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The Salmon of Doubt: Hitchhiking the Galaxy One Last Time1 

Many of us envy and even view with awe the ease with which others write. Program directors and faculty educators often find writing to be uncomfortable, slow, and readily postponed. Yet with a dearth of useful information regarding successful, feasible, and affordable strategies to teach the next generation of physicians, educators must contribute to the national and international discussion.

In addition, “publish or perish” is an often-heard term for persons involved in training residents and fellows, particularly at university-based institutions. Whether used to describe research interventions, policy matters, or reviews, writing skills share common elements and fortunately (for those who believe they lack them) are not genetic traits but learned abilities. This editorial will present some current evidence and expert recommendations regarding strategies to move your ideas outward—onto paper or computer screen.

One caveat: the goal is not to publish material that is inaccurate or of little use to other educators. According to British pharmacologist David Colquhoun, “Any paper, however bad, can now get published in a journal that claims to be peer-reviewed.”2 The explosion of journals with varying peer-review processes has resulted in exponential publication of marginally worthwhile papers: an estimated 1.6 million papers in 23 000 journals were published in 2006.2 For the purposes of this editorial, we will assume that your work or ideas are important, and the primary deficiency lies instead in generating your words.

Why Is It So Hard?

Although most of us have not had formal training in writing, we may have had uncomfortable experiences with writing in the past. Teachers may have responded to our writing primarily with criticism, with a focus on perfection. This can lead to low confidence in skills, fear of failure, anxiety about writing, and procrastination.3 

Without a specific time for writing in our overscheduled days, it can be postponed indefinitely. It is one of the “high importance, low urgency” tasks described by Richard Covey in his classic, The Seven Habits of Highly Effective People.4 Some studies have reported that time is perceived as the main barrier to writing, yet other studies have found that highly productive writers have the same amount of time as less productive writers.5 Thus, host factors, such as attitudes about writing and personal writing habits, may play as large a role in successful authorship as external factors, such as protected time, available mentors, and instructional sessions on writing.

Research About Writer's Block

Although psychoanalyst Edmund Bergler6 first described writer's block in 1947, you will be relieved to know that it is not considered an official psychiatric disorder. Over the ensuing years writer's block has been described variously and colorfully. In brief, it is a condition in which authors are unable to begin or continue writing, although they have the basic cognitive tools and desire to perform. Anxiety, viewing one's work as poor quality, excessive self-consciousness, and many other elements can interact to slow or stop the flow of words. Although “no time” is the most common reason faculty cite for not writing, time-flow studies of academic teachers demonstrate that they typically have several 20- to 30-minute blocks of free time per week. For most of us, procrastination is likely a key element, in combination with unfamiliarity regarding how to organize or structure a scholarly publication. For writers with difficulty organizing a scholarly paper, many useful articles on this topic have been published: see the writing papers link on the Journal of Graduate Medical Education (JGME) website, Resources for Authors–Education Research (http://www.jgme.org/page/resources_for_authors) for one.

In the 1990s, Dr. Robert Boice began to study productive versus nonproductive faculty writers.7 His books on the topic are considered must haves by many faculty.3,8 Boice surveyed habits of exemplary writers in the academic population—about 3% to 5%—and discovered that these productive faculty shared certain habits. These habits included working patiently; working regularly; writing with stable and calm emotions; feeling less uncertainty and pain, and a greater sense of fun and discovery; welcoming criticism; and working efficiently.3 Successful writers were more likely to write regularly for short periods rather than “bingeing” with long, infrequent sessions.3 

Useful Strategies

From his observational studies Boice developed exercises to develop writing muscles, which are detailed in his books. He has used these exercises successfully in group and individual coaching over the past 2 decades. Boice's exercises can be performed as part of a group or alone. One of his key tenets is that lack of self-consciousness about writing is beneficial, and that one should write without feeling ready.3 Particularly for faculty who experience anxiety about writing or difficulty getting started, his books appear to be useful guides.

Other educators have focused on the benefits of peer writing groups. Most researchers have found increased productivity and quality of work in groups that meet regularly.9,10 Articles have also described effective writing retreats in which senior writers mentor junior writers.11 Most reports have examined the benefits of small groups, with 3 to 6 members, who meet regularly to discuss progress and plan individual goals for the coming week. Groups in which members also share content knowledge can provide reviewing expertise as well. If members do not share content expertise, the focus is on accountability in the context of a supportive community. Members should prioritize attendance; those who regularly miss meetings may need to temporarily leave the group. Writing groups are most useful for discovering and refining the writing topic, maintaining momentum to complete the project, and identifying potential sources for publication.9,10 

Writing regularly is highly recommended. Boice recommends starting with free writing, in which no particular topic is in mind.3 Free writing, journaling, brainstorming, and group discussions about your work are particularly useful for those who are having difficulty getting any words on the page. For many of us, finding time in our schedule to write is the greater challenge. Rather than looking for a large block of time, find 20 to 30 minutes several days per week. If necessary, substitute a writing period for “time bandits” in your schedule: reading/responding to e-mails, surfing the net, chatting with colleagues, TV, social networking, and so on.4 Regularity appears to be the most critical ingredient for many successful faculty writers.

Finally, researchers recommend that authors embrace editor and reviewer comments. This will be facilitated by maintaining an open mind and curiosity about your work. Regularly sharing your work with others, such as in peer writing groups, may facilitate openness to changes in your overall approach or written products.

Medical Education Papers

For those engaged in conducting education research or creating new curriculum, the content of your writing is clear.9 Many articles have been published that discuss common organizational strategies, appropriate journal selection, and opportunities to enhance (or hamper) your paper for the review process. However, there are other submission categories to consider, particularly as you get started on the writing path: reflective personal essays, review papers, and policy white papers. These are critical areas as well, and will require ongoing practice for you to develop papers that can be submitted, published, read, and understood by colleagues.

As an example, the criteria used in judging JGME's personal essay category, On Teaching, are quite different from those for the original research category. First, the essay must provide an insight that is relevant to teaching or learning in medicine. Second, the clarity of the message or lesson is critical: these are short, pithy articles, with a lightbulb, aha-type moment for the reader. The writing style should be engaging, the story should compel the reader, and the reader's emotions and intellect should be engaged.

Just Get Started

In summary, graduate medical educators often have years of experience, are passionate about teaching and the quality of medical education, and are actively engaged in ongoing medical education innovations. Whether you are writing research reports, narrative review papers, position statements, or personal essays, writing successfully requires practice to develop writing muscles. Useful habits, derived from studying productive faculty writers, can be practiced in the short periods of time that are available to the busiest clinician educators. Viewing writing time as an occasion for calm reflection rather than as a painful, rushed exercise appears beneficial. Working in groups is also associated with increased productivity and is feasible for most settings. Future physicians and their patients will benefit from your insights, questions, and discussion. Start writing now.

Box Useful Writing Strategies
  1. Form or join a peer writing group.

  2. Attend writing workshops at your regional or national meeting.

  3. Scan the table of contents of 1 or 2 medical education journals regularly, and read articles in areas of your interest or ongoing projects.

  4. If writing is difficult, speak aloud and then transcribe your words.

  5. Start writing the section of the piece that you find easiest (or, for some, do the most critical first).

  6. Write at least 1 hour per week, and preferably 20 to 30 minutes several times per week.

  7. Keep a nonjudgmental attitude about your writing, and approach writing not as a painful necessity but as a time to relax, reflect, and be calm.

  8. Welcome critiques of your work, including reviewer comments.

  9. If writing remains difficult, try exercises found in writing self-help guides.3,8 

  10. Start writing now.

References

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Author notes

Gail M. Sullivan, MD, MPH, is Editor-in-Chief of the Journal of Graduate Medical Education.