Why write?
Authors: A. Anstey
Journal: British Journal of Dermatology (2013)

I recently saw a patient with early-onset, genetically determined female-pattern hair thinning. I searched for a well-written patient information leaflet to complement the advice I was giving, recognizing that my patient was disappointed and was not taking in what I was saying. Despite her having a common condition, I was unable to find anything suitable. A few days later I asked a new dermatology resident if she would be interested in working with me to create a good-quality patient information leaflet for the website of the British Association of Dermatologists (BAD). She agreed and we briefly discussed the form it might take. To my surprise, a few days later, the dermatology resident had written the patient information leaflet. More surprising was that it required minimal editing. She could write! A few weeks later it had been through the quality system of the BAD with minimal amendment, and then appeared on the BAD website, accessible to patients and clinicians.1 From start to finish this took well under 6 months. I now direct my patients to this resource, recognizing that it underpins and reinforces the advice I give for this troubling disorder. It is easier to think of reasons not to, rather than reasons to, write: there is no time to write; there is nothing new to write about; I have nothing to say; no one would listen to me; I will be laughed at by my colleagues; the rejection rate is so high my piece is sure to be rejected; writing is best left to academics; there is no point in someone like me writing; I function pretty well without academic writing; I can't write; no one else that I know takes writing seriously. These are all great reasons not to write. However, these excuses challenge our notion of professionalism and, when analysed, do not stand up to scrutiny. Even if writing does not lead to a publication, it still provides an opportunity to create something thoughtful and personal, and may in itself be the catalyst for professional interaction that leads to change in practice and improved patient care. Whatever the intended reasons for writing, the process itself may have a beneficial effect. Thus, writing with the rigour of an academic becomes a tool that all clinical dermatologists can use to improve patient care. How does this work in practice? Dermatologists who are not involved in academic work probably see themselves as front-line workers caring for legions of patients with skin disease. Most of this work occurs in teams, typically multidisciplinary, delivering dermatology services in a range of scenarios. Such teamwork is complex and costly, requiring leadership, expert management and coordination. When change is needed, the usual starting point should be a written proposal, typically a business plan. The process of writing such a proposal is greatly enhanced by following the same structure as when writing a scientific paper. This was concisely summarized nearly 50 years ago as follows: ‘Why did you start? What did you do? What answer did you get? What does it mean anyway? That is a logical order for a scientific paper.’ (Sir Austin Bradford Hill, 1965.)2 A dermatologist working within a team might, for example, be interested in adopting a new technology, believing this to have the potential to enhance patient care. Hearing how other dermatologists have utilized this new technology reinforces the dermatologist's conviction that this is the way to go; it will also address some problems within the existing model of care. But how can the dermatologist persuade her colleagues, a couple of whom are set in their ways? She needs to write a proposal. The proposal should start by describing the current problems in the service (why did you start?). It should then move on to describe the new technology and how it might be used within the existing system of care (what did you do?). It will then describe how the impact of the new technology would be measured and monitored (what answer did you get?). Finally, it should attempt to describe what success would look like and what this would mean for patient care (what does it mean anyway?). By writing this proposal document, the dermatologist creates an opportunity for the whole team to read, reflect, discuss and debate. This process is analogous to submitting a paper for peer review, where a dialogue is established between the authors and the reviewers, leading to modification and improvement of the original manuscript. The end product is usually quite different from the first draft, and is much improved. The debate that informs each new iteration of the document must focus on what the team is trying to accomplish, so that there is clarity about how to evaluate the change. Importantly, this scholarly approach has clinical practice leading to theory (the current system is not working; my theory is that introducing a new technology will address these problems) and theory leading to practice (we will collect data over a period of time to evaluate the change; this will help us to assess whether the change produced by the technology represents improved care). Thus, the author of a scholarly proposal draws in the rest of the team, allowing them to contribute in a way that a less disciplined approach does not. The scholarly approach is at the core of quality improvement systems in health care, as promulgated by Don Berwick3 and others at the Institute of Healthcare Improvement. What other reasons are there for a dermatologist to write a paper? The process of writing may lead to self-improvement. Committing thoughts and ideas to paper transforms the writer from spectator to participant. Once in the debate, ideas are exchanged, positions modified and new ideas assimilated. At its best, the debate is thrilling; at its worst it may be bruising. It's a bit like playing team sport: with a disciplined and thoughtful approach a well-prepared team is likely to prevail, despite taking some knocks on the way. However, even well-prepared teams sometimes lose games. Those who succeed with academic writing are able to turn rejection and failure into future strengths, by learning from the experience and raising their subsequent level of performance. Thus, the very process of academic discourse leads to maturation in understanding of medicine and health care that would not take place in isolation. Writing is a skill honed through…writing: letters to the editor, patient information leaflets, text for a newsletter, proposals for a change in practice, grant applications, study protocols, research studies, review articles, systematic reviews, abstracts, editorials, commentaries, opinion pieces, peer reviews and books. How is this writing skill relevant to patient care? The ultimate aim of dermatological research is to improve patient care and to achieve better clinical outcomes. What role in this process is played by journals such as the British Journal of Dermatology? To enhance the stock of dermatological knowledge and thereby contribute to advancing patient care. ‘The British Journal of Dermatology strives to publish the highest quality dermatological research. In so doing, the journal aims to advance understanding, management and treatment of skin disease and improve patient outcomes.’ As with service improvement, so for clinical and laboratory research; it all comes down to improving patient outcomes. What about the papers on basic dermatological science, how do they affect patient outcomes? In publishing basic science papers alongside clinical research, the British Journal of Dermatology acknowledges the importance of translational research in underpinning improved patient care. However, basic science requires exceptional writing scholarship if it is to be understood and acted upon by clinicians. Anything less is destined for ignominy, to be unread and ignored. In contrast, translational research that adopts the maxim of Sir Austin Bradford Hill has the potential to influence clinical practice. The writing gives meaning to the research endeavour, making it widely accessible and easier to understand. Importantly, those engaged in translational research utilize the scholarship of integration to interpret their research, placing it within a broader context, and making wider connections. The British Journal of Dermatology uses commentaries and editorials to enhance the translation of key academic papers into something more palatable to the busy practitioner. Thus, distilling key up-to-date messages from the literature is another reason for writing. Why write? Because you can write; you have something to say; your ideas will have a better chance of being adopted; you want to make a difference; to act as a catalyst for change; to contribute to the debate; to share your ideas with others; to help patients beyond those whom you care for personally; it is your professional duty; it is the right thing to do; to be taken seriously by your colleagues; to enhance your own professional development; to help others to understand what may be obvious to you. All this is true; however, the fundamental reason is to improve patient care.