Thursday, May 15, 2014

Creative Writing for Surgeons

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



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.

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