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
McPhee J. Draft No. 4. Farrar, Straus and Giroux; 2017.
Lowenstein SR. Tuesdays to Write: A Guide to Time Management in Academic Emergency Medicine. Acad Emerg Med. 2009.
“There are strengths and weaknesses associated with introverted traits and with extroverted traits. Extroverts thrive in social situations, can rapidly form relationships with team members, and are comfortable with spontaneous brainstorming, thinking aloud and offering ideas quickly and assertively. Introverts’ strengths include thoughtfulness, listening, humility, and forming deep connections. They process internally, share fully formulated thoughts, and prefer to avoid bringing attention to themselves.”
—Kendall Jones, University of Washington School of Medicine
by Kendall Jones, University of Washington School of Medicine
When I meet a patient in clinic, I am in my comfort zone, focused on connecting and creatively problem-solving. But when I leave the exam room, I feel overwhelmed and misunderstood—my mind races as I struggle to communicate my thinking. Patient care settings can be chaotic and the requirement to perform on-the-spot for evaluators frequently does not create a learning environment that accommodates introverts.
While improving the learning environment for students from all backgrounds is an ongoing effort in medical education, I haven’t heard discussion about the experience of introverted students in clinical rotations. The current model of clinical phase medical education frequently does not create a safe learning environment for introverted students. For me, this has contributed to a negative cycle of anxiety and underperforming. Patients appreciate my careful listening and thoughtful responses. But in a rushed clinic, I feel any information I can share is treated as redundant. As I present, I feel concerned about taking up too much space despite the importance of this presentation for my grade. Preceptors observe my hesitancy and lack of self-assuredness and interpret it as failure. But confidently voicing my thinking process is much more difficult “on stage” than in a real-life patient-care setting. Awful feelings related to these experiences day-in and day-out are a significant challenge: I observe myself reaching burnout faster than other classmates, and I worry that I don’t have the energy-levels, constitution, and extroversion required to succeed in medical school and residency. However, I found that research and commentaries validate my feelings and experiences. I am not alone.
Over the course of the last three decades, the Center for Research in Medical Education and Health Care has investigated medical student personality and personal characteristics and correlations with student success and patient care. In 2004, they found that greater self-esteem and higher scores of extroversion could predict global ratings of clinical competence in core clerkships in medical school. Systematic reviews support the finding that introverted students tend towards poorer evaluations related to interpersonal behavior during clerkship rotations. 1 In 2005, Davis and Banken identified significant positive correlation of extrovert traits with clinical performance in an OBGYN clerkship but no correlation with performance on the standardized subject exam, consistent with other studies finding lack of correlation between more subjective clinical evaluations and more objective measures of clinical knowledge. They thus questioned, as have others before, whether clinical evaluations should be included in the overall evaluation score or if they should be labeled ‘interpersonal skills’ rather than ‘clinical evaluation’ to more accurately describe what the evaluation reflects. 2 Surveying nearly 3,000 students who completed core clerkships, Lee et al. found that more reserved students were more likely to report lower grades while more assertive students received lower grades less frequently. 3 A possible mediator for these findings is extroversion. This allows students to demonstrate their enthusiasm and knowledge to their evaluators which can improve their subjective grade. Another explanation is that the stress of constantly trying to impress evaluators has a greater effect on introverted students while extraverted students are more at ease; introverted students are known to feel less comfortable expressing themselves in high-pressure environments and are inclined to hold back and speak only if they are 100% sure of themselves. 4, 5 While inferior evaluations can affect students’ chances at residency, the challenge of having an introverted tendency in medical training can negatively affect students’ health as well.
Multiple studies have shown an association of introversion with burnout. 6, 7 Qualitative research agrees with these findings with introverted students reporting feeling like ‘misfits’ and that they must change their identities to succeed in medical school. 1 Introverts report working to make others comfortable at the expense of their own comfort and energy levels. 1 When introverted students experience medical training invalidating their innate style of thinking and social engagement, they are more likely to experience chronic stress and anxiety. Leadership research finds that both introverts and extroverts lend important and distinct contributions to teams. 8 Learning environments ought to be tailored to fit students who fall anywhere within this temperament spectrum.
There are strengths and weaknesses associated with introverted traits and with extroverted traits. Extroverts thrive in social situations, can rapidly form relationships with team members, and are comfortable with spontaneous brainstorming, thinking aloud and offering ideas quickly and assertively. Introverts’ strengths include thoughtfulness, listening, humility, and forming deep connections. They process internally, share fully formulated thoughts, and prefer to avoid bringing attention to themselves. In clerkships, extraverted traits are beneficial for adapting to the constant rotation of locations and team members. Extraverted students are likely to be more comfortable with presenting information in quick succession and processing this information as they speak, whereas introverts desire to thoroughly gather information and feel a need for focused time to formulate assessments before sharing them with others. Not only are extroverted traits are preferred in clinical rotations, they are preferred in modern Western society as a whole. As noted by Davidson et. al., “This trend of devaluing or pathologizing introverted behavior has been noted in national studies and is emphasized in Susan Cain’s best-selling book on introversion (Quiet: The Power of Introverts in a World that Can’t Stop Talking9) that Western society has shifted from appreciating a thoughtful approach of interaction with others to a more demonstrative social and assertive approach.” Natural introverts sense these preferences, and this can negatively affect students’ self-esteem. Introverts can try to act more extroverted, but this adds yet another obstacle in an already challenging environment.
In a review of literature, Davidson et. al. find that when a student’s personality and behavioral characteristics are harmonious with the learning environment this typically results in optimal performance, while an incongruent fit can lead to maladaptive behavior. 1 Unfortunately, this is personal for me—in the fast-paced, high-pressure, zero-continuity environment of clinical clerkships my introversion and anxiety increase. I’m evaluated as underperforming; I feel bad about myself, and I don’t recognize myself—someone who, when in a familiar environment, is passionate and conversational. But my brain is plastic and I have hope. I can remember the times when the learning environment was a good fit and I rose to the occasion and was recognized for what I truly have to offer. A bad fit was the rushed environment of a busy family medicine residency clinic where we were always behind and I didn’t want to hold anyone up. When I felt I had to choose between addressing the patient’s foremost concerns and impressing my preceptor, I struggled. But on inpatient medicine I knew what to expect— my attending gave me a defined time to plan for my admit and prepare to present; I was rewarded with the affirmation that my plan was nearly exactly what he would have done. The residents on the team gave daily helpful feedback allowing me to improve more during the next day’s rounds. I felt encouraged and supported in my growth as a student doctor. Unfortunately, I can’t say the same for other places I rotated.
I know the learning environment and I both have room for improvement, and we can meet in the middle. I will fight my learned anxiety with everything I can and will work on cultivating extraverted skills including thinking aloud, assertiveness, and sharing ideas before I’m 110% sure, even though it’s uncomfortable. But I demand better from the learning environment: in some patient-care settings, it feels as if there is little thought towards the goal of fostering the growth of student doctors. Showing support, encouragement and a little bit of empathy for students goes a long way, as does setting clear expectations and allowing time and space for the introverts to prepare and feel comfortable, whenever possible. If the student appears anxious, avoidant or introverted, try to meet them where they are rather than turning a blind eye. After all, as Lebin et. al. write, “the inclusion of both introverts and extroverts in leadership roles strengthens teams, departments, and organizations. We therefore champion embracing introversion in trainees, colleagues and, most importantly, in ourselves.” How can you better recognize introverted students for their thoughtfully, albeit more deliberately-formed ideas? How can you provide encouragement and attention to creating opportunities for these more reserved students to prepare and present their knowledge and reasoning?
References
Davidson, B., Gillies, R. A., & Pelletier, A. L. Introversion and Medical Student Education: Challenges for Both Students and Educators. Teaching and Learning in Medicine, 2015; 27(1), 99-104. https://www.tandfonline.com/doi/abs/10.1080/10401334.2014.979183
Davis K. R., Banken J. A. Personality Type and Clinical Evaluations in an Obstetrics/gynecology Medical Student Clerkship. Am J Obstet Gynecol. 2005 Nov;193(5):1807-10. doi: 10.1016/j.ajog.2005.07.082. PMID: 16260239.
Lee, K. B., et al. “Making the Grade:” Noncognitive Predictors of Medical Students’ Clinical Clerkship Grades. J Natl Med Assoc. 2007; 99, pp. 1138-1150
Noureddine L., Medina J. Learning to Break the Shell: Introverted Medical Students Transitioning Into Clinical Rotations. Academic Medicine. 2018; 93 (6): 822-822. doi: 10.1097/ACM.0000000000002222.
de Jongh, R., de la Croix, A. 12 Tips to Hear the Voices of Introverts in Medical Education… and to Improve the Learning Climate for Everyone. MedEdPublish, 2021; 10(107), 107. https://mededpublish.org/articles/10-107
Hojat, M., Erdmann, J. B., & Gonnella, J. S. Personality Assessments and Outcomes in Medical Education and the Practice of Medicine: AMEE Guide No. 79. Medical Teacher, 2013; 35(7), e1267-e1301. https://www.tandfonline.com/doi/full/10.3109/0142159X.2013.785654
Mariana’s commitment to her community, love of learning, and sincere support inspired me to become a family physician. This blog post is my way of thanking her and showing the influence she’s had on me and my journey and goals in family medicine.
It was an early fall evening in Rochester, Minnesota, and I was trying to put on my newest possession, a big black down-filled coat which made me feel twice as wide and five times as clumsy. I stumbled into the workroom of our free smoking cessation clinic at the local Salvation Army, shrugging the glorified sleeping bag over my shoulders. It was 2010 and I was in my first year of medical school, still trying to figure out how to layer against the cold.
“Hey, are you from Hawaii?”
I turned around, almost knocking over the objects behind me, and saw a smiling, brown-eyed, brown-haired young woman, maybe a few years older than me. “Um–yeah…?”
“Hi, I’m Mariana!”
This was my introduction to Mariana Cook-Huynh, one of the most influential people in my journey to family medicine.
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