reprinted from Issue 13, Fall 2011 of Frontiers of Medicine (PDF)
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"When you come face to face with patients who have a stroke because they couldn't afford to pay for their blood pressure medicines, it can be very demoralizing," says Alice Chen, MD, MPH, medical director of the Adult Medical Center at San Francisco General Hospital (SFGH).
She recalls teaching a resident who was shocked by a patient's circumstances. "she said, 'Is this right? Is this permissible?' I told her, 'It's not right, but it is permissible. And how do you change something that's not right, but permissible? You should write about it, and make a case for what should be done instead.'"
Chen and Louise Aronson, MD, MFA, are helping residents do just that through Writing for Change, a three-session seminar which teaches residents to connect their on-the-ground experiences with larger advocacy issues.
At a recent session, third-year resident Larissa Thomas, MD, reads a draft of her piece out loud. She describes how the undocumented status of her patient, "Ana," impacts almost every aspect of her life, including her health. The class responds enthusiastically, with specific ideas for strengthening the piece.
"Expose your calculus and just lay out the facts," says a resident, suggesting that Thomas cite how much Ana earned back home in El Salvador compared to here in San Francisco, rather than getting bogged down in rhetoric about "freedom" or "choice." Others throw out ideas for restructuring the beginning of the piece to give it more punch. Aronson and Chen point out how newsworthy this piece is, with Alabama's governor signing a sweeping immigration bill into law that day. "I don't know what you're doing the next few days, but this is very timely," says Chen. "I'm working this weekend," says Aronson, offering to help edit the piece further.
'Peanut Butter and Chocolate'
Writing for Change is part of the Partnership for Physician Advocacy Skills curriculum. This course was designed by Chen, Sharad Jain, MD, director of the SFGH Primary Care Residency Track, and Anda Kuo, MD, director of the Pediatric Leadership for the Underserved residency program, in collaboration with policy and advocacy experts at the California Pan-Ethnic Health Network. The two-year curriculum, funded by a grant from the Institute on Medicine as a Profession, helps medicine and pediatric residents based at SFGH gain skills to improve care for underserved patients at a level beyond the individual patients they see each day.
Residents participate in seminars on the fundamentals of government, lobbying, and legislative, administrative and media advocacy. Chen and Aronson co-teach Writing for Change, with additional support from Jain, Kuo, Vanessa Grubbs, MD, a faculty member in the Nephrology Division, and Jenny Siegel, MD, a recent Department of Medicine chief resident.
Chen is a leader in advocating for improved access to quality healthcare for patients with limited English proficiency. Aronson, a UCSF geriatrician who cares for homebound elders, is a medical educator and fiction writer who runs the Program in Narrative Medicine and directs UCSF Medical Humanities. "I very much have a policy perspective," Chen says. "Louise focuses on writing as craft, and how we really make a piece sing to people. The partnership ends up producing essays that are both compelling, and have a potential policy impact. It's like peanut butter and chocolate — an unexpected combination where the two elements really complement each other."
The class also helps residents process their intense experiences working at SFGH, one of the nation's premier public hospitals and the major health care provider for San Francisco's uninsured. "Trainees who are so committed and idealistic really connect with our patients, and quickly realize that the fundamental cause of a patient's headaches and back pains and depression is often a lack of housing, or inability to find work," says Chen. "We wanted to give them a forum where they could reflect on their experience and connect patients. stories to their policy implications."
"It's amazing what we get used to seeing, and yet so difficult to explain to people outside SFGH what's going on and why it matters," says Sanjay Basu, MD, a second-year resident whose Writing for Change piece was accepted by the New York Times. "The class helped me learn how to articulate a little better about what happens to our patients, in a way that people will understand and appreciate."
"A lot of us came into this [residency] program because we were interested in advocacy and social determinants of health," says Thomas, the resident who wrote about Ana. "Sometimes in the middle of residency, you feel very far away from that. This class has definitely helped me remember why I chose this program, and why I wanted to go into primary care."
The Power of Story
"In medicine, anecdote is generally considered a lesser form of evidence — even though we interact with people at the level of stories," says Aronson. "We say, 'Let me tell you about the admission I had last night,' or, 'This sad thing happened at work today.' Most medical journals now have some story-based section. In JAMA (the Journal of the American Medical Association), 'A Piece of My Mind' is the most-read section of that journal. That's where people turn first. Story is compelling!"
The Writing for Change residents have a range of backgrounds in writing; some were English majors, and others dislike writing. Aronson recalls one resident who said, "I am not a writer. I'm a science person," noting with a laugh that the resident's piece was immediately accepted by the New York Times. "Yes, you have to be a competent writer, but we aren't necessarily writing literature for the ages," says Aronson. "People have to understand what you.re saying, and you have to advocate in a compelling way."
The group discusses a range of examples, from newspaper stories to medical journal articles. Then residents have in-class time to start writing their own pieces. "We ask them, 'What's a story you've been telling everyone?'" says Aronson. 'they are residents — it pours out of them. They encounter all these poignant, tragic stories, and there's not enough time in the day for them to tell those stories."
The class is run like a writing workshop: residents take turns reading their drafts aloud, and are not allowed to preface their readings or to speak while the class provides initial feedback. "this way, you can hear what the initial reaction is," says Basim Khan, MD, MPA, a third-year resident whose pieces from the class have been published in the Huffington Post. "When there's a piece out there, you don't have a chance to preface it."
The class is an incubator for writing, but all of the published works have required editing beyond the class sessions. Chen, Aronson and their colleagues have served as in-house editors, helping residents polish their work until they are ready for submission. In addition to the New York Times and the Huffington Post, residents' work has appeared in the Annals of Internal Medicine and Health Affairs.
The class also discusses potential audiences for the piece, and which venues might have the most impact. "say you're a primary care pediatrician, and there's no pediatrician in your community's emergency department," says Aronson. "We know children in that community will be more likely to die. It may be a little more prestigious to be in the New England Journal of Medicine, but if what you want is a pediatrician in the ER in your community, you're better off publishing in the Fresno Bee, or wherever you are."
The class may also cultivate skills which help residents be better doctors. "Chart notes are all about communicating what you're thinking and what matters," says Aronson. "Or maybe there's some legislation that you want to write a brief about, or a cause you want to raise money for. Perhaps how we care for people, and how our systems work, could be improved if we were better at communicating about what's really going on."
Aronson also teaches a version of the Writing for Change class to medical students, and eventually would like to offer the course to a larger group of residents. Her dream is to create a center for what she calls "public medical communication," which would become a hub for trainees, faculty and visiting scholars to work for change through writing. "Business and law schools tend to teach advocacy, writing and communication more explicitly," says Aronson. "I think it's a fundamental skill, and one that translates to everything you do."
Published pieces by Writing for Change residents:
- Palav, Babaria, MD, MHS: Threatened Hope — PEPFAR and Health in Africa (The New England Journal of Medicine)
- Sanjay Basu, MD: A Worker With No ID and Great Medical Need
- Jennifer Chang, MD: It Was Benign, but Almost Killed Him
- David Dowdy, MD, PhD: Trained to Avoid Primary Care
- Basim Khan, MD, MPA: Health Reform Was Worth It
- Basim Khan, MD, MPA: HIV in America: Why You Should Get Tested