Charles Atkins's Blog - Posts Tagged "publishing"
Pearls to get You Puiblished
As I prep for the release of my latest mystery--VULTURES AT TWILIGHT (Severn House)I came upon the following that I wrote for the now defunct Byline Magazine. It's all about the circuitous route to getting published. For me, this is all about the journey. The product is great, but how we get from point "A" to "B" is endlessly interesting--at least to me.
Furrballs & Pearls
Published in Byline Magazine as “Pearls that Get you Published”
Charles Atkins, MD
At four-thirty on Monday morning my cat throws up on The Chicago Manual of Style. This is not an omen, I reassure myself while cleaning it up and moving on to the morning’s writing.
This time in the dark, while the rest of the world sleeps is when I work on novels, map out marketing strategies, answer emails from my agent, publisher, and publicist and hammer out the next column or article. These are words written when my brain is sparking to life under the kindling effects of the day’s first cup of coffee. I never know where the words will lead me, but that’s the excitement of writing while half asleep. At seminars when people ask me how I do it, I tell them that the secret is one of trusting the process and trying not to think too much. Don’t think . . . write.
The Chicago Manual of Style, from here on marred with a small brownish stain, was a concession to my first agent who harangued me about my ignorance of the comma, “Buy a book, learn this and move on,” she instructed me after receiving a three-hundred page manuscript with the same comma error repeated several hundred times,
My path to becoming a writer, and now a published author, is constructed of thousands of such mornings. I’d always wanted to write a book, but I’d never had the discipline, at least that’s what I’d thought. Then came medical school, internship, and residency. Like eight years of boot camp they trimmed away all of my self-defeating habits with endless chapters to memorize followed by sleepless nights on-call. As a writer this discipline gives me the stamina to start a book on one day and finish it two to three months later. It’s easy; each day is a thousand words, and don’t skip days.
For the past couple years I’ve taken that writing to the market place. It’s like jumping hurdles; each one brings me further along on the road. Pearls of wisdom, like luminous guideposts, help steer the process. It’s a path that others have been down, but it’s obscured and like those three-D images that appear when your eyes have sufficiently lost focus, the way to publishing is not always clear.
So what are the pearls?
The first is the basic, “writer’s write.” If you don’t make time on a regular basis, it’s not going to happen. The book won’t get written, the screenplay you’ve been carrying around in your head won’t make it to the printed page, and that groundbreaking article on the perfect orgasm will never make it to Cosmo. All of the successful writers I’ve encountered have a writing habit. It’s best to put something down on paper everyday. Beyond that, like other habits, it’s helpful to set up a regular time and place. The “when” is unimportant, but it should be daily.
The next pearl has to do with creativity, and how to avoid writer’s block. My understanding of creative process is what allows me to sit down at my computer and have perfect faith that what I’m going to write will make sense, and have a beginning, a middle, and an end. As a psychiatrist, I have years of experience in seeing what shuts down creativity. The number-one killer of the muse is criticism. More often than not, it’s internally generated. When I worked at Yale providing counseling to graduate students, I mentally divided them into two groups, those that whizzed through their theses without a problem and those that stalled out. I found that the stymied pre-docs were critiquing their work as they tried to create it. Invariably, they found it wanting; it wasn’t good enough, or important enough, or what their supervisor wanted. These self-critical messages made it impossible to maintain the creatively mushy brain state that allows for interesting writing. This phenomenon was articulated for me at a creative writing seminar where the instructor encouraged us to write without editing. You can always edit later, but when it’s time to do a rough draft—for me at least—the goal is to get it down on the page. If it’s horrible I can always come back later and burn it.
So once you have a book written, how do you take it to market? The first piece of advice I received about publishing was from another physician author. He said, “Publish something small first, like a short story. It’ll help build your credentials.” He was right, but this also falls under the category of easier said than done. This became my introduction to rejection letters. Like most authors, I have received many of these. But rejection is not all bad. In amongst the form letters that assure me it’s not my writing but simply, “does not meet our requirements at this time,” are often helpful hand-written lines and paragraphs that let me know the real reason. Sometimes they steer me in the direction of another publication, and sometimes they clue me in to some key element that I need to incorporate. Maybe it’s not a rejection letter after all, but a request for me to redo the piece in a manner more in keeping with the needs of the publication.
The first novel I wrote, a medically based-action-adventure-gay-themed-romantic-comedy thriller—now safely buried at the bottom of a drawer--received the following comment scrawled in the margin of a quarter-sheet form letter, “this is very unprofessionally formatted!!!!” I overlooked the three exclamation marks, told myself it was written by someone with the emotional maturity of a seventh grader, but I did take the message to heart. I bought a book on manuscript formatting. Sure, I’d double-spaced and laser printed, but my headers were wrong and all of the other conventions that separated the pros from the amateurs hadn’t been observed. It was a great, albeit snotty, rejection letter, that helped me clear a hurdle.
A rejection letter, and the emotions it can fuel inside of us, is a potential pitfall for many would-be authors. I often hear people talking about the one or two times they submitted something and had it returned. They feel devastated and defeated. For some, they never clear this hurdle. Rejection has an annoying way of finding deep resonance within us. This is where some careful reminders can help us stay on track. Rejection is not personal and more often than not, the piece we sent really isn’t right for the publication, or they have no space to print it, or they just ran a similar piece, or…When I started submitting articles and essays, I told myself that I was doing well if one in ten were accepted. That’s now down to about one in three. Rejection letters are part of the business of writing, not to be confused with the art of writing; it’s important to keep these separate. When I receive a rejection letter, I read it, file it in a folder, and forget about it—unless of course there’s something handwritten that is useful. They’re not something to stew over. And as another author told me about rejected pieces, “don’t let them sit longer than twenty-four hours in the house.” What he meant was, look the piece over, revise it if necessary, and then send it somewhere else.
The next step is critical; if you want to get a book published you need an agent. When I started I wasn’t certain that this was necessary—haven’t we all read such success stories? But then I met the ex-owner of a publishing house at a conference. He set me straight with two sentences, “Sure we read unsolicited manuscripts. But in the twenty years I ran **** Press we never once published one.” It was a pearl not to be overlooked. I refocused my efforts, bought a book on the subject, wrote a succinct query letter, and got an agent.
Once I had representation the quality of rejection changed. No longer were manuscripts getting returned from editorial assistants, but they now came back with letters from senior editors and vice presidents. And then, wonder of wonders, we got a nibble, and then another, and then a two-book deal.
Now that I’ve entered the realm of the published—my first book came out last year and I have another coming out this fall--I face a new series of hurdles. But as before the pearls are dropping and I’m just the little piggy who’s going to pick them up.
I now spend considerable time on marketing and publicity—a subject that fills many books and more in-depth articles. What I’ve learned is that I am ultimately responsible for how my books sell. New authors, in the age of cost-conscious, downsized publishing houses, must not depend on the marketing department. They will provide some basics, but on beyond that you’re on your own. But here again, there’s a road. I do a lot of talks, charity events, and every television and radio interview I can land. An author friend of mine refers to it as being a “publicity slut”, where she’s been on Oprah seven or eight times, I’m not about to argue.
As I look back through this article, I can’t help but think, “what an awful lot of work this is.” And that’s the truth. I write because I have to, because it’s a passion--a labor of love. As a psychiatrist, I am all too aware that most people move through life with no passion. So I pay attention to those things that nurture my craft. I practice daily, and listen to the wisdom of those that are further down the path; I find this works.
Bio—Charles Atkins is a practicing psychiatrist and author. He has written both fiction and non-fiction. His latest mystery--VULTURES AT TWILIGHT (Severn House) will be released in the UK in January 2012, and May 2012 in the US.
Furrballs & Pearls
Published in Byline Magazine as “Pearls that Get you Published”
Charles Atkins, MD
At four-thirty on Monday morning my cat throws up on The Chicago Manual of Style. This is not an omen, I reassure myself while cleaning it up and moving on to the morning’s writing.
This time in the dark, while the rest of the world sleeps is when I work on novels, map out marketing strategies, answer emails from my agent, publisher, and publicist and hammer out the next column or article. These are words written when my brain is sparking to life under the kindling effects of the day’s first cup of coffee. I never know where the words will lead me, but that’s the excitement of writing while half asleep. At seminars when people ask me how I do it, I tell them that the secret is one of trusting the process and trying not to think too much. Don’t think . . . write.
The Chicago Manual of Style, from here on marred with a small brownish stain, was a concession to my first agent who harangued me about my ignorance of the comma, “Buy a book, learn this and move on,” she instructed me after receiving a three-hundred page manuscript with the same comma error repeated several hundred times,
My path to becoming a writer, and now a published author, is constructed of thousands of such mornings. I’d always wanted to write a book, but I’d never had the discipline, at least that’s what I’d thought. Then came medical school, internship, and residency. Like eight years of boot camp they trimmed away all of my self-defeating habits with endless chapters to memorize followed by sleepless nights on-call. As a writer this discipline gives me the stamina to start a book on one day and finish it two to three months later. It’s easy; each day is a thousand words, and don’t skip days.
For the past couple years I’ve taken that writing to the market place. It’s like jumping hurdles; each one brings me further along on the road. Pearls of wisdom, like luminous guideposts, help steer the process. It’s a path that others have been down, but it’s obscured and like those three-D images that appear when your eyes have sufficiently lost focus, the way to publishing is not always clear.
So what are the pearls?
The first is the basic, “writer’s write.” If you don’t make time on a regular basis, it’s not going to happen. The book won’t get written, the screenplay you’ve been carrying around in your head won’t make it to the printed page, and that groundbreaking article on the perfect orgasm will never make it to Cosmo. All of the successful writers I’ve encountered have a writing habit. It’s best to put something down on paper everyday. Beyond that, like other habits, it’s helpful to set up a regular time and place. The “when” is unimportant, but it should be daily.
The next pearl has to do with creativity, and how to avoid writer’s block. My understanding of creative process is what allows me to sit down at my computer and have perfect faith that what I’m going to write will make sense, and have a beginning, a middle, and an end. As a psychiatrist, I have years of experience in seeing what shuts down creativity. The number-one killer of the muse is criticism. More often than not, it’s internally generated. When I worked at Yale providing counseling to graduate students, I mentally divided them into two groups, those that whizzed through their theses without a problem and those that stalled out. I found that the stymied pre-docs were critiquing their work as they tried to create it. Invariably, they found it wanting; it wasn’t good enough, or important enough, or what their supervisor wanted. These self-critical messages made it impossible to maintain the creatively mushy brain state that allows for interesting writing. This phenomenon was articulated for me at a creative writing seminar where the instructor encouraged us to write without editing. You can always edit later, but when it’s time to do a rough draft—for me at least—the goal is to get it down on the page. If it’s horrible I can always come back later and burn it.
So once you have a book written, how do you take it to market? The first piece of advice I received about publishing was from another physician author. He said, “Publish something small first, like a short story. It’ll help build your credentials.” He was right, but this also falls under the category of easier said than done. This became my introduction to rejection letters. Like most authors, I have received many of these. But rejection is not all bad. In amongst the form letters that assure me it’s not my writing but simply, “does not meet our requirements at this time,” are often helpful hand-written lines and paragraphs that let me know the real reason. Sometimes they steer me in the direction of another publication, and sometimes they clue me in to some key element that I need to incorporate. Maybe it’s not a rejection letter after all, but a request for me to redo the piece in a manner more in keeping with the needs of the publication.
The first novel I wrote, a medically based-action-adventure-gay-themed-romantic-comedy thriller—now safely buried at the bottom of a drawer--received the following comment scrawled in the margin of a quarter-sheet form letter, “this is very unprofessionally formatted!!!!” I overlooked the three exclamation marks, told myself it was written by someone with the emotional maturity of a seventh grader, but I did take the message to heart. I bought a book on manuscript formatting. Sure, I’d double-spaced and laser printed, but my headers were wrong and all of the other conventions that separated the pros from the amateurs hadn’t been observed. It was a great, albeit snotty, rejection letter, that helped me clear a hurdle.
A rejection letter, and the emotions it can fuel inside of us, is a potential pitfall for many would-be authors. I often hear people talking about the one or two times they submitted something and had it returned. They feel devastated and defeated. For some, they never clear this hurdle. Rejection has an annoying way of finding deep resonance within us. This is where some careful reminders can help us stay on track. Rejection is not personal and more often than not, the piece we sent really isn’t right for the publication, or they have no space to print it, or they just ran a similar piece, or…When I started submitting articles and essays, I told myself that I was doing well if one in ten were accepted. That’s now down to about one in three. Rejection letters are part of the business of writing, not to be confused with the art of writing; it’s important to keep these separate. When I receive a rejection letter, I read it, file it in a folder, and forget about it—unless of course there’s something handwritten that is useful. They’re not something to stew over. And as another author told me about rejected pieces, “don’t let them sit longer than twenty-four hours in the house.” What he meant was, look the piece over, revise it if necessary, and then send it somewhere else.
The next step is critical; if you want to get a book published you need an agent. When I started I wasn’t certain that this was necessary—haven’t we all read such success stories? But then I met the ex-owner of a publishing house at a conference. He set me straight with two sentences, “Sure we read unsolicited manuscripts. But in the twenty years I ran **** Press we never once published one.” It was a pearl not to be overlooked. I refocused my efforts, bought a book on the subject, wrote a succinct query letter, and got an agent.
Once I had representation the quality of rejection changed. No longer were manuscripts getting returned from editorial assistants, but they now came back with letters from senior editors and vice presidents. And then, wonder of wonders, we got a nibble, and then another, and then a two-book deal.
Now that I’ve entered the realm of the published—my first book came out last year and I have another coming out this fall--I face a new series of hurdles. But as before the pearls are dropping and I’m just the little piggy who’s going to pick them up.
I now spend considerable time on marketing and publicity—a subject that fills many books and more in-depth articles. What I’ve learned is that I am ultimately responsible for how my books sell. New authors, in the age of cost-conscious, downsized publishing houses, must not depend on the marketing department. They will provide some basics, but on beyond that you’re on your own. But here again, there’s a road. I do a lot of talks, charity events, and every television and radio interview I can land. An author friend of mine refers to it as being a “publicity slut”, where she’s been on Oprah seven or eight times, I’m not about to argue.
As I look back through this article, I can’t help but think, “what an awful lot of work this is.” And that’s the truth. I write because I have to, because it’s a passion--a labor of love. As a psychiatrist, I am all too aware that most people move through life with no passion. So I pay attention to those things that nurture my craft. I practice daily, and listen to the wisdom of those that are further down the path; I find this works.
Bio—Charles Atkins is a practicing psychiatrist and author. He has written both fiction and non-fiction. His latest mystery--VULTURES AT TWILIGHT (Severn House) will be released in the UK in January 2012, and May 2012 in the US.
A Road Well Traveled: The Physician-Author and the Continuum of Story
A Road Well Traveled: The Physician-Author and the Continuum of Story
By
Charles Atkins, MD
“There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.”
--William Osler
It’s no accident that there are so many physician authors, from Somerset Maugham and Arthur Conan Doyle to modern best-sellers like Robin Cook, Tess Gerritson, Michael Palmer, Michael Crighton and F. Paul Wilson. As I pursue dual careers of author and psychiatrist I realize that this connection is logical and rooted in our profession’s reliance on stories: hearing them, using them and telling them. How we get from one end of the storytelling spectrum to the other is a well-trod road that takes us from the clinical record through authoritative non-fiction to the mainstream novel.
It starts with the doctor’s training. We learn to take a history. “So, what brings you in today?” It’s the simplicity of an open-ended question that invites any response. “I’ve had a cough that won’t go away,” “I got this rash after I came back from Vegas,” “Every time I walk up a flight of stairs I feel heaviness in my chest.” The answers come with emotion and body language; we observe it all: the pain, the fear, the embarrassment. We shape the story, and even enter it, as our attitude and willingness to listen have a strong bearing on whether our patient will trust us enough to give us the truth, the whole truth and nothing but the truth. The more interested, relaxed and non-judgmental we are, the greater the chances of getting the information. We generate hypotheses about the cough, the rash, and the heaviness. We ask more questions, “How long have you had the cough?” “What happened in Vegas?” “Tell me about the feeling in your chest.” We’re careful not to jump too quickly to a diagnosis, as missteps in the gathering of a history lead to wasted time and bad treatment. A cough could be the common cold, or the only symptom of a malignancy. The rash could be from the detergent used on the hotel’s sheets or a psychosomatic concern over an extramarital liaison. Is the chest pain indigestion, angina, panic? Ultimately, it’s the physician’s skill in taking and interpreting a history that is our single most-important tool. It’s all about gathering the data, interpreting it, and putting together a story that makes sense.
As I think back through medical school and residency, I can see that I was taught basic truths about the nature of story that have helped me both clinically and as a writer:
• Common things are common; when you hear hooves, don’t think zebras.
• Consider all angles, who, what, when, where, why?
• Don’t jump to conclusions; generate a differential.
• Consider your reader.
Once we’ve fleshed out the story, it’s time to write it down. As medical students and trainees we learned how to present and write up a case. I remember how as a med student I would be assigned a patient in the emergency room, work them up, and then, with little or no sleep, present them to a room full of other trainees and a Chief of Services who delighted in grilling us. He wanted the whole story and he wanted it with multiple possible endings. “So Dr. Atkins, please enlighten us with the story of your patient, Mr. Jones…”
I presented in the time-honored way. It’s clinical, it’s dry as dust, but it is a story. “Mr. Jones is a 42 year old never-married Caucasian man who presents with three days of sub-sternal chest pain that he describes as, ‘crushing, like something is sitting on me’. It’s worse with exertion, is relieved with rest and radiates to his jaw, but not down his arm…”
Learning to obtain a history and present a case—in both written and oral fashion--lays much of the groundwork for the doctor-writer. Obviously, there’s a difference between what and how we write in a medical record and what’s likely to become a blockbuster novel, but similar skills are required for both. I’ve come to view these different approaches to story as points on a continuum. On one end we have the most-objective clinical reporting and on the other, personal narrative and finally fiction.
Similar to popular non-fiction and fiction, the medical record as a repository of story serves multiple purposes and has multiple readers. All of which must be considered when leaving a note in a medical record. The histories we write lay out the clinical data upon which we arrive at our diagnostic impressions and conclusions. Our notes reflect why we’re prescribing various treatments and whether, and how, they’re working. Our charts must meet criteria for ‘medical necessity’ as defined by various insurers, Medicare and Medicaid should we wish to get paid and not get hauled into court for fraud. We need to remember the Joint Commission reviewer who will look at what we’ve written to see that we’re staying current, are avoiding confusing abbreviations and are cognizant of all aspects of the human being—as defined in their hundreds of published standards of care. What we write needs to be clear so that a colleague covering in the middle of the night knows what is going on. Should there be a bad clinical outcome, the chart is a legal record where the written story is all that matters, ‘if it’s not in the chart, it didn’t happen’.
Just as when writing a novel or non fiction book, I need to consider my readers whenever I document in a chart. As someone who teaches clinical documentation I stress the importance of imagining everyone who could one day read your note standing over your shoulder: the insurance reviewer, the attorney for a patient wishing to sue you, the hospital risk manager, the patient’s mother, the patient, your colleagues, and of course, you.
The medical record requires a particular type of storytelling. It must be factual and free from editorializing. Judgment-laden words and phrases like, patient is manipulative, non compliant, difficult, should be eliminated. Just stick to what happened, what was observed. Or as they say in writer’s lingo “show, don’t tell”.
Even with this attention to the facts, the medical record is highly subjective. When teaching, I’ll give a class of students the data from a single patient and instruct them to write up their formulation and present the case aloud. If there are ten students I’ll hear ten different stories.
From the case presentation or case study we come to the jumping off point that separates clinical writing from narrative and fiction. For physician-authors this leap is not far or difficult. Take the following examples of a standard History of Present Illness, which is then rewritten as a personal narrative (it could also be viewed as the inner monologue of a character in a novel).
Case 1: Case Presentation:
Patient is a 48 year old Caucasian man brought by ambulance to the emergency room following a near fatal suicide attempt by carbon monoxide poisoning in the context of multiple recent stresses—loss of job, separation from spouse and children and severe financial difficulties. For the past four weeks the patient has experienced worsening symptoms of depression including diminished sleep with difficulty falling asleep, early morning awakening and mid-night arousal, feelings of worthlessness and hopelessness and increased thoughts of suicide with a plan to kill himself, which he attempted earlier today. Client was discovered by a neighbor who was concerned by the sound of the car engine in the closed garage.
Case 1: Personal Narrative:
It’s so hard to find words. Everything inside me feels dead. I don’t want to write this, or think. I’d like to go away and be done with everything. I’m so sorry. I’ve screwed up everything; my life…Peg’s the kids. I can’t shake this, and they’ll be better off without me. I should be looking for a job. John told me the layoff wasn’t anything to do with my performance. Others got laid off—I know this--but how do you not take it personally? I feel like a total failure. Like everything I’ve worked for all of these years didn’t matter. You’re with a company for 20 years and they tell you it’s not personal when you have two weeks to say goodbye, clean out your desk, and go for job counseling, which was pointless. I can’t sleep. I lay there, the same thoughts over and over through my head, everything is coming undone. Two month’s of not paying the mortgage. I don’t have the money for the taxes. No one’s going to hire me, not for anything close to what I was making. I’m almost fifty. My whole life is unraveling and there’s nothing I can do to stop it. I get up and even the television is too much. I can’t focus. I hear Leno tell a joke, I used to think he was hysterical; it’s not funny, even though I hear the audience laugh. I used to laugh all the time. People would come up to me and tell me what a happy person I must be because I’m always smiling. Every day, every hour I think about the car and how easy it would be to do this. The weird part is that thinking about killing myself doesn’t feel bad, more like a relief, just be done with it. I think that’s what I’ll do. I’ll do it in the morning.
Once across this divide, how far we go as writers is limited only by our interest, perseverance, talent and skill. My interest as a novelist has been to take psychiatric and forensic topics and explore them in fiction. I picked the mainstream genre of the psychological thriller, ‘A’ because I like to read these, ‘B’ because they’re commercially viable and ‘C’ because as a psychiatrist I know something about human nature and why we do the things we do -- even bad things. The medium of novels is ideal for in-depth exploration of complex subject matter.
For the would-be doctor-writer, there aren’t a lot of absolute rules, but there are some helpful hints. Go with your expertise and write what you know. Beyond that most of the principles of clinical writing continue to apply, you need to think of your reader, and pay attention to the conventions of whatever genre you’ve picked. Just as you consider the Medicare, Managed Care and Joint Commission reviewers when writing in a chart, think about who’s going to read your book and give them what they want.
In novels the first goal is to entertain—why else would someone purchase one? Because I write thrillers they need to generate tension, suspense and fear; they must snag the reader at the first page and not let up. Beyond that I want to educate, both the reader and myself about topics I find interesting, confusing and important. This is where clinical skill and experience can inform fiction.
For instance, in my first book, THE PORTRAIT (St. Martin’s Press 1998) I wrote a thriller that had a hero with a serious mental illness, in this case an artist with Bipolar Disorder (manic depression). I wanted to create an insider’s view of what it’s like to have a serious mental illness, to become psychotic, paranoid and even suicidal. I chose a first-person narrative so that the reader could have this voice inside their head.
“It was funny, the times I had been in the hospital; they didn’t seem quite real, that this, my real life, would be a memory, like a trick done with mirrors. So many ghosts followed me—quick friendships on locked wards, endless mouth checks with hard-faced nurses. The ghosts filled my paintings, worlds populated with earthbound saints and tormented devils. My own Faustian dilemma became a little clearer each year. If I took the pills, so I was told repeatedly, I could avoid the hospital. I could also kiss painting good-bye. So I juggled.”
When I came to my second book, it was at a time when I was working with troubled teenagers who were coming for evaluations at the request of the court, the schools, or parents faced with an out-of-control kid. RISK FACTOR (St. Martin’s Press 1999), allowed me to demonstrate in fiction the process by which a child grows up to become a sociopath. I relied heavily on the theory of experimental psychologist John Bowlby, combined with what I was seeing in my clinical practice. I created situations and a cast of characters that allowed me to show many sides of Attachment Theory. My protagonist was a single mother of two working with troubled teenagers in both inpatient and outpatient settings.
In a sense, the novel can be a delivery system for information. Material that might otherwise be dry and conceptually difficult can be brought to life in ways that are crisp and evocative.
More recently, in the wake of 911, Hurricane Katrina and some personal tragedies, I took the topics of Trauma, PTSD etc. and wove them into a thriller, THE CADAVER’S BALL (St. Martin’s Press 2005/Leisure Books 2006). I wanted to demonstrate through multiple characters how life-threatening events change us, how some people recover and others are destroyed by the experience. In this case my protagonist is a psychiatrist who has been severely traumatized.
“After a year of intensive therapy, I know this. I feel it claw at my sanity. Oh, God, make it stop!
My fingers claw at smoldering steel, as black smoke burns my eyes, “come on, Beth!” I can’t see, I can’t breathe. The smell of gas. Help me! Somebody help me! She’s not moving, her hair caught in the shoulder strap? I smash the window, but I can’t get the door. She’s not breathing. I suck in and put my head through shattered glass, my mouth over hers, tasting her lipstick. Headlights come through the fog. I stagger into the road. My hands wave, “stop!” The whites of a man’s eyes stare through the darkened glass. “Please stop.” He slows and I grab for the closed window; it’s cold against my blistering palm. Why isn’t he stopping? I bang my hand against his window. “She’s dying! Help me!” My palm print, smeared in blood, slips away; he’s speeding up. I scream. A blue sparks turns to flames; it’s in her hair. Help me!
I startled and blinked as a hand tapped my shoulder.
“Doctor Grainger. Peter, are you okay?”
I coughed and fought back the nausea that always comes. “I’m fine,” I said, not knowing where I was, wondering how long I’d been gone.
While the characters are products of my imagination, what they go through is real. This is what I find most-exciting about fiction; we can get to truths about mental illness and human nature and present them in ways that are easily understood by the reader.
When physicians span this continuum of clinical storytelling, from the medical record and case presentations to narrative and fiction, something has been completed. It’s taking what we’re taught in our training and in our clinical practice and giving it life. It’s a practical fusion of the science we learn as medical professionals and the art of being both a doctor and a writer. Beyond that, pushing clinical material into the realm of fiction offers endless opportunities to gather insight into the wonderful complexity of being human. For physicians, this is a well-trod path that’s worth the trip. Our training as doctors starts us on the road; should we choose to follow, it brings us to the whole story, the whole person and the bigger truth.
The Cadaver's BallCharles AtkinsThe Prodigy: A Novel of Suspense
By
Charles Atkins, MD
“There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.”
--William Osler
It’s no accident that there are so many physician authors, from Somerset Maugham and Arthur Conan Doyle to modern best-sellers like Robin Cook, Tess Gerritson, Michael Palmer, Michael Crighton and F. Paul Wilson. As I pursue dual careers of author and psychiatrist I realize that this connection is logical and rooted in our profession’s reliance on stories: hearing them, using them and telling them. How we get from one end of the storytelling spectrum to the other is a well-trod road that takes us from the clinical record through authoritative non-fiction to the mainstream novel.
It starts with the doctor’s training. We learn to take a history. “So, what brings you in today?” It’s the simplicity of an open-ended question that invites any response. “I’ve had a cough that won’t go away,” “I got this rash after I came back from Vegas,” “Every time I walk up a flight of stairs I feel heaviness in my chest.” The answers come with emotion and body language; we observe it all: the pain, the fear, the embarrassment. We shape the story, and even enter it, as our attitude and willingness to listen have a strong bearing on whether our patient will trust us enough to give us the truth, the whole truth and nothing but the truth. The more interested, relaxed and non-judgmental we are, the greater the chances of getting the information. We generate hypotheses about the cough, the rash, and the heaviness. We ask more questions, “How long have you had the cough?” “What happened in Vegas?” “Tell me about the feeling in your chest.” We’re careful not to jump too quickly to a diagnosis, as missteps in the gathering of a history lead to wasted time and bad treatment. A cough could be the common cold, or the only symptom of a malignancy. The rash could be from the detergent used on the hotel’s sheets or a psychosomatic concern over an extramarital liaison. Is the chest pain indigestion, angina, panic? Ultimately, it’s the physician’s skill in taking and interpreting a history that is our single most-important tool. It’s all about gathering the data, interpreting it, and putting together a story that makes sense.
As I think back through medical school and residency, I can see that I was taught basic truths about the nature of story that have helped me both clinically and as a writer:
• Common things are common; when you hear hooves, don’t think zebras.
• Consider all angles, who, what, when, where, why?
• Don’t jump to conclusions; generate a differential.
• Consider your reader.
Once we’ve fleshed out the story, it’s time to write it down. As medical students and trainees we learned how to present and write up a case. I remember how as a med student I would be assigned a patient in the emergency room, work them up, and then, with little or no sleep, present them to a room full of other trainees and a Chief of Services who delighted in grilling us. He wanted the whole story and he wanted it with multiple possible endings. “So Dr. Atkins, please enlighten us with the story of your patient, Mr. Jones…”
I presented in the time-honored way. It’s clinical, it’s dry as dust, but it is a story. “Mr. Jones is a 42 year old never-married Caucasian man who presents with three days of sub-sternal chest pain that he describes as, ‘crushing, like something is sitting on me’. It’s worse with exertion, is relieved with rest and radiates to his jaw, but not down his arm…”
Learning to obtain a history and present a case—in both written and oral fashion--lays much of the groundwork for the doctor-writer. Obviously, there’s a difference between what and how we write in a medical record and what’s likely to become a blockbuster novel, but similar skills are required for both. I’ve come to view these different approaches to story as points on a continuum. On one end we have the most-objective clinical reporting and on the other, personal narrative and finally fiction.
Similar to popular non-fiction and fiction, the medical record as a repository of story serves multiple purposes and has multiple readers. All of which must be considered when leaving a note in a medical record. The histories we write lay out the clinical data upon which we arrive at our diagnostic impressions and conclusions. Our notes reflect why we’re prescribing various treatments and whether, and how, they’re working. Our charts must meet criteria for ‘medical necessity’ as defined by various insurers, Medicare and Medicaid should we wish to get paid and not get hauled into court for fraud. We need to remember the Joint Commission reviewer who will look at what we’ve written to see that we’re staying current, are avoiding confusing abbreviations and are cognizant of all aspects of the human being—as defined in their hundreds of published standards of care. What we write needs to be clear so that a colleague covering in the middle of the night knows what is going on. Should there be a bad clinical outcome, the chart is a legal record where the written story is all that matters, ‘if it’s not in the chart, it didn’t happen’.
Just as when writing a novel or non fiction book, I need to consider my readers whenever I document in a chart. As someone who teaches clinical documentation I stress the importance of imagining everyone who could one day read your note standing over your shoulder: the insurance reviewer, the attorney for a patient wishing to sue you, the hospital risk manager, the patient’s mother, the patient, your colleagues, and of course, you.
The medical record requires a particular type of storytelling. It must be factual and free from editorializing. Judgment-laden words and phrases like, patient is manipulative, non compliant, difficult, should be eliminated. Just stick to what happened, what was observed. Or as they say in writer’s lingo “show, don’t tell”.
Even with this attention to the facts, the medical record is highly subjective. When teaching, I’ll give a class of students the data from a single patient and instruct them to write up their formulation and present the case aloud. If there are ten students I’ll hear ten different stories.
From the case presentation or case study we come to the jumping off point that separates clinical writing from narrative and fiction. For physician-authors this leap is not far or difficult. Take the following examples of a standard History of Present Illness, which is then rewritten as a personal narrative (it could also be viewed as the inner monologue of a character in a novel).
Case 1: Case Presentation:
Patient is a 48 year old Caucasian man brought by ambulance to the emergency room following a near fatal suicide attempt by carbon monoxide poisoning in the context of multiple recent stresses—loss of job, separation from spouse and children and severe financial difficulties. For the past four weeks the patient has experienced worsening symptoms of depression including diminished sleep with difficulty falling asleep, early morning awakening and mid-night arousal, feelings of worthlessness and hopelessness and increased thoughts of suicide with a plan to kill himself, which he attempted earlier today. Client was discovered by a neighbor who was concerned by the sound of the car engine in the closed garage.
Case 1: Personal Narrative:
It’s so hard to find words. Everything inside me feels dead. I don’t want to write this, or think. I’d like to go away and be done with everything. I’m so sorry. I’ve screwed up everything; my life…Peg’s the kids. I can’t shake this, and they’ll be better off without me. I should be looking for a job. John told me the layoff wasn’t anything to do with my performance. Others got laid off—I know this--but how do you not take it personally? I feel like a total failure. Like everything I’ve worked for all of these years didn’t matter. You’re with a company for 20 years and they tell you it’s not personal when you have two weeks to say goodbye, clean out your desk, and go for job counseling, which was pointless. I can’t sleep. I lay there, the same thoughts over and over through my head, everything is coming undone. Two month’s of not paying the mortgage. I don’t have the money for the taxes. No one’s going to hire me, not for anything close to what I was making. I’m almost fifty. My whole life is unraveling and there’s nothing I can do to stop it. I get up and even the television is too much. I can’t focus. I hear Leno tell a joke, I used to think he was hysterical; it’s not funny, even though I hear the audience laugh. I used to laugh all the time. People would come up to me and tell me what a happy person I must be because I’m always smiling. Every day, every hour I think about the car and how easy it would be to do this. The weird part is that thinking about killing myself doesn’t feel bad, more like a relief, just be done with it. I think that’s what I’ll do. I’ll do it in the morning.
Once across this divide, how far we go as writers is limited only by our interest, perseverance, talent and skill. My interest as a novelist has been to take psychiatric and forensic topics and explore them in fiction. I picked the mainstream genre of the psychological thriller, ‘A’ because I like to read these, ‘B’ because they’re commercially viable and ‘C’ because as a psychiatrist I know something about human nature and why we do the things we do -- even bad things. The medium of novels is ideal for in-depth exploration of complex subject matter.
For the would-be doctor-writer, there aren’t a lot of absolute rules, but there are some helpful hints. Go with your expertise and write what you know. Beyond that most of the principles of clinical writing continue to apply, you need to think of your reader, and pay attention to the conventions of whatever genre you’ve picked. Just as you consider the Medicare, Managed Care and Joint Commission reviewers when writing in a chart, think about who’s going to read your book and give them what they want.
In novels the first goal is to entertain—why else would someone purchase one? Because I write thrillers they need to generate tension, suspense and fear; they must snag the reader at the first page and not let up. Beyond that I want to educate, both the reader and myself about topics I find interesting, confusing and important. This is where clinical skill and experience can inform fiction.
For instance, in my first book, THE PORTRAIT (St. Martin’s Press 1998) I wrote a thriller that had a hero with a serious mental illness, in this case an artist with Bipolar Disorder (manic depression). I wanted to create an insider’s view of what it’s like to have a serious mental illness, to become psychotic, paranoid and even suicidal. I chose a first-person narrative so that the reader could have this voice inside their head.
“It was funny, the times I had been in the hospital; they didn’t seem quite real, that this, my real life, would be a memory, like a trick done with mirrors. So many ghosts followed me—quick friendships on locked wards, endless mouth checks with hard-faced nurses. The ghosts filled my paintings, worlds populated with earthbound saints and tormented devils. My own Faustian dilemma became a little clearer each year. If I took the pills, so I was told repeatedly, I could avoid the hospital. I could also kiss painting good-bye. So I juggled.”
When I came to my second book, it was at a time when I was working with troubled teenagers who were coming for evaluations at the request of the court, the schools, or parents faced with an out-of-control kid. RISK FACTOR (St. Martin’s Press 1999), allowed me to demonstrate in fiction the process by which a child grows up to become a sociopath. I relied heavily on the theory of experimental psychologist John Bowlby, combined with what I was seeing in my clinical practice. I created situations and a cast of characters that allowed me to show many sides of Attachment Theory. My protagonist was a single mother of two working with troubled teenagers in both inpatient and outpatient settings.
In a sense, the novel can be a delivery system for information. Material that might otherwise be dry and conceptually difficult can be brought to life in ways that are crisp and evocative.
More recently, in the wake of 911, Hurricane Katrina and some personal tragedies, I took the topics of Trauma, PTSD etc. and wove them into a thriller, THE CADAVER’S BALL (St. Martin’s Press 2005/Leisure Books 2006). I wanted to demonstrate through multiple characters how life-threatening events change us, how some people recover and others are destroyed by the experience. In this case my protagonist is a psychiatrist who has been severely traumatized.
“After a year of intensive therapy, I know this. I feel it claw at my sanity. Oh, God, make it stop!
My fingers claw at smoldering steel, as black smoke burns my eyes, “come on, Beth!” I can’t see, I can’t breathe. The smell of gas. Help me! Somebody help me! She’s not moving, her hair caught in the shoulder strap? I smash the window, but I can’t get the door. She’s not breathing. I suck in and put my head through shattered glass, my mouth over hers, tasting her lipstick. Headlights come through the fog. I stagger into the road. My hands wave, “stop!” The whites of a man’s eyes stare through the darkened glass. “Please stop.” He slows and I grab for the closed window; it’s cold against my blistering palm. Why isn’t he stopping? I bang my hand against his window. “She’s dying! Help me!” My palm print, smeared in blood, slips away; he’s speeding up. I scream. A blue sparks turns to flames; it’s in her hair. Help me!
I startled and blinked as a hand tapped my shoulder.
“Doctor Grainger. Peter, are you okay?”
I coughed and fought back the nausea that always comes. “I’m fine,” I said, not knowing where I was, wondering how long I’d been gone.
While the characters are products of my imagination, what they go through is real. This is what I find most-exciting about fiction; we can get to truths about mental illness and human nature and present them in ways that are easily understood by the reader.
When physicians span this continuum of clinical storytelling, from the medical record and case presentations to narrative and fiction, something has been completed. It’s taking what we’re taught in our training and in our clinical practice and giving it life. It’s a practical fusion of the science we learn as medical professionals and the art of being both a doctor and a writer. Beyond that, pushing clinical material into the realm of fiction offers endless opportunities to gather insight into the wonderful complexity of being human. For physicians, this is a well-trod path that’s worth the trip. Our training as doctors starts us on the road; should we choose to follow, it brings us to the whole story, the whole person and the bigger truth.
The Cadaver's BallCharles AtkinsThe Prodigy: A Novel of Suspense
