Link is below 🙂
An Anesthesiologist's Notes from the Operating Room
“The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn”Alvin Toffler
During the 20th century, a college degree used to be a true sign of education. In 1960, only 18% of Americans graduated high school, 6-8% graduated college, and <1% completed an advanced degree (census.gov). Today, degrees are much more common. By 2015, 88% of Americans graduated high school, 33% had a bachelor’s degree, and 12% held a more advanced degree (census.gov).
Increasing access to higher education had an unintended consequence. Bachelor’s degrees became a status symbol sold like a commodity without quality control. As the number of degrees increased the quality declined. College became a place to meet people, party, and prove you can pass multiple choice tests. In 2021 years of education are no longer synonymous with learning.
Millennials learned this lesson the hard way: they are the poorest generation in the last hundred years, despite having the most years of schooling. Spending the time and money to earn college degrees did not translate into assets later in life. By 2023, the millennial generation will own only 3% of America’s wealth. At the same median age, Baby Boomers owned 21% (Washington Post).
The difference between years of schooling and education became apparent to me over the last year when I wrote a non-fiction book for the general public, called “Vigilance: An Anesthesiologist’s Notes on Thriving in Uncertainty.” Vigilance explains how anesthesiologists successfully navigate uncertain situations, told through my experiences as a medical student and resident. It then applies those strategies to modern day systemic problems. I wanted to document how anesthesiologists think, what we do, and how our methods might be valuable outside of medicine.
In order to finish the book I reversed many of my academic thinking habits. As the 21st century continues, writing a high-quality book will join the long list of skills that supersede years of education.
Here are six reasons why I think writing a quality book is the new college degree:
1. Writing a quality book means you understand the difference between quality and quantity.
Volume of writing is different from quality writing. I wrote the manuscript for my book in 360 days. I wrote about 500,000 words total, but the final manuscript is only 50,000 words. That means my readers will only see the most relevant 10%.
A high-quality book means the author knows how to prioritize what is important to the reader. Good writing requires “killing your darlings,” which is removing all unnecessary parts unrelated to your message. Writing is meant to communicate a message; good writing means the author knows how to focus on what’s important. Writing without an audience is not a book it is just a diary.
2. Writing a quality book signals communication and leadership skills.
Writing a book is a team sport. In order to succeed, I surrounded myself with people who had skills, perspectives, and experiences I lacked. I partnered with editors, graphic designers, accountants, lawyers, and a publishing company to make the book a reality. Instead of micromanaging, I focused on accurately articulating my vision, then gave my partners freedom to do their best work.
Research, writing, editing, proofreading, graphic design, marketing, and finance happened simultaneously. I quickly learned to organize complex tasks into individual parts, delegate appropriately, and be ultimately responsible for quality control. My work became people-centric, rather than task-centric.
3. Writing a quality book means you respond well to criticism.
Writing is easy if you ignore criticism in order to preserve your ego, remaining blissfully unaware of the chasm between your perception and objective reality. For an author, the greatest barrier to overcome is yourself. Early in the writing process I realized I could not evaluate my writing objectively. I had two choices: either accept the limit of my perspective, or live in my own omniscient fantasy; I chose reality.
I recruited editors with different backgrounds and diverse perspectives. Allowing others to criticize my thoughts elevated my writing beyond what I could achieve alone. Constructive criticism became my most valuable asset. Rather than assuming my editors were wrong and trying to prove why I was right, I instead assumed my editors were right and tried to prove why I was wrong.
4. Writing a quality book means you can think critically.
As 21st century knowledge assessments rely more on standardized tests and numerical benchmarks, students don’t learn to define their own values, engage in constructive argument, or communicate outside of academic settings. College has become less about critical thinking and more about following directions. Students have become fragile and helpless rather than curious and resourceful. Today, a college degree signals you can show up and follow directions.
Writing a book signals you’re an original thinker with independent value. Books can’t be written by following someone else’s directions, memorizing a textbook, or process of elimination. Writing a book means the author has defined an important topic, then organized his thoughts to communicate that topic. A book is reflection of what the author thinks is important.
5. Writing a quality book signals legitimacy.
Publishing a book means allowing others to examine your thoughts. Are you willing to take that risk? To allow countless strangers the power to evaluate your most deeply held beliefs?
Taking a risk for what you believe in is a signal of legitimacy. Unlike academia, there is no such thing as a “free” action. By releasing my book, I’m taking the risk that my ideas are correct; however, I could also be very wrong and permanently damage my future. Time will tell!
I find people have a lot opinions, but when they have to take a risk for those opinions, suddenly they have fewer of them. Talk is cheap.
6. Writing a good book means you know how to work hard and follow through.
There are no shortcuts in publishing. The title must be chosen. The cover must be designed. The manuscript must be written, edited, then proofread. Printing and distribution are next. Finally, marketing commences to figure out how to reach your intended audience. No one can buy your book unless you complete 100% of the steps. 99% completion means failure.
In order to finish my book on schedule, I wrote early in the mornings and late at night in addition to my residency responsibilities. I estimate I worked 7 days per week, 12-18 hours per day for a year. I didn’t have a boss cracking a whip. I chose to work hard because I believed in what I was doing. Writing a quality book means you can build an asset from nothing.
Vigilance will be released June 22, 2021.
The Vigilance manuscript was finished last week. The entire process from my first outline to the final manuscript took about 12 months.
Initially I thought I was done in September of last year. After getting feedback I decided to scrap the second half of the manuscript and re-write it. This represented a 25,000 word shift, about 50% of the manuscript. The initial draft of the 12 chapter manuscript was completed in January 2021.
After that the editing process started. Editing means choosing what “big picture” content will be included in the final manuscript. Entire chapters were dissected, condensed, then re-written. Subheadings were added for better organization. Every editing pass yielded a 5,000-10,000 word change, which is 10-20% of the manuscript.
When I was happy with the content in each chapter I moved from editing to the QA (quality assurance) stage. QA is a general term for editing at the paragraph level. That meant fact checking, choosing where paragraphs start and stop, and deleting all unnecessary sentences. Every QA pass yielded a 1,000-2,000 word change, which is about 2-4% of the manuscript.
After QA came proofreading. Proofreading is a final check for grammar, sentence structure, and an additional round of fact-checking. This was the most stressful part for me because I had to confirm every name was spelled correctly, every fact was verified, and the manuscript was free of grammatical errors. Every proofreading pass yielded a 500-1,000 word change, which is about 1-2% of the manuscript.
We’re not done yet! After editing, QA, and proofreading the manuscript was formatted for a book. The layout phase was primarily done by Scribe. At this point I was so burned out I didn’t want to even look at the manuscript. I had a heart attack when I noticed someone’s name spelled incorrectly in a footnote of chapter 12. Luckily the error was corrected before the layout was approved.
Finally, the book is converted to a single file then sent to the printer. In 4-6 weeks I will have the paper copy of the book!
Vigilance will be released on June 22! Stay tuned 🙂
The peripheral IV is the first test of anesthesiology residents. Success means your patient might not guess you are less than 100% confident in your skills. Failure means your patient will stare at you for five minutes as you hold pressure on the blown vein. They might give you another chance…or maybe not.
Thank you to the American Society of Anesthesiologists for publishing the article!
Physician Outlook Magazine published a profile of my last month!
Thank you Marianna Seefeldt, Rachel Torregiano, and Marlene Wust Smith!
Published my first article on the American Society of Anethesiologists website!
“You must learn to write poorly before you learn to write well”Rick Kreinbring
“Writing without an audience is a diary”Tucker Max
The only way to become a better writer is to write. Since I started writing my book in May 2020 I consistently write between 500-2000 words per day. My single day (24 hour) record is 5500 words in three 4-hour blocks. Overall my book is 50,000 words but the total amount of words written was about 500,000. Why did I write 10x more words than necessary?
High quality writing is not writing a lot of words, it is using the minimum number of correct words to communicate a specific message. That means increasing the number of concise sentences and removing vague, confusing, or extraneous sentences. The writer should keep only what is absolutely necessary. Everything else should be eliminated. Only 10% of what I wrote made it into my book.
How did I figure out what to keep and what to delete?
I wrote 500,000 words, but only had room for 50,000 in my manuscript. That meant I could only keep 10% of what I wrote. In order to choose the best 50,000 words I relied on editors for high quality feedback. I needed their independent perspective I was too close to my own writing process to understand what it looked like from an outside perspective.
I purposely chose three kinds of editors. One group were my physician colleagues who saw medicine from the same inside perspective as me. The second group were non-physicians who had some knowledge of healthcare, psychology, and economics. The third group were people without any knowledge of medicine. The physicians would check the internal validity of my writing, the non-physicians would check if my medical writing was relatable to non-medical people, and the outsiders would check to if I was explaining medicine in a way anyone could understand.
Writing is coding human thoughts into language. By writing, I automatically limited my own perspective. I could no longer accurately perceive how my writing would be decoded by readers. Editing is refining language so it can be decoded and read by a variety of people. Editors have a unique perspective the writer can never have: they have the ability to see writing from a 3rd person perspective.
The graphic below describes the differences in perspective from a reader and writer
In order to give and accept criticism both parties must come from a place of good will and commit to making the writer’s internal world the same as the reader’s external world. This is easier said than done. The writer must acknowledge the editor is trying to help him or her. The editors must know how to give high quality feedback.
The writing-editing feedback process resembles an improv comedy skit more than a scripted play. The writer and editor are reacting to each other in real time to shape an idea rather than reading and rereading the same lines. Figuring out how to enable each other in order to make the writers internal word match the reader’s external world takes time, understanding, and patience.
Below are characteristics of good writers and good editors:
Editor feedback should be embraced rather than avoided. Rejecting editor feedback does a disservice to both yourself and your reader. By rejecting feedback you are saying: “my ego is more important than my message.” Writing without a corresponding audience is a diary.
Good writers succeed because they find ways to compensate for their limitations, poor writers fail because they don’t recognize their limitations. If no one can read what you wrote then your writing cannot communicate anything. Likewise, the more high quality feedback you incorporate into your writing the more likely your reader will understand you.
And isn’t that that what writers want? To be understood by their reader?
Creativity is widely misunderstood to be a single “Aha moment”. The reality is both more complex and more interesting. Creativity is preparation followed by recognition of opportunity.
My book, Vigilance: An Anesthesiologist’s Notes on Thriving in Uncertainty is about the intersection of anesthesiology, cognitive psychology, and behavioral economics. Vigilance describes how anesthesiologists use cognitive psychology and behavioral economics to save lives every day in the operating room; then applies their unique methodology to large catastrophic events of the 21st century. The book is a practical way to describe uncertainty, characterize rare cataclysmic events, and create a more stable future.
How did I get the idea to combine three (seemingly) unrelated fields?
From an outside perspective it started with COVID-19. When COVID-19 became a pandemic in March 2020 it also became a case study in how people deal with uncertainty. Initially there was no way to test for the virus, no one knew how it spread, and hospitals filled up without warning. I saw both constructive and destructive responses to the overwhelming uncertainty. When I read an article about how Sweden chose not to shut down suddenly a lightbulb went off in my brain. I finished my first outline of the book on April 30, 2020. Looking back COVID-19 was just the tip of the iceberg.
Since I started medical school in June 2013 I noticed science was only a small part of Medicine. Human Factors, the application of psychology to processes and systems, determined whether the knowledge acquired in medical school actually worked in reality. A common saying in medical training is “patients don’t read textbooks” meaning how patients display disease in reality can be very different or even opposite from how textbook say they are supposed to do it.
Perhaps this gap between what is supposed to happen and what actually happens wasn’t only in medicine?
As I scoured the internet to describe what I saw I stumbled upon two fields: cognitive psychology and behavioral economics. Cognitive psychology compared how people perceived their thoughts to objective data collected by researchers. Turns out human perception is not representation of objective reality. Behavioral economics compared how humans should make decisions to what they actually chose in reality. Turns out humans consistently make illogical decisions when faced with economic tradeoffs. Both fields highlighted the gap between what humans are supposed to choose compared to what they actually choose.
COVID-19 connected all three of these fields for me. Medicine, psychology, and economics were suddenly blended together in a real world experiment. Perhaps I was just the right person in the right place at the right time?
Did I just get lucky? Or was my book more than a lucky accident?
Going to medical school was certainly not an accident. My undergraduate years were spent researching organic chemistry, volunteering in nursing homes, and working in student affairs. This was in addition to the time commitment necessary for excellent academic achievement. Time management was the key to balance my academic workload, extracurricular activities, and maintain my own well being.
After I started medical school I had even less free time. I created better time management strategies to compensate for the increased workload. Part of my free time was used to read about psychology and economics because I wanted to know how human factors transformed science into medicine. The more I read in books the more I could see it in my life. My journey down the rabbit hole accelerated.
In my anesthesiology residency I continued to read 1 book per month despite spending 60-90 hours per week in the hospital. My learning reached new heights because I could make my own decisions. Rather than reading about the experiments of others I became the subject of my own experiment! The positive feedback loop between reading, experimenting, and more reading produced new insights and ideas.
12 years of sustained effort, time management, and focused practice is certainly not an accident. However, the book (probably) wouldn’t have happened without COVID-19 tying all of those ideas together in a once-in-a-lifetime event. Maybe I would have eventually written the book for other reasons…maybe not. There is no way to confirm or deny an alternate reality that didn’t happen. Perhaps the book was a combination of both skill and luck.
The eyes can only see what the mind knows.
Lucky breaks cannot be perceived by those who cannot recognize them. Creativity is therefore a combination of years of preparation followed by a single lucky break. From an inside first person perspective success looks like years of hard work. From an outside third person perspective success looks like a single lucky break.
I happened to be in medical training when cognitive psychology and behavioral economics were taking off. I happened to have Amazon to purchase books at a price I could afford. I happened to have an extensive knowledge of medicine, psychology, and economics at the exact time COVID-19 occurred. All of this was situational luck.
However, my recognition of the “lucky break” would have never occurred if I was unprepared to see it. Preparation is the only one of those two factors that can be controlled. My insight only occurred because I was willing to go down a rabbit hole searching for something I didn’t know existed. I took a risk by investing my precious free time into my own knowledge.
Creativity for me was seeing something old (medicine) in a new way (cognitive psychology and behavioral economics). I’m not more intelligent than anyone else- I’m just more willing to take chances and learn from my experiences. Creativity is not inherently present in certain people. It is developed through years of preparation, focused practice, and learning.
Below are three pieces of advice to be more creative:
Humans are optimized for face-to-face communication using tone of voice, facial expressions, and body language. People commonly say 80% of communication is non-verbal. While the statistic is not technically true, scientific consensus seems to be non-verbal communication is more important than the actual words we say. People are generally good at understanding each other even if the wrong words are spoken.
What does this have to do with writing? Well, writing is a communication style void of non-verbal communication. Readers cannot experience my facial expressions, tone of voice, or body language. Therefore I have to code my message so readers can understand it without the advantages of non-verbal communication. This is why writing is unnatural and difficult to learn. Humans are not cognitively optimized to express themselves without non-verbal cues.
Face-to-face communication is highly decentralized: either person can direct the conversation towards the subject he or she specifically needs at any time for any reason. A conversation between two people about computers can be paused or diverted an infinite number of times until both people understand the content. Perhaps Person 1 needs to ask Person 2 a specific question about software. Go ahead! Then Person 2 forgot a specific detail about hardware: “one sec, let me Google that.” Natural communication is a two people building a mutual understanding from the bottom up.
Writing is highly centralized: only one narrative can exist then can’t be changed to accommodate individual needs. A single narrative must be understood by hundred or even thousands of people at the same time. Errors of fact, unnecessary details, or digressions now carry a very steep price because they distract the reader. Writing is an unnatural one-sided lecture from someone you have never met. It is a single idea expressed from the top down.
I had to find a way to outmaneuver hundreds of thousands of years of evolution…turns out that wasn’t going to happen. I quickly learned how I initially expressed myself was beyond my control, but processing the initial writing was 100% in my control. I adapted by word vomiting all of my ideas out on paper, taking a break of 1-7 days, then re-organize those ideas into meaningful writing. Periods of uninhibited, inventive creative expression were followed by periods of deliberate, draconian editing.
Every iteration of creative expression followed by editing yielded a more precise message. It felt like tending to a garden: I would plant seeds, see what grew then adjust my gardening techniques to optimize growth of the best ideas. My creative process was like a random idea generator. My editing process was highly methodical and systematic.
I also figured out never to delete anything: no writing is useless it is just in the wrong place or occurred at the wrong time. Some of my best writing was saved for months until its purpose became apparent.
Below is a graphic describing my writing process:
Above all else this process required humility. I had to accept only 10% of my ideas were worth keeping. I also realized I was terrible at choosing which ideas were the good ones! I showed my writing to my editor, colleagues, and friends then followed their advice. When all parties gave the same feedback I knew the feedback was probably true. Writing a book meant accepting criticism with grace. If I wanted a quality book I had to leave my ego behind.
I had to make every decision based on what my audience wanted not what I wanted. This meant deleting irrelevant stories I really liked. William Faulkner called this “killing your darlings”. A strong emotional connection with a story has nothing to do with whether the story should be included in a book. The most painful part of the writing process was removing my favorite stories, knowing they might never see the light of day.
An unexpected byproduct of this harsh editing process was enough material for at least one more book! A second book may or may not be already outlined 🙂
Designing a cover is a team sport. Luckily for me I had a wonderful teammate named Rachael Brandenburg who helped me through every step of the way. She gave quality feedback even when I disagreed with her. She knew when to bend and when to hold her ground. My only job was to spew ideas at her! After the initial round of brainstorming where Miss Brandenburg showed me four different designs I had a vision for the cover. My vision looked like this:
Looks great, right?!?!?! After 4 more rounds of editing Miss Brandenburg showed me this:
I was speechless. The cover turned out better than I even imagined. I can’t say enough good things about Miss Brandenburg and my publisher Scribe Media.
Miss Brandenburg can be reached on LinkedIn by clicking on this text
More information about Scribe Media can be found by clicking on this text