Growing Your Writing Practice

by Sarina Schrager, MD, MS, Family Medicine Editor-in-Chief, and Jose Rodriguez, MD, FAAFP

“It’s none of their business that you have to learn how to write. Let them think you were born that way.”

—Ernest Hemingway

Writing is hard; there are no two ways about it. Starting a paper or narrative can be daunting. How should I start? What if it is not good? Will anyone want to read it? These questions arise even for accomplished writers. The best writers still work very hard at writing. In this blog, I share lessons I have learned during more than 30 years of writing in academic family medicine, along with resources I have found helpful. I encourage you to read these suggestions and share what works for you.

Find Time to Write and Block Your Schedule

It may seem like an oversimplification to say, “Just find the time to write.” We all know it can be difficult to fit writing into busy schedules filled with clinical, teaching, and administrative responsibilities. However, if you do not block time on your calendar to write, writing will continually be pushed to the bottom of your to-do list. You have to make the time to write.

In his 2009 article, “Tuesdays to Write,” Lowenstein describes restructuring his schedule so that his academic work occurred on Tuesdays, allowing him to carve out dedicated writing time each week.1 Some people write best early in the morning, whereas others are most productive late at night. For example, I write best early in the morning, whereas a colleague does their best writing at night. After 4 PM, my writing brain simply does not work.

Similarly, some people can write productively during a spontaneous 30-minute opening in their schedule, whereas others need at least a 2-hour block. Consider scheduling dedicated “writing time” on your calendar so other meetings are less likely to replace it.

Plan to Revise

“Almost all good writing begins with terrible first efforts. You need to start somewhere.”

—Anne Lamott, Bird by Bird

Becoming a good writer—or producing good writing—takes time, effort, and multiple revisions. In Draft No. 4, John McPhee describes routinely writing at least 4 drafts of every manuscript.2 By the fourth draft, the manuscript has usually become coherent enough to share with others. His process can be summarized as follows:

  • Draft 1: Get something on the page.
  • Draft 2: Develop your argument.
  • Draft 3: Refine word choice and improve the flow of your argument.
  • Draft 4: Polish the writing, use a thesaurus if needed, and read the manuscript aloud.

Ask for Feedback

Once you reach Draft 4, you are ready to seek feedback. Many authors submit manuscripts without asking colleagues or friends to review them first. Although the peer-review process provides valuable suggestions, colleagues often identify many of the same opportunities for improvement before submission.

There are several low-stress ways to receive feedback. An accountability partner or writing partner (eg, Prolific Partners) can be helpful. Writing groups are another excellent option because everyone shares their work, reducing the self-consciousness that often accompanies sharing your writing.

Reflect on Your Writing Process

Everyone writes differently, so there is no single perfect list of writing tips. Think about the times when you are most productive. Where were you? What time of day was it? What aspects of the setting contributed to your productivity?

Before I begin writing, I spend time thinking about how I want to structure the piece and how I want to begin. I create an outline, although it often resembles a stream of consciousness. Draft 1 is the hardest part for me because getting started is difficult. Once I have something on the page, revision becomes much easier.

Others find drafting easy but struggle with editing, searching endlessly for the “perfect” word. Still others never reach Draft 4 because they continually discover new ways to improve a sentence. Every writer is different.

Other strategies may also improve writing productivity. Consider working on 2 projects simultaneously. Pairing a small project with a larger one—or a challenging project with one you enjoy—allows you to switch between them and maintain momentum. Joining a writing challenge can also provide encouragement and accountability. Writing challenges vary in length, lasting anywhere from 1 week to 1 month, but they all encourage participants to write consistently each day.

The STFM community is filled with prolific, talented writers. What strategies have helped you develop your writing practice?


References

  1. McPhee J. Draft No. 4. Farrar, Straus and Giroux; 2017.
  2. Lowenstein SR. Tuesdays to Write: A Guide to Time Management in Academic Emergency Medicine. Acad Emerg Med. 2009.

This Picture Has a Story

By Jennifer Hammonds, LCSW

This picture has a story—one that still makes me shake my head a little.

The other day, I had an important letter that needed to go in the mail on my way to work. The night before, I did everything “right”: sealed it, stamped it, put it in my purse, and left myself a reminder on the front door. Halfway through my commute, I realized I had forgotten to drop it off. Frustrated, I glanced at my purse and the envelope wasn’t there.

When I got to work, I called my husband to search the house: the floor, the office, even the porch. Hours later, a thought occurred: Could I have put it in the mailbox on autopilot? Surely not. A text from my husband confirmed it: not only was the letter in the mailbox, it wasn’t even addressed. My brain fog had officially reached new levels.

Looking back, this moment was funny but also part of a bigger story. Years earlier, I had spoken with my primary care physician about new symptoms: heart palpitations, trouble sleeping, itchy skin. I was told it was likely work stress. Later, at my gynecology visit, I asked what felt like an uncomfortable question: Could this be perimenopause? I was reassured I was too young and reminded that stress affects everything.

Then came hot flashes, weight gain, and most unsettling – brain fog.

“I have to be smart at my job,” I said. “What is wrong with me?”

My husband was supportive but confused. Memory lapses, poor focus, and lack of follow-through were uncharacteristic. At one point he suggested, “Maybe you need one of those memory clinic assessments like the ones you do at work.” Cue panic.

Around this time, I started seeing emerging research and personal stories about women’s health. For the first time, I recognized myself. Motivated, I sought a gynecologic provider with expertise in women’s health. I finally received education, hormone testing, and validation. In coordination with my PCP, we developed a treatment plan that included hormone therapy and Vyvanse, as declining estrogen appeared to unmask longstanding inattentive ADHD. Combined with behavioral strategies I already knew, I began to feel more like myself than I had in years.

As I felt better personally, I reflected professionally. How many times had I attributed similar presentations in midlife women to anxiety or stress alone? How often had workups stopped at a normal TSH? How many “scatterbrained” patients were experiencing cognitive load and executive dysfunction related to menopause? Or even unmasked ADHD?

In conversations with female colleagues, we began shifting our clinical lens. Viewing menopause through a cognitive load framework helped us better differentiate menopause-related cognitive changes from ADHD. Treatment became more tailored, often combining hormone therapy with ADHD-specific pharmacologic and behavioral interventions. Patients felt heard, and we felt less frustrated as vague cognitive complaints became navigable.

A colleague and I hope to present this work in the coming months, but even now, our approach to women in midlife (and the questions we ask) has changed.

As a long-time therapist, I am trained to keep personal experiences private, so sharing this story requires vulnerability. But in family medicine and behavioral health, lived experience sharpens clinical instincts. This journey has made me a more thoughtful, patient-centered clinician—and a more empathetic partner to the women I serve.

How to Do A Peer Review: Part 3

by Sarina Schrager, MD, MS, Family Medicine Editor-in-Chief, and Jose Rodriguez, MD, FAAFP

Discussion/Conclusion 
The discussion section of a paper restates what the paper found and then goes on to explain how these findings fit into the existing literature and how they impact the field. We also expect the authors to document how the study answered their original research question. Occasionally, we see a paper with an interesting finding, but that finding is not related to its a priori research question. This is something to review.  

One of the biggest mistakes we see in discussion sections is when authors overstate the importance or significance of their findings. For example, a study of 12 residents doing a rotation to learn about social determinants of health may find a significant change in their behavior. Still, it doesn’t provide evidence to add such a rotation to all residencies. Results of such a small study cannot make such an impact. We also expect reviewers to conduct a limited literature search themselves. If the authors claim that their paper is the first to do something, then the reviewer has the responsibility to double-check that fact. Reviewers should search PubMed and one other index (Scopus, CINAHL, ERIC, etc.) for verification. Reviewers should not use AI for this task.

We also expect authors to include limitations to the study. Most papers could have had larger sample sizes or more diverse samples. The reviewer wants to see that the authors have considered the study’s limitations and have commented on how the results remain valid despite them. The end of the discussion section should include a summary of the study, a repeat of the key results, and a statement about future research. Do the authors suggest repeating the study with more participants, at several different residencies, or broadening the sample to include medical students? Reviewers should ensure that the authors provide limitations, a summary of findings, and have placed their findings in the context of the current literature. When authors have not done this, they can rewrite the discussion using the direction provided in the article by H.G. Welch (https://cancer.dartmouth.edu/sites/default/files/2019-05/papertrail.pdf)

Tables and Figures 
Using figurative methods to explain results (and sometimes methods) can be a great way to help readers understand your study. As such, we expect reviewers to carefully review all tables and figures. Are they easy to understand? Do the numbers add up? (This is more common than you would think.) Do they enhance understanding of the results? If the tables and figures are confusing or unclear, the editors want to know. Because if you, as the reviewer (someone who is spending a lot of time with the paper), don’t understand, then the reader won’t either. As the reviewer, you expect Table 1 to describe the demographics or other characteristics of the study participants. Then you expect to see more tables with the study outcomes, including statistical calculations to demonstrate significance. We would like reviewers to comment on whether a figure or graph would help explain the results. 

All tables should stand on their own. To relate the table to the text, the authors should refer to the table after a summary sentence, e.g., “Patient demographics are included in Table 1.” The only other information from a table to be included in the text is the most significant finding, such as “Although we conducted our study in Salt Lake City, UT, 96% of our respondents identify as Black.” (This is significant because Salt Lake City, UT, has a notoriously small Black population (about 2.5%). If you find that the authors are repeating everything from the table in the text, you should encourage the authors to choose the table or the text.

References   
As stated above, reviewers should do a brief literature search about the topic covered in the paper. It is excellent to suggest papers for the authors to consider if they are not included in the reference list. As many reviewers are experts in the field, they can also suggest documents that they have authored. Other specific aspects of the reference list to review include the type of papers (i.e., meta-analyses or systematic reviews vs. small non-randomized trials). Are the documents referenced old or current? Do you know of any studies that are not included? One reason you may be asked to serve as a reviewer is that you have worked in a similar area, so you would be familiar with the literature. Do the authors cite their own papers over other publications? In this age of AI, we also suggest checking the DOIs of the articles in the reference list to ensure they are valid. Often, real DOIs are reported with references that do not exist. Reference checking is an important quality control step, and reviewers should hand-check references for accuracy. (Please do not use AI for it; AI may lie).

How Peer Review Can Help You:
Working as a peer reviewer can help you become a better writer. You can see how other people structure a paper or even how they describe methods, and can take away from that ways that you want to do it in your own work (or not). Being a peer reviewer will also help you stay up to date with the science in your field. To be a highly regarded family medicine academician, you will need to have a sense of what journals are publishing. Thirdly, being a high-quality peer reviewer can advance your career. Editors are often leaders and will invite skilled peer reviewers to be on Editorial Boards or become part of the editorial team. It is a great way to build your reputation.

Peer reviewing can also give you ideas and help you further your scholarship. JR once reviewed a paper for the New England Journal of Medicine (NEJM) that described hypothetical diversity interventions. This inspired him to submit an article to the NEJM on verified diversity interventions that was eventually published.

We hope that these blogs have helped support your work as a peer reviewer. Please visit the reviewer page on Family Medicine’s website for other resources or to sign up (Family Medicine).