Writing is a Deep Conversation

Originally published in the 10/29/2021 issue of the Transformational Times

 

 

Writing is a Deep Conversation

 

Adina Kalet, MD MPH

 

 

Dr. Kalet, who recently published the latest edition of her book, Remediation in Medical Education: A Mid-Course Correction, which she coedited with UCSF faculty member, Calvin Chou, MD, shares her feelings about the value of writing together with others, and why authorship is among the most complex and critical aspects of what we do. She proposes that, if we can do it well, solid writing opens important conversations and can be deeply satisfying …

 

 

If writing seems hard, it is because it is hard. It is one of the hardest things people do.

-William Zinsser, On Writing Well: The Classic Guide to Writing Nonfiction

 

 

As an early-career physician and clinical educator, I felt none of the traditional “publish or perish” academic pressures because, for most of my working life, I had no particular desire to be promoted. So, you may ask, why do I spend so much of my time writing now? The answer to this has evolved. I write to work things out and begin dialogues, much as Joan Didion hinted when she said, “I write entirely to find out what I am thinking.” Once a concept or project has been committed to the page, I am better equipped to engage in conversations about the things that matter to me. 

 

 

I didn’t always love to write

 

Thanks to a few generous mentors, editors, and spell checkers, I now love to write. This was not predictable. Despite a good-enough elementary education, it never occurred to me that writing could be a deeply satisfying communal experience. Like most of us, I learned the rules of grammar, parts of speech, sentence, paragraph, and essay structure, and how to appropriately use quotations and citations to passively draw on the ideas of others. It was all done in a dry, uninteresting, and lonely way. It wasn’t until I discovered, through writing for publication, that one was entering into deep, complex, and important conversations with others, that I became willing and eager to do the hard work. And it is very hard work. But luckily, it is almost never a solo pursuit. 

 

As medical education scholar, Lorelei Lingard, asserts in her stupendous new book Story, Not Study: 30 Brief Lessons to Inspire Health Researchers as Writers (Springer International, 2021): 

 “Medical education moves forward because we share insights, question methods, argue the relevance of emerging ideas and build on one another’s efforts. All of this is possible in large part because of writing, and it explains why writing is such a highly valued currency ….”

Dr. Lingard has taught me through her “writing about writing” to think of the process as a way of entering critical conversations to clarify our thinking. We converse with those who came before us by reading the relevant literature, we converse with those with whom we work by writing together (not easy by any stretch of the imagination, more on that later), we converse or spar with editors and peer reviewers and, finally if we are lucky, we get to converse with our readers. It is a cacophony of conversations. 

Learning the value of writing with others rather than alone

 

One of my most beloved mentors, medical sociologist Jo Anne Earp, ScD, had a framed picture in her office which, literally, is how I really learned to write.  It is a line drawing of a young child on tippy toes, holding a bright red crayon, caught in the act of crossing out and rewriting the statement, “A good mentor accepts ,expects, respects a first draft.” Sitting in her office, struck dumb by the anxiety of having to write about my work, facing that picture, I truly understood for the first time that writing could be a collaborative process. I was paralyzed as I tried to start writing my very first 300-word abstract to submit to a professional meeting. Recognizing my predicament, Jo Anne took her pen and lined yellow pad in hand and asked, “What should we title this?”  I dictated; she wrote. We switched roles.  Sentence by sentence, we polished the words until we were done. It took one hour, an hour in which I learned the key to collaborative writing—what I now call “yoked pair” writing—a process that I use with my colleagues and mentees almost every day. Now, we sit in front of a computer screen and ask each other, “What do we think?” 

 

Writing is hard. No question. Yet now I see that writing can also be a highly valuable, satisfying, and fundamentally communal experience. Since I learned the value of writing collaboratively with others, my writing partners will tell you I am relentless in extoling its virtues. This is because I believe that writing together is the best way to think clearly and develop ideas. 

 

 

Now, I am an enthusiastic writing coach

 

I regularly share my inner writing nerd. On my shelf is a stack of slim books which I both read and give away. My favorites are the latest edition of Strunk and White’s The Elements of Style illustrated by Maira Kalman (I adore the Basset Hound on the cover), Stylish Academic Writing and The Writer’s Diet both by Helen Sword (where I first discovered that I was a “flabby” writer  - yikes!), the hilarious Eats, Shoots & Leaves: The Zero Tolerance Approach to Punctuation! by Lynne Truss from whom I finally understood commas; How to Write a Sentence and How to Read One by Stanley Fish and, now, Lingard’s Story Not Study, which is an expansion of a series of papers she edited for the journal Perspectives in Medical Education entitled the “Writer’s Craft.” Of course, writers must also be readers and must have very good editors! 

 

 

Ode to our TT editorial team

 

This is my sixty-seventh Transformational Times Director’s Corner. Before March 2020, all the writing I had done had been as part of a team. I had never published an essay as a single author. When the newsletter was launched and I committed to writing a weekly column, Bruce Campbell became my editor. It requires great talent and generosity to craft someone else’s words. Bruce has done this for me almost every week for the past eighteen months as an act of kindness and compassion despite his surgical and clinic schedules, the publication of a book, and the responsibilities of a professor of otolaryngology at MCW. 

 

I experience his editing as I do an honest conversation with a close colleague.  What he does is the writing equivalent of “active listening.” By reading and rearranging my words, he is saying, “I hear you. Now let me restate that a bit and see if we can make it truer and clearer.”

 

This has been a profound learning experience. At the beginning, my drafts were “messier” and he had to push up his sleeves, often late at night, to find the wheat and eliminate the chaff. By rereading my words with his edits, I have learned how to write in this short essay format.  Originally, he did a heavy edit, rewriting sentences, reorganizing paragraphs and titling sections to hammer the piece into a readable form. Now he takes a lighter touch, refining the words, aligning the tenses, shortening the sentences, and very occasionally rearranging the paragraphs. We have learned to write together, and this has made all the difference.  

 

 

So, let’s get writing!

 

As the Kern Institute moves the mission to transform medical education forward, we must define, refine, and share our ideas. Writing and publishing are critical to this process. Consider writing as a team sport! I hope you enjoy this issue of the Transformational Times as we examine the highs and lows—and the nuts and bolts—of academic publishing. 

 

 

Adina Kalet, MD MPH is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.

 

 

 

Reposted: Our Ancestors’ Wildest Dreams: From Slave & Immigrant Families to Ivy League Residents

Updated and reposted from the April 21, 2023 issue of the Transformational Times

Our Ancestors’ Wildest Dreams: From Slave & Immigrant Families to Ivy League Residents  

British Fields, MD and Adriana Perez, MD 

 

Drs. Fields and Perez are two first-generation, underrepresented in medicine (URiM) physicians who navigated a system that once didn’t accept people that looked like them. They describe creating a space of advocacy for patients and future generations of Black and Brown medical students ...

 

“No, I’m not the interpreter. No, I’m not the cleaning staff. I’m a student doctor.” These phrases became all too familiar to us as we embarked on the journey to becoming physicians. We had gone from being praised for being the first doctors in our families, to countless encounters with patients and medical staff assuming we weren't the student doctor because of the color of our skin.  

 

The Culture Shock 

Being first-generation medical students came with a lot more struggles than we anticipated. One of the hardest challenges to overcome was that of being financially disadvantaged. Who knew there would be a whole hidden curriculum requirement? Spending money to get on an equal footing seemed like an impossible task as our families didn’t understand that there was much to becoming a doctor than what was taught in lectures.  

We both soon realized we weren’t in Kansas anymore. The rigor of medical school was something we did not fully grasp until we both failed the first quiz after two weeks of nonstop studying. After many failed exams, we spiraled into four years of secret self-doubt, self-loathing, and imposter syndrome.   

Although these feelings became ingrained in us, we knew that there was a bigger purpose at play here as our patients said “¡Si se puede hermanita, necesitamos mas doctores como tu!” (You can do it little sister; we need more doctors like you!). 

 

Our Commitment to Changing Culture 

While we knew coming into medical school that we were not in the majority, the differences in our identities and background were further amplified. Although these feelings initially weighed us down, we learned to harness and use them as fuel to support each other and other students throughout our journey. We quickly became involved with different organizations at MCW that shared goals of supporting students who are racially/ethnically and economically disadvantaged at the institution, in the community, and eventually at a national level through the Student National Medical Association (SNMA), Latinx Medical Student Association (LMSA), and White Coats for Black Lives (WC4BL).  

 It didn’t always feel like we were having an impact, but we were reminded to continue our work when we heard comments like, “Your story inspired me to take a gap year to retake the MCAT and apply next year!” 

We also sought ways to increase our involvement in caring for historically marginalized and vulnerable communities in Milwaukee. Through the Saturday Clinic for the Uninsured (SCU) and Walker’s Point Community Clinic (WPCC), we were reinvigorated to solidify our place in medicine as patients told us, “You’re the first doctor I’ve had that looks like me.” These were the times that inspired us to keep pushing in moments of self-doubt on patient rounds or failed exams.  

  

The Light at the End of the Tunnel 

At MCW, we found the things that we are most passionate about, mentors who believed in us, and served as role models. We gained the exposure and the tools necessary to continue to pursue our work in addressing healthcare disparities through research and within medical education through teaching and mentoring students at all levels of training.  

No, we are not just future physicians. We are advocates, teachers, mentors, change agents, and hermanas (sisters).  

 

British Fields, MD graduated from MCW in 2023 and is now a Pediatric resident at Harvard University’s Boston Combined Residency Program in the Leadership in Equity and Advocacy Track. 

Adriana Perez, MD graduated from MCW in 2023 and is now a resident in the Yale University School of Medicine Department of Anesthesiology. 

Photography and the Medical Humanities

 From the 4/9/2021 edition of the Transformational Times

Photography and the Medical Humanities

Carlyle Chan, MD

Dr. Chan served on the AAMC Arts and Humanities Integration Committee that drafted the FRAHME (Fundamental Role of Arts and Humanities in Medical Education) report. He shares how a deeper dive into the humanities, and photography in particular, can teach physicians to be better observers and help “defy acceleration” in their lives …

“The arts teach creative means of expression, understanding of different perspectives, an awareness of knowledge and emotions throughout the human experience, and the sharing of perceptions through artistic creation and practices in the expressive world.”

“The humanities teach close reading practices as an essential tool, an appreciation for context across time and space, qualitative analysis of social structures and relationships, the importance of perspective, the capacity for empathic understanding analysis of the structure of an argument…”

-NASEM 2018

Similar to the NASEM (National Academies of Sciences, Engineering, and Medicine) report, the object of the AAMC FRAHME (Fundamental Role of Arts and Humanities in Medical Education) initiative was to “improve the education, practice, and well-being of physicians through deeper integrative experiences with the arts and humanities.”

Photography is a visual art that consists of many sub-categories including, but not limited to, landscape, fine art, portrait, street, food, and photojournalism.  Like other visual arts a photograph can evoke very different personal responses from each individual viewing an image.  Photographer Minor White utilizes the term Equivalence to describe this response.   In psychiatry, we might describe this as a form of transference.  That is, we bring our past experiences into our present-day life.  

For the photographer, photographs have a magical element.  In a fleeting moment, a person can preserve a scene in perpetuity.  As the saying goes, “Take a picture.  It lasts longer.”  However, the camera is not as sensitive as the human eye.  With the exception of photojournalism, adjusting an image after capturing one (a.k.a. postproduction) allows the photographer the creative freedom to better represent what was seen in the mind’s eye.  This is not unlike a painter who may add clouds and move objects to improve a scene’s composition.  Both these activities, picture taking and postproduction, are creative processes.  The former requires, among other skills, powers of observation, perspective taking, composition, and appreciation of lighting.  The latter includes the same skill sets plus technical ones to help develop the final product.  

It has been said that one way to relieve stress is to find an activity that defies acceleration.  Taking and processing photos does slow down the pace of life.  One views and studies the scene to be captured and similarly views and studies the image to be rendered.  Engaging in photography not only provides a diversion from the demands of clinical practice and a respite from life pressures, but also an outlet for creative endeavors.  Photographs are another vehicle for implementing Visual Thinking Strategies while helping avoid burnout.  Parenthetically, the best camera to have is the one you have with you, be it a professional grade SLR or one on a smartphone.  Lastly, and perhaps most importantly, photography is fun.

Carlyle Chan, MD, is Professor and Vice Chair for Professional Development and Educational Outreach in the Department of Psychiatry and Behavioral Medicine at MCW. 

Remediation: A Story About Maryam

Reprinted from the January 27, 2023 issue of the Transformational Times

Remediation: A Story About Maryam 

Cassie Ferguson, MD 

 

Dr. Ferguson, who is a reknowned mentor and educator at MCW, tells the story of one student who came to her when on the edge of academic despair ...

The most rewarding mentoring relationship I’ve had with a medical student began the day she came to see me in my office to tell me about her experiences on academic leave. Maryam* had heard that I started a task force to learn about our school’s remediation process and wanted to share her story with me. I now know her to be a fierce, determined daughter of immigrants, but that day in my office she sat hesitantly on the very edge of her chair, backpack on, and glanced frequently at the door, as if she hadn’t yet decided to stay. Her voice was flat, and she rarely made eye contact when she spoke. She told me that after failing a course by less than a percentage point, she was asked to take an academic leave of absence before her first year ended. She might be able to come back, she was told, in the fall and repeat her entire first year. What she was not told was that when she drove to school the day after her leave began, her student ID would not work, and she would not be let into the school’s parking lot.  

“They just threw me away,” she said.   

Maryam’s story—her whole story—would take me years to learn. How she was diagnosed with multiple sclerosis during her first year of medical school after months of attributing her symptoms to stress. How she learned that she was dyslexic in her second year of medical school. How intense test-taking anxiety finally drove her to seek help from a psychologist. That information would be given to me in pieces as she grew to trust me, and I have slowly and carefully put those pieces together. Even now, four years after we met for the first time and three years of meeting with her every other week, I know that Maryam has not revealed all the pain she felt during that time, or during the struggles she has had since. I believe that this is in part because of her reluctance to seem as if she is making excuses, in part because of the intense shame that accompanies failing in medical school, and in part out of deference for the archaic medical hierarchy that still hangs over our profession, and the accompanying perception that my time is somehow more valuable than hers.  

That hurt we embrace becomes joy. / Call it to your arms where it can change.

-Rumi 

Medical school is not for the faint of heart. As a result, supporting medical students—particularly those who are struggling—requires love, grit, and fierce compassion. I have learned both through my own experience with failure and from working with students like Maryam that if we are to live up to the titles of teacher, mentor, and advisor we must walk with our students; we must show up even when showing up is uncomfortable. It is precisely when things get hard that we need to lean in and wade through the uncertainty and pain with our students. This requires that we recognize that we have something to offer because of our own life experiences, but I believe the bigger imperative is that we acknowledge that the boundaries of our experiences limit our ability to know what our students are going through. The only way to begin to truly understand is to get very quiet and listen to their stories.  

When we listen to a story, research using fMRI demonstrates that our brain activity begins to synchronize with that of the storyteller; the greater our comprehension, the more closely our brain wave patterns mirror theirs. The areas of our brain involved in the processing of emotions arising from sounds are activated, particularly during the more emotional parts of the story. Even more amazingly, when we read a story, the networks of our brain involved in deciphering another person’s motives—in imagining what drives them—prompts us to take on another person’s perspective and even shift our core beliefs about the world. 

It is impossible to engage properly with a place or a person without engaging with all of the stories of that place or person.

-Chimamanda Ngozi Adichie 

These findings should not come as a surprise to those of us whose work includes caring for patients. As an emergency medicine physician, I have heard thousands of stories. Whether they are snapshots relayed through EMS of how a 14-year-old child was shot in the head at two in the morning on Milwaukee’s north side, an exquisitely detailed account of a 3-year-old’s fever and runny nose from her mother, or a reluctantly provided history of pain and despair that led a 12-year-old to try and kill himself, each of these stories should transform us. They should move us to want and do better for our patients, for our communities, and for our world.  

At the same time, it is essential that as physicians and educators we also recognize what Nigerian author Chimamanda Ngozi Adichie describes as the “danger of the single story.” As an emergency medicine physician, I only hear stories of peoples’ suffering; I am listening to them when they at their most vulnerable, on what may be the worst day of their life. I only hear of the tragedies that have befallen a neighborhood we serve. As an educator who mentors students who are struggling, I often miss out on their stories that are not about failure or crisis. Adichie warns that when we only listen for the single story, there is “no possibility of feelings more complex than pity, no possibility of a connection as human equals.”  

So then our charge as physicians, as educators, and as human beings is to make room for more than just a single story—to remember that all of us are much more than our worst moments, and that compassion and connection arise authentically when we recognize the full spectrum of humanity in one another.  

*Names have been changed.  

Catherine (Cassie) Ferguson, MD, is an Associate Professor in the Department of Pediatrics, Section of Emergency Medicine at MCW and Associate Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.