anecdotes. You
can take an anecdote and shape it into a story, but you have to do the work and
you have to understand the structure and conventions of a short story – these
shape the expectations (consciously or unconsciously) of your readers.
That odd thing that happened during your last call night? It’s an
anecdote. Put it into the structure of a story – add a protagonist (hero), a
task, a complication, and a resolution; change the clinical facts, and it might
be a short story. When I think of the structure of a story, I remind myself of
the fairy tales I read as a child. Most of them began something like this:
“Once there was a ____. Every day, she _____. Then one day, _____. So she ____”
etc. and so on until “And they lived happily ever after” Your story doesn’t
have to state those parts explicitly, but your clinical anecdote might provide
the interruption – the “then one day…” element. How did that occurrence
complicate your life, change your life, or change your outlook? It doesn’t have
to be a huge change, but there must be some kind of transformation.
The nice thing is that it’s fiction! So the clinical details, all the
identifying information, are easy to change, once you set your mind to it. Was
it a case of a critically injured burn patient? Well, change the mechanism of
the injury, the age and gender of the patient, the distribution of the burn
over the body, the clinical issues; create a composite out of all the
experiences you have had, and draw essential truth of the story from how you
were affected. Or maybe change it to a critically injured non-burn trauma
patient. The possibilities are limitless.
WRITING CREATIVE NONFICTION
The best creative nonfiction draws on techniques used by fiction
writers to create interest, suspense, or to move the reader. The difference is
that nothing has been changed. As I noted above, there is an increasing trend
to involve the patient (or patient’s family) and to get consent, rather than to
omit identifying details and simply press on.
Creative nonfiction for surgeons actually encompasses a wide range of
forms. There is memoir, clinical vignette, reflections on your own illness or
professional experience, the transformation of going from medical student to
resident, or the clear explication of medical facts in such a way as to
fascinate the lay public (Gawande,
Oliver Sacks).
I ventured into creative nonfiction when, a little over a year ago, I
was diagnosed and successfully treated for Stage I breast cancer. At this point
in my career, my practice consists exclusively of patients with breast disease,
so there was a certain irony. When I began to reflect on the experience,
nonfiction narrative offered the perfect vehicle. I started to think about
scars, the scars of burn patients, the scars of surgical patients, physical and
emotional scars of all kinds. I wrote a rambling lengthy reflection on scars
which I submitted to Pulse – Voices from the Heart of Medicine. A
generous-hearted editor went through several iterations with me and the final
piece, balancing fact and reflection, was published in their online journal.
What I learned from the process was the importance of emotional
distance from the experience, and the balance between the triggering event or
events and the internal reflection on those events.
SUBMITTING TO LITERARY JOURNALS
Let’s shift gears and talk about getting published. And I ask you to
forget for a moment the world of The New Yorker, Paris Review and the Atlantic.
If you are publishing in those, you really don’t need my advice. For the rest
of you, follow me into the world of small literary journals where many creative
writers are happy to find a niche.
Getting published in the world of creative writing follows a completely
different set of rules than the kind of scientific, or technical writing that
we are used to. To start from the most basic rule – when you submit a paper to
one of the surgical journals, you follow the rule of “no simultaneous
submissions.” When I send a story to a literary journal, I (and all the other
creative writers out there) routinely send it to five, ten, sometimes twenty at
the same time. This is just simply reality. I have had stories accepted for
publication on the first go-around, and I have had others accepted after 50 or
60 rejections (and some revision).
It can take a journal a year to decide to reject a story – and life is
short. Because the literary journals have failed to exercise draconian rules,
each small but established journal may receive thousands of submissions for an
issue, of which they may publish 30. You can do the math.
In some ways, publishing in literary journals is very similar, however.
Just as some surgical research papers are ideally suited for the Annals of
Surgery and others belong in Transplantation (or some other subspecialty
journal), so too literary journals have niches. To take a clear example, there
is a literary journal called The Healing Muse (see below) that is housed at the
Center for Bioethics at SUNY Syracuse. That journal occupies a clear niche that
will be different from, say, The Chicago Review. Look through some copies of
the journal before you submit.
A complete listing of literary journals can be found at New Pages (see
resources at the end of this article).
Here is a short list of small literary journals that concentrate on
medical humanities and that accept submissions from individuals outside their
own institution:
WRITING BOOKS
This all usually culminates in the desire to write a book and have it
published. Books have a kind of permanence and heft, a gravitas that pieces
published in periodicals do not. As with shorter pieces, if you are going to
write a book, it needs to fit into one or another type or genre. Will it go on
the Memoir shelf or the Novel shelf? Will it be history, or historical fiction?
Maybe you are going to write science fiction. Choose a genre and study the
forms, expectations, and best examples of that genre.
Generally you will need a completed manuscript before you approach an
agent or publisher. University presses are natural publishers of nonfiction
books (such as memoir, or the history of a department of surgery or a
specialty), but tend to shy away from fiction. A third option, besides
commercial publishers and academic presses, is self-publishing. Options such as
CreateSpace and Kindle Direct have made this easy, painless, and sometimes the
best option. There are a large number of excellent books about the process of
writing (and getting published). I recommending going to a large local
bookstore (or public library) and browsing the “writing” section.
A FEW LAST WORDS
As I said in the beginning of this piece, writing is a learned art just
like surgery. You can learn how to do it, if you wish. Three elements for
success as a writer are:
- Material – we have no shortage of that as
surgeons!
- Writing – in other words, sit down and write. Perseverance
helps here
- Knowledge of, and respect for, the craft – study
the craft of writing, and READ, read, read
As surgeons, we have unparalleled access to the human experience, and
the demonstrated ability to persevere when we take on a task. Take time to add
some knowledge of the craft and go forth and get published! It is so much fun
to send something out into the world and then hear back from an old friend at
another institution (or a colleague at your own institution) who just read it.
RESOURCES
- Julia Cameron The Artist’s Way: A Spiritual Path to Higher Creativity.
New York, Putnam Books, 1992. This will get you started on your “Morning Pages”
journal.
- Robin Hemley Turning Life into Fiction. St Paul MN, Gray Wolf
Press, 2006. Although geared to fiction writers, this book deals with a lot of
issues related to transforming actual events that happened to real people into
printed words.
- Carolyn Forche and Philip Gerard (eds) Writing Creative Nonfiction.
Cincinnati OH, Story Press, 2001. Lots of great chapters dealing with all
aspects of nonfiction writing, although not specifically medical.
- John Gardner The Art of Fiction: Notes on Craft for Young Writers.
New York, Vintage Books, 1984. A classic, inspiring as well as offering
guidance.
- Janet Burroway Writing Fiction: A Guide to Narrative Craft. 5th
edition. New York, Longman Press, 2000. Lots of examples of good fiction, as
well as concrete guidance.
- NewPages.com: This is an online listing of Literary Magazines – of all kinds, not just
medical – with links to their websites
- Mark Strand and Eavan Boland. The Making of a Poem: A NortonAnthology of Poetic Forms. Good basic information if you want to write
poetry.
- The Iowa Summer Writing Festival - An annual offering of weekend and week-long courses in all aspects of creative
writing. Relatively inexpensive, and totally accessible (anyone can come) with
classes limited to 12. Great value and great fun!
- The Examined Life Conference - An annual conference dedicated to writing as a part of the medical humanities.
Carol Scott-Conner is Professor and former Head of the
Department of Surgery at the University of Iowa Carver College of Medicine. As
she grew older, she turned to creative writing as a way of conveying the rich
and varied experiences she has had as a surgeon. A
collection of her short stories was published as A Few Small Moments and other short stories are available at her website.
