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The Write Stuff: How Good Writing Can Enhance Patient Care and Professional Growth

2013; Elsevier BV; Volume: 126; Issue: 6 Linguagem: Inglês

10.1016/j.amjmed.2012.11.020

1555-7162

Harvey B Simon,

Pain Management and Placebo Effect

Life is short, said Hippocrates, the art long. Human lifespan has lengthened substantially in the 2400 years since the Father of Medicine wrote, but these gains have been dwarfed by the explosive discoveries that have revolutionized the art and science of medicine. Faced with the need to master so much scientific data, it's not surprising that medical educators and clinicians pay scant attention to verbal and written communication skills. But while writing will never displace molecular biology, it does deserve attention and respect. I believe writing is important for patient care, for professional communication, for educating the public, and for personal growth and satisfaction. The time-honored first step in patient care is the history and physical. Listening to the patient, itself an acquired skill, is the first step. It is necessary but not sufficient.1Alpert J.S. Some simple rules for effective communication in clinical teaching and practice environments.Am J Med. 2011; 124: 381-382Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The next step is to reflect on the patient's story, organize relevant information, and construct a coherent narrative. Writing a narrative history is an active process. A good narrative should be complete but compact, organizing important medical events and their personal impact into a coherent story. It should be dispassionate and nonjudgmental while still capturing something of the personality and characteristics that make your patient unique. A coherent narrative can bring your patients back to life when you return to their charts after months or years. It can communicate your findings to consultants and other providers. Above all, the act of writing will help you understand your patients and plan an approach to their clinical problems. You don't have to be a great novelist to agree with Flannery O'Connor, who said “I never know what I think until I read what I wrote.” Indeed, writing is learning. A well-written narrative has always been important for patient care, but it has gained urgency as patients seek access to their medical records.2Zulman D.M. Nazi K.M. Turvey C.L. et al.Patient interest in sharing personal health record information.Ann Intern Med. 2011; 155: 805-810Crossref PubMed Scopus (119) Google Scholar Sharing medical records can bolster patient-centered care3Barry M.J. Edgman-Levitan S. Shared decision making—the pinnacle of patient-centered care.N Engl J Med. 2012; 366: 780-781Crossref PubMed Scopus (2172) Google Scholar by building trust and transparency and by allowing patients to add personal perspectives and call attention to errors. But medical records also can spark confusion, fear, or anger.4Walker J. Levelle S.G. Ngo L. et al.Inviting patients to read their doctors' notes: patients and doctors look ahead.Ann Intern Med. 2011; 155: 811-819Crossref PubMed Scopus (162) Google Scholar Good writing can help minimize the risks and maximize the benefits of information sharing. Electronic medical records make information sharing easy and efficient, but they also introduce new barriers to good communication.5Hartzband P. Groopman J. Off the record—avoiding the pitfalls of going electronic.N Engl J Med. 2008; 358: 1656-1658Crossref PubMed Scopus (141) Google Scholar A new patient's record begins with a blank page; that can be daunting, but it forces the clinician to create an original narrative. After that, though, the ability to copy and paste presents an almost irresistible temptation to cut corners by importing another person's narrative. I understand the time pressures that lead so many doctors to copy and paste existing narratives. Still, I urge you to resist shortcuts that will prevent you from digesting and synthesizing your patient's story and also may enshrine errors that have crept into the record. The pitfalls of digital technology are not limited to copy-and-paste applications. Templates make it easy to comply with the mandates of third-party payers, but they introduce observations that may not be credible. When I read that a cardiac consultant finds our mutual patient's pupils equal, round, and reactive to light and accommodation, I suspect a waste of time and brainpower or a minor mendacity; neither builds confidence. Because we can import reams of laboratory data with a few clicks of a mouse, many electronic records become burdened with reports that are irrelevant or distracting. And while we're thinking about laboratory results and radiology reports, our colleagues in clinical pathology and radiology could enhance patient care by presenting their findings in patient-friendly formats. Consult notes, whether digital or hand-written, present particular challenges to effective clinical communication.1Alpert J.S. Some simple rules for effective communication in clinical teaching and practice environments.Am J Med. 2011; 124: 381-382Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Doctors request consultations to get varying degrees of practical help, specialty education, and reassurance. A good consultant will provide all 3 in proportion to the needs and desires of the requesting physician. In every case, though, a consultant should strive for clarity and brevity instead of dazzling erudition. One of the most important things I learned as an infectious disease fellow came from an attending who told me, “Keep it simple, Simon.” And another infectious disease attending set a benchmark that would be impossible to duplicate in today's highly regulated environment. A crusty senior internist asked us for a nonacademic consultation to answer 3 questions: What does my patient have? What tests should I order? And what antibiotics should I give? In reply, my colleague wrote simply “1. Virus. 2. None. 3. None.” Those were the days … Good writing can promote good patient care, but it's an acquired skill. Table 1 offers some tips that may help.Table 1Tips for Clinical CommunicationWrite with pride. Write as if your patients will read their charts; sooner or later, they will.Be concise and clear, complete but not exhaustive.Use everyday language. Avoid acronyms, abbreviations, jargon, and unnecessary technical terms.Avoid stilted, formulaic words and phrases. Your patients are men and women, not males and females. Your patient is not a good or poor historian; you are the historian, for better or worse.Get personal. Your patient has a name; use it: “Mrs. Jones tells me,” not “the patient claims.”When appropriate, incorporate direct quotes from your patient.Be descriptive but discreet. Note that Mr. Smith is forceful, not aggressive; forgetful, not demented. If a patient displays seductive behavior, you can capture it simply by noting that a chaperone was present throughout your examination.Make electronic records useful. Do not copy and paste to create a narrative. Use templates honestly and sparingly. Defeat digital diarrhea by editing reports and deleting obsolete or irrelevant data.Proofread and edit. It's particularly important for dictations that use voice recognition software; errors are sometimes amusing but are always distracting and sometimes dangerous.Focus on the essentials, especially for consult notes and letters.Use relevant communication tips from Table 2. Open table in a new tab Good writing can promote good care by helping physicians understand their patients, organize clinical information, and communicate effectively with other providers. I believe that writing also can help patients by allowing them to express feelings, which may enhance well-being. This belief is based on personal experience with psychological distress and a randomized clinical trial focusing on physical symptoms.6Smyth J.M. Stone A.A. Hurewitz A. Kaell A. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis.JAMA. 1999; 281: 1304-1309Crossref PubMed Scopus (623) Google Scholar I first witnessed the healing potential of writing after my father died. My stepmother was shattered, but she was a brilliant and articulate woman. Within a matter of weeks, Mom began to deal with loneliness and loss by writing letters to Dad. She knew full well that her letters would never be read, much less answered, but the act of expressing feelings in writing helped enormously. Over the past 25 years, I've recommended a similar strategy to many bereaved patients. I've never tallied the results, but a substantial number of people who accept the idea appear to benefit. And my anecdotal experience suggests that writing letters or keeping journals can help people across a wide educational and socioeconomic spectrum. A 1999 trial conducted a systematic evaluation of emotionally expressive writing.6Smyth J.M. Stone A.A. Hurewitz A. Kaell A. Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis.JAMA. 1999; 281: 1304-1309Crossref PubMed Scopus (623) Google Scholar The study evaluated community-dwelling patients with well-documented asthma (n=61) or rheumatoid arthritis (n=51). After undergoing medical and psychological evaluations, volunteers were randomly assigned to spend 20 minutes on 3 consecutive days writing, either about the most stressful experience of their lives (the experimental group; n=71) or about emotionally neutral topics (the control group; n=41). Disease activity was evaluated before the intervention and at 2, 8, and 16 weeks afterwards. At each interval, the participants rated their own health status; patients with asthma underwent spirometry, and patients with rheumatoid arthritis were evaluated by rheumatologists who did not know whether the patient was in the experimental or control group. As compared with patients who wrote about mundane topics, those who wrote about stress demonstrated statistically significant improvements in asthma at 2, 4, and 16 weeks. In contrast, emotionally expressive writing appeared to reduce rheumatoid arthritis activity only at 16 weeks. In all, 47.1% of experimental patients versus 24.2% of control patients met criteria for clinically relevant improvement (P=.001). It's a relatively small and brief study, and it's naïve to hope that expressive writing could ever replace beta-agonists or disease-modifying antirheumatic drugs. More study is needed, but writing may have benefits similar to other forms of emotional expression for patients, and with medical as well as psychological problems. Department chairs and medical school deans may roll their eyes in denial, but the academic imperative does contain a germ of truth. Whether you are writing a grant or preparing a manuscript, good writing is important for success. And communication skills also are crucial for oral presentations. Each of us should develop a personal style and voice, but all of us can benefit from simple guidelines that apply in settings as diverse as international meetings, patient care conferences, talks to community groups, and writing for publication in elite scientific journals or mass circulation magazines. Table 2 offers some tips that may help.Table 2Tips for Professional CommunicationWhen you have a choice, pick a topic that interests you. Even if the subject is assigned, find an aspect that excites you. Enthusiasm is infectious. So is boredom.Know your audience. Physician-scientists speak to each other, but they also communicate with students, patients, community groups, and even children. Tailor your tone, language, and level of detail to your readers or listeners.Respect your audience. Never talk down to people, however unsophisticated or young. If you try to show how smart you are, you're likely to seem stuffy at best, arrogant at worst.Tell a story. Every communication should have a beginning, middle, and end. Use the beginning to explain why the topic is important and interesting, both to you and your audience. Outline your plan before you get started; if your material is complex or lengthy, remind your audience of where you're taking them as you go along. Conclude with a brief summary of key points, then note areas that deserve more study.Use direct, clear language and a conversational tone. Avoid jargon, inflated language, and 10-dollar words; a cleverly-titled paper documents the pitfalls of inflated language.7Oppenheimer D.M. Consequences of erudite vernacular utilized irrespective of necessity Problems with using long words needlessly.Behav Sci. 1985; 77: 199-214Google ScholarUse the active voice: “we obtained samples from all the patients,” not “samples were obtained from all the patients.”Vary your sentence structure. Beginning writers always put the subject first. Variety, however, is the hallmark of engaging writers.Avoid redundancy. It is useful, even important, to emphasize key points by restating them at appropriate places, but it's never wise to repeat minor or obvious information. So avoid repetition and redundancy. Do not repeat yourself, either.Minimize echoes. Refer to people who advance medical knowledge as scientists, investigators, workers, or researchers instead of repeating a single identifier. Clinicians, too, can be called physicians, doctors, or clinicians.Think of how your manuscript will look. Use subheads, short paragraphs, bulleted lists, graphs, and illustrations when appropriate. Be as concise as possible.Use visual aids for oral presentations—but make them clear and legible.Use humor when it suits your voice and style, but only if it's appropriate and tasteful. The gonococcus may be worth a chuckle, but the meningococcus may not.Proofread and use software to check spelling and grammar. It's true that errors may still crop up, but sloppiness is a dagger in the heart of credibility.Acknowledge others. You do not have to thank your mom every time you boot up, nor should you hide your own achievements under a rock. Still, we've all learned from mentors and have benefited from collaborators. Whenever appropriate, use a humble “we” instead of a self-aggrandizing “I.”Practice your oral presentation, seek editing for your writing, and ask for feedback whenever possible. No matter how good you are, you can be better next time. Open table in a new tab When I finished my fellowships, I knew that clinical medicine would be challenging, but I thought my major tasks would be diagnosis and therapy. After just a few weeks in practice, though, I recognized a third challenge: informing and motivating my patients. It's always been a crucial element of good care, but it's more important than ever in the era of shared decision-making.8Stiggelbout A.M. Van der Weijden T. De Wit M.P.T. et al.Shared decision making: really putting patients at the centre of healthcare.BMJ. 2012; 344: e256Crossref PubMed Scopus (650) Google Scholar Whether you call it compliance, adherence, or cooperation, good clinical outcomes depend on active participation by patients, often in concert with family members. Multiple interventions are needed to enhance adherence,9Steiner JF. Rethinking adherence. Ann Intern Med. 2102:157:580-585.Google Scholar but many patients will benefit from clear, specific written information. Low health literacy presents a barrier to understanding medical instructions and drug information, which is one reason low literacy is associated with increased mortality.10Bostock S. Steptoe A. Association between low functional health literacy and mortality in older adults: longitudinal cohort study.BMJ. 2012; 344: e1602Crossref PubMed Scopus (390) Google Scholar Individual practitioners cannot correct the educational and socioeconomic problems that limit literacy, but we can and should tailor our communications to our patients' abilities.11Raynor D.K. Health literacy.BMJ. 2012; 344: e2188Crossref PubMed Scopus (11) Google Scholar Now that doctors have been transformed from gods to guides, a growing number of physicians strive to provide medical guidance to the public at large. When I first embarked on consumer health writing in the 1970s, there was a dearth of physician-authored material and it was relatively easy to reach readers. In the digital age, it's easier to get a platform but much harder to cut through the blizzard of medical chatter to connect with the community. But because so many web-based sources are incomplete, frightening, or misleading, responsible consumer health information is more important than ever. Because they are trained to read and understand scientific literature, physicians should be in an ideal position to interpret data for the public. Media reports written by journalists often rely on press releases issued by health care organizations and medical journals; incomplete press releases contribute to inaccurate articles in the lay press.12Schwartz L.M. Woloshin S. Andrews A. Stukel T.A. Influence of medical journal press releases on the quality of associated newspaper coverage: retrospective cohort study.BMJ. 2012; 344: d8164Crossref PubMed Scopus (109) Google Scholar In turn, “spin” in press releases can often be traced back to “spin” in the conclusions presented in the abstract section of medical journal articles.13Yavchitz A. Boutron I. Bafeta A. et al.Misrepresentation of randomized controlled trials in press releases and news coverage: a cohort study.PLoS Med. 2012; 9: e1001308Crossref PubMed Scopus (189) Google Scholar Physicians who write for scholarly publications should be sure their abstracts and articles contain balanced, responsible conclusions. And doctors who write for the public should read and digest the medical literature as carefully as they would in writing for peer-reviewed journals or scholarly texts. Table 3 lists some common pitfalls to avoid.Table 3Writing for the Public: Common PitfallsNot identifying the duration of a study and the composition and size of the study population.Inferring causality from observational studies.Reporting relative risks but not absolute risks.Reporting statistical significance without clinical significance (or insignificance).Omitting side effects and other negative aspects.Omitting context, including previous research.Omitting conflicts of interest and other potential biases (including your own). Open table in a new tab In writing for the public, as in writing for peers, accuracy is necessary but not sufficient. The tips in Table 2 apply to writing for all audiences, but successful consumer health writing requires additional techniques. The first task is to capture the attention of your readers. An article that's engaging but not instructive is still engaging; an article that's instructive but not engaging is algebra. Table 4 offers some tips for consumer health writing.Table 4Tips for Consumer Health WritingTell a story. Begin with a lead that will capture attention and explain why your topic is important and relevant. Try not to rely on “XXX is the leading cause of YYY.” Construct a clear narrative arc for the middle of your story. End with a clincher; try not to rely on “In conclusion …”Find your voice. Be authentic, conversational, and direct.Identify your readers. Tailor your tone and medical sophistication to your target audience.Respect your readers. Don't talk down to them or inflate your own importance.Use shorthand with care. Does exercise actually prevent heart disease or does it simply reduce the risk of cardiac events?Don't sensationalize or oversimplify. Don't hype your article by proclaiming “New hope” or “No hope.”Use personal anecdotes but objective data.Eliminate weasel words (such as “essentially”) and use adverbs very sparingly (such as “very”).Favor short paragraphs and bulleted lists but don't fear compound sentences; semicolons are your friends.Don't be snarky; chiropractors are people (and readers) too.Sprinkle in quotes when appropriate. Shakespeare and Yogi Berra are among many notable quotables.Remember that words have power. “Dr. Alpert claims” and “Dr. Alpert says” both refer to a doctor's statement but have different connotations.Allow yourself to break any of these “rules” as long as it's intentional. Fragments, clichés, and other infractions can serve a purpose. Open table in a new tab Every practitioner writes in the course of providing clinical care, many physicians write for scholarly publications, and some doctors engage in consumer health writing. A smaller number of physicians have made writing a major part of their careers; Table 5 lists some notable examples.Table 5Select Physician-WritersClinical and scientific writing Lewis Thomas, Sir William Osler, HippocratesWriting about medicine for the public Jerome Groopman, Atul Gawande, Siddhartha Mukherjee, Oliver Sacks, Sherwin NulandLiterary fiction and drama Abraham Verghese, Ethan Canin, Daniel Mason, Walker Percy, Somerset Maugham, Anton ChekovPopular fiction Michael Crichton, Michael Palmer, Robin Cook, Sir Arthur Conan DoylePoetry William Carlos Williams, John Keats Open table in a new tab It's an inspiring list, but an intimidating one. Few writers can achieve this level of success, and physicians generally face even greater challenges than people who choose writing as their primary careers. Before you embark on a major writing project, understand that literary fame and fortune are long shots at best. Remember, too, that serious writing can add stress to a busy professional life. Winston Churchill, one of the most brilliant and successful writers of the 20th century, said that writing a book begins as an adventure and amusement that soon becomes a mistress, then a master, and finally a monster. Still, if you have something to say and the need to say it, writing can add an important dimension to your life. Writing is teaching, and teaching is learning. I am grateful to Dr Robert Leibowitz for reviewing this manuscript and offering helpful suggestions.