Scribes and scrubs: A healthy mix

By Mary Knudson

Three years ago I read a book that made me think about training medical writers in a new way. The book was "Complications: A Surgeon's Notes on an Imperfect Science" by Atul Gawande, a surgeon at Brigham and Women's Hospital and a staff writer for The New Yorker. Gawande wrote riveting accounts of doctors grappling with on-the-job training and, no matter how far advanced in their careers, often diagnosing and treating patients in the face of uncertainties and unknowns. I began to envision a course that would bring my graduate writing students face to face with the same gray areas of medicine that Gawande revealed so honestly in "Complications."

Journalists have much easier access to the successes of medicine through press conferences, press releases, tip sheets, phone and e-mail solicitations from hospital public information officers and journals that typically print studies about what works. I wanted to establish a course that would provide balance by showing students the challenges, problems, complications and complexities involved when doctors care for patients, especially in hospitals.

Before health care writers begin to write about health care they should have a thorough understanding of the health care system. If rooted in the reality of how medical treatment is decided and what it's like to be a doctor, writers should be better able to critically assess new diagnostic and screening tools and new drugs and less apt to over-promise what medicine can't deliver.

I got approval to proceed from David Everett, the director of the Master of Arts in Writing Program at Johns Hopkins University, and last fall my imagining became reality as the inaugural class of Medicine in Action took root inside Johns Hopkins Hospital in Baltimore.

For this kind of learning opportunity to take place, the university writing program or department has to find an ally inside a medical center. I had the good fortune to meet Charles M. Wiener, M.D., vice chair of the Department of Medicine and director of the Osler Medical Training Program, the highly competitive training grounds for medical residents. I had enlisted Diana Sugg, the Pulitzer Prize-winning former medical writer for The Sun in Baltimore, to teach this course with me. She introduced me to Wiener, who readily understood what we wanted to do and why.

"As a clinician, I am constantly frustrated by the oversimplification of patient care that I see in the visual and print media," Wiener explained. "I can understand why journalists and consumers appreciate simplicity, medical drama and hyperbole, but those types of situations are the exception, not the rule."

Almost no case is black and white, he said, because "when you take a patient-care situation and factor in the medical, social, financial, ethical, educational, research, modulating factors, the situation becomes gray very quickly. That is the real-world decision making that clinicians deal with and we often feel that patients/consumers are not well educated about complexity."

Wiener felt that "Educating journalists about complexity can be a start toward educating the public." That was exactly my reason for wanting to launch this course.

I wanted our classroom to be inside the hospital to make it convenient for doctors to drop in and talk to our students. And I wanted our students to be able to shadow doctors as they worked in the hospital. Wiener, who instructors and students alike would quickly come to know as Charlie, overturned initial concerns from the public affairs office that the hospital was too crowded to accommodate our class and that the privacy rules wih the Health Insurance Portability & Accountability Act of 1996 (HIPAA) would prevent my students from watching doctors at work with patients.

Wiener assigned us a regular classroom, the same room that many of the medical specialties use each week for Grand Rounds. He said that as long as the students took a HIPAA certification course, they would be cleared to shadow his residents. Students and instructors took an online HIPAA certification course.

Before the class got underway Sugg was whisked away to Switzerland for two years by her husband, Dr. Albert Wu, who was tapped to work with the World Health Organization on new safety measures. I was so fortunate to find health and medical writer Shannon Brownlee to be a co-instructor and co-organizer. Brownlee was a fellow at New America Foundation and is the author of "Overtreated: Why Too Much Medicine is Making Americans Sicker and Poorer." Her expertise and writing and speaking interests dovetailed with the goals of our course.

We wanted doctors to talk to our students as openly as they would to another doctor and we felt we would only get this freedom if the doctors knew that what they said would not leave the classroom. The instructors wrote up a confidentiality agreement that students and Brownlee and I signed. We stipulated that everything doctors said in the classroom and students heard and observed while shadowing doctors in the hospital was for the students' learning experience and could not be written about unless they returned to the doctor and said "I am now contacting you as a writer." The student would have to get permission from the doctor to write about a specific moment observed in the hospital or something a doctor revealed to students in the classroom. Students wrote an article on a topic relevant to the course.

Each week, doctors from various specialties talked to us about problems they faced in treating patients. One week we heard the step-by-step account of how a woman who came in to the emergency room for a routine procedure ended up dying. Another week Barry Kramer, associate director for disease prevention at the National Institutes of Health, gave a thought-provoking talk on why some screening tests for cancer remain unproven and may not cut cancer death rates, but rather can lead to a net harm in those who get them. Our students also spent a half day especially arranged for them at the National Institutes of Health Clinical Center. Susan Molchan Whiteman, a doctor who worked on Alzheimer's disease at NIH and a recent graduate of our writing program, helped set that up.

Wiener matched each writing student with a resident for a 15-hour shift. The resident's shift was actually 30 hours, but we couldn't ask a student to hang there that long and Wiener believed 15 hours was enough for students to understand what a resident faces on the job. The writing students donned scrubs and blended into the hospital routine for experiences they could never get in a classroom.

For student Peter Mouton, the shadowing experience really made the course stand out from any others. "During my 15-hour shift, from 7 p.m. to 10 a.m. the next morning, I learned a great deal in general about the operation of a major urban teaching hospital, and more specifically about the role of interns in the delivery of primary care," Mouton said.

He and another student, Mayer Baker, were both surprised by the extent of the decision making and care giving first-year residents [interns] have. "Starting only a month or so after their graduation from medical school, interns assume an enormous amount of responsibility for patient care," Mouton said.

"It was a great surprise to me that the first-years have as much authority as they do," Baker said. "I think I had expected that their attendings would be around much more or at least called on by the interns more than they were. One thing that my intern said that night that stuck with me was that Hopkins was special because of that very thing – they didn't hover over the first-years and seemed to have a lot more trust in them as capable doctors than many of the other institutions that took in residents.

"I also was able to observe on a more intimate basis how being a doctor affects one's interaction and relationship with patients as well as with nursing staff, regardless of the level of experience," Baker added.

Brownlee and I were as excited by the course as any of our students. "Medicine in Action is the kind of course I wish I could have taken as a young writer," Brownlee says. She sums up the experience: "It offers students an unusual range of provocative topics and unparalleled access and insight into the inner workings of medicine."

We got through the first year with no casualties of students, doctors, or patients and we're ready to go again, bringing on board even more doctors.

"My limited experience with journalists has reinforced my assumption that they are intelligent, honorable, dedicated people who are happy to embrace the more complex picture of health care if given the opportunity. Having the opportunity to help in that process and meet new interesting people drew me to the course," Wiener said.

In our second year we will again visit Wiener and his residents and this time our students will also get to look in on a Department of Surgery Morbidity and Mortality Conference, in which surgeons confront one another over mistakes in the spirit of learning to avoid them in the future.

Mary Knudson, an independent medical writer, is the science-medical writing adviser in the Master of Arts in Writing Program at Johns Hopkins University. She can be reached at mknudson@jhu.edu.