Writing as a Tool for Physicians and Physician Leaders

This transcript of their discussion has been edited for clarity and length.

Mike Sacopulos:

Benjamin Rattray is a neonatologist. Dr. Rattray serves as Associate Medical Director of Neonatal Intensive Care at Cone Health Women's and Children's Center. He is the author of When All Becomes New: A Doctor's Stories of Life, Love, and Loss. Dr. Rattray, welcome to Sound Practice.

Dr. Benjamin Rattray:

Thanks so much for having me.

Sacopulos:

I'm so pleased that you're with us. Please, can you give us an overview of When All Becomes New?

Rattray:

When All Becomes New is a collection of patient stories. Each chapter is a different story for a different patient. Most of the stories follow the patients through their time in intensive care, often starting at the delivery of the baby and then going through until discharge. There are a couple of other stories as well. There's a story of one of my co-residents, but for the most part, each story is just a different patient story.

Sacopulos:

Ernest Hemingway said that, "There's nothing to writing. All you do is sit down at a typewriter and bleed." How difficult is it for you to write?

Rattray:

I think the bleed part is right because it is incredibly difficult for me to write. One of the things that will answer the question here is it took me six years to publish this book. Each chapter has been revised probably 25-30 times. Each sentence has been agonized over. There's so many parts to writing to think about, from just the granular part of which words to use in the sentence structure to the overall narrative arc and really thinking through what it is you're trying to portray. I think the bleeding part is definitely true.

Sacopulos:

I have to say, I know it was six years, but it was time well spent because the book is very well written. As you know, this is a podcast for the American Association for Physician Leadership. Could you please tell us about your journey as a physician leader?

Rattray:

My journey actually starts with a mentor that is a physician leader, and a long time ago, I met him at a conference, and we started chatting, and he talked about his MBA training and then went on to describe his CPE training. I think when I talked to him, I realized that was really the path that I wanted to take. For multiple reasons, I really wanted to pursue an MBA so that I could speak the language when talking with administrators, have some understanding of the business side of medicine.

What I have found is that in my training, I'd been completely focused on medicine and especially focused on just that one patient in front of me and then, at a larger level, just running the neonatal intensive care unit. But what I really started to realize was that there's so much more to decision making that impacts patients, and I felt like the MBA was a really good way of kind of understanding some of those other issues. I really enjoyed my CPE training because that was a little more hands on and more leadership focused than the MBA was. The MBA was a lot more nuts and bolts of business whereas I found the leadership academy really focusing on leadership, and so I feel like there's a really good marriage between the MBA and the CPE training.

Sacopulos:

Who's the intended audience for When All Becomes New?

Rattray:

That's a great question. One of the things that they always teach you is you should start with your audience in mind. It turns out that is a really difficult thing to do sometimes. I think there are some authors that they know that they're writing a beach read that's going to target a certain audience, but for this book, I've been a little surprised. One of the surprising things is that the nursing community has really rallied around the book, and I've had so many nurses who have read the book and given me feedback. In some ways, I guess that is a little bit of a surprise because the book details a lot of kind of everyday life that we encounter in the neonatal intensive care unit, and so my thought was that may be a little boring for people who do that on a day-to-day basis. They may not want to sort of read these stories when they get home. But all that to say, that's been maybe one of the surprises.

But the intended audience are people that are interested in medical drama and medical stories, so people that, for example, like to watch Call the Midwife, or people that like to read books like Paul Kalanithi's book, When Breath Becomes Air. Anybody that's interested in medicine and wants to go behind the closed doors. Especially for neonatal intensive care, we're a lockdown unit, so the only people that can ever come into the unit are the parents and sometimes the family members, so a lot of people really don't get a good glimpse of the neonatal intensive care unit other than reading a book like this.

Sacopulos:

Behind the locked door, what is something that would surprise me from the neonatal intensive care unit?

Rattray:

One of the things that surprises a lot of people is number one, that we actually exist. Because a lot of people come into the hospital, and they have a baby, and they go home maybe two, three days later, and they don't realize that just one floor above them is an entire intensive care unit dedicated to babies. So unless somebody actually has a reason to see us, they may not be aware that we're there. And then one of the other things that often surprises people is just the number of babies that do go through intensive care unit; it's about half a million babies per year in the U.S., which is a pretty good number of babies that need some sort of help. And then of course those babies sometimes vary from really minor things like some low blood sugars that they need some fluids, and they're with us for several days, all the way to the extremes of extreme prematurity and staying with us for three or four months.

Sacopulos:

In an essay, you wrote that the process of writing heightens your senses, that it makes observation more focused. How does that happen?

Rattray:

One of the quotes that I really love is by an author called Anthony Doerr, and he has a book called Four Seasons in Rome where he actually had a one-year sabbatical in Rome, and one of the things that he writes in his book is he says, "The easier an experience or the more entrenched or the more familiar, the fainter our sensation of it becomes. This is true of chocolate and marriages and hometowns and narrative structures." And I think that that's so true. I think that in our daily life it's really easy to start going through kind of the same routine every single day. I think we probably all had that experience where you're driving to work, and you get to work, and you realize you can't remember a single thing about your drive to work.

I think that one of the possibilities and one of the dangers is that that same thing can happen in patient care. If we're kind of seeing the same sort of illness and the same kind of patients over and over again, it's easy to get into that rut and to just sort of miss some of those clinical details, so I think one of the things that writing does is it forces me to stop and look around and look for those details to draw the reader in and to really force myself to notice this individual patient, these individual parents, and kind of what's unique about their situation. And I think honestly, just that process of trying to describe a baby on paper will really force you to look at each individual thing.

Sacopulos:

Medicine is both art and science. Do you believe that too little attention is given to the art component of medicine?

Rattray:

I do. I think that one of the things that we're really focused on in medical training is the disease pathology. So everything really, most of the medical curriculums, that's kind of the central focus and the way that we approach disease. I think that an imbalance that can come in is to lose sight of the patient and to lose sight of kind of the emotional aspect of medicine, but the truth is that medicine is inter-relational, and so that's a big focus. And I think that the emotions that people have both on the caregiver side and on the patient side are really critical, important parts of medicine. If we're not careful, if we're just focusing on the technical aspect, we can almost just manage the patient from the computer. You can look at the lab values, you can look at the X-rays, you can kind of change the ventilator settings, but you can certainly miss out on a lot of other aspects if we're just doing that kind of medicine.

Sacopulos:

You quote Ford Madox Ford saying, "Some writing is just to get visions out of your head." First, not nearly enough attention is given to Ford Madox Ford. Thank you. Second, is your writing for this purpose as well?

Rattray:

It partly is, yes. It's certainly not only a cathartic exercise. I think a lot of the book is intended to show people the emotions that we feel as physicians, how much we care, but certainly part of it is to tell some of these stories that had stuck with me over the years. I think that part of our function in healthcare is to bear witness, and I think we're especially seeing this right now in the pandemic. We certainly do bear witness in the ways that journalists do. Lots of people, I think, when they go through these different experiences, they want to bear witness, and they want to share these experiences that they've had, and so I think that there definitely is that element of that in the book.

Sacopulos:

Is there one story from the book that comes to mind as an example of this?

Rattray:

Definitely one example is that I was taking care of a pre-term baby. This baby was born early and was about half a week to a week into his stay in the intensive care unit, and things were going really well. We were weaning down his ventilator support, we were going up on his feeding volumes, and his dad was actually a sniper in the army. I had the opportunity to meet the mother at the bed side, and we were talking each day, and then one day the dad came in, and we were able to start talking, and I learned a little bit about who he was and what he did.

The next morning I came in for sign-out, and there was an x-ray pulled up on the computer, and it showed all the hallmark signs of a disease that we call necrotizing enterocolitis which is a really tragic disease where the bowel essentially gets sick and inflamed and often dies. And it turned out that it was the sniper's son's X-ray, so this baby went to surgery. Actually, we did bed side surgery in the intensive care unit, and when the surgeon got in, all of the intestines were dead.

This is a baby that we ended up having to withdraw support on, but we wheeled the baby into a private room, and the father came, and with him were a group of his army colleagues all in their dress blues. And just that image of these men standing by, supporting this dad and supporting this mom, is something that really stuck with me. That was one of the stories and the chapter's called “The Sniper's Son.”

Sacopulos:

My next question is mechanical. Shelby Foot wrote a three volume history of the civil war. I think it was over a hundred thousand words. He wrote it all by hand, much of it with a dip pen, because he said that his writing was so much better by hand than it was if he composed at a keyboard. How do you write?

Rattray:

I actually do a mixture. Most of my writing at this point is on the computer. One of the things that I really love about the computer is it's easy to edit, so you can quickly move words and sentences around, and so that turns out to be a pretty big part of my writing at this point, but I actually do have a couple of journals that I've filled up. Sometimes, for example, if I'm at the hospital on a call night, I might just have a little bit of time to sit down and journal, and often I do find that just that mechanical hand, pen to paper can be a great way of working through different ideas. Sometimes when I have a sentence that I'm really struggling with, I'll actually end up getting a journal and kind of writing down the sentences that way and then transcribing it back onto the computer.

Sacopulos:

This may seem like a silly question, but does the subject of your writing matter? Is it just the act of writing that gives the benefit of heightened observance, or does it need to be contextually based?

Rattray:

I don't think it needs to be contextually based, and I've eventually turned to writing fiction right now, and I find that I have the same sort of heightened noticing with this sort of writing as well. Some people really like to do travel writing, for example. I think one of the things about traveling is it really opens your eyes and opens your senses to these different sites and smells and things around you, so I think, for example, when you're traveling, that's a really great way of doing that. So I think just a journal entry can certainly do that. For me, because I spend so much time at the hospital, I think that's sort of a natural thing for me to write about.

Sacopulos:

Do your writing skills spill over or apply to charting? It seems to me that EMR systems are designed for purposes maybe other than prose. How transferable are your skills?

Rattray:

That's a good question. I think that they're two very different writing styles, so I'm not sure that they do impact each other too much because typically when I'm writing in the chart is very technical, and my goal is to be very to the point, whereas in writing, it's more of a creative enterprise where you're trying to help people to see things in a different way and kind of describe things in more of a narrative structure. So, I mean, certainly there are similarities, but I think for the most part, I'm sort of wearing two different hats when I'm doing those two different kind of writing styles.

Sacopulos:

As we wrap up our time together, Doctor, tell me what does the future hold for you as far as your writing? What are you working on?

Rattray:

That's a great question. My goal is to be a physician writer. And the question is, what does that mean? So I'm working on individual blog posts, different articles for different magazines and journals, and then I'm actually working on a novel, which is something that I haven't actually said out loud yet to anybody, so you're the first one to know that's what I'm working on. And it feels like such a flimsy endeavor because every single time you sit down, it feels just as difficult as when you started. I don't think, it never gets easier, which may be going back to Hemingway and you just sit down and bleed. Maybe that's why that's so true because it doesn't get easier, and you never know if something's going to work out until you've poured all these hours and all this time into it. Sometimes you'll get to the end of a chapter, and it's just no good, and it has to be thrown out. So that's certainly the way that I feel about anything right now, whether it's an article or working on this novel.

Sacopulos:

You mentioned a blog post. Where can listeners find your blog?

Rattray:

My website is my name, Benjaminrattray.com. And at that website, I have some information about the book and some blog posts as well. Most of my blog posts tend to revolve around medicine and just our observations in medicine.

Sacopulos:

Excellent. The book is When All Becomes New: A Doctor's Stories of Life, Love, and Loss. My guest has been Dr. Benjamin Rattray. Doctor, thank you so much for your time.

Rattray:

Thanks so much for having me.

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