Charles Atkins

2012-02-25T05:45:00.001-08:00

Here's a fun--and free--murder story I've posted on my Redroom page. If you like, please repost and share around.

http://redroom.com/member/charles-atkins/writing/the-dancer

Congratulations On Your New Book | Charles Atkins | Blog Post | Red Room

2012-02-15T04:54:00.000-08:00

Congratulations On Your New Book | Charles Atkins | Blog Post | Red Room

Congratulations on Your New Book

Charles Atkins

Years back I was in therapy. "What?" you ask, "You, the epitome of mental health? Say it's not so." Well, let's just say it was part of my training as a psychiatrist. All of which brings me to something brilliant my therapist said. It was this,

"Congratulations."

"For what?" you ask.

For getting my first book written. Not published, just written. And here's the point. Why is it so difficult for many of us to acknowledge the good things in life in the moment? We are admonished to 'not rest on our laurels'. I think it goes even deeper, that somehow stopping to enjoy our achievements is wrong or big headed.

Let me break it down. For years, possibly my entire conscious life I've been a writer, and have wanted to write books. As a medical student this blossomed and I began to win some essay contests and have smaller pieces published in literary journals and some of the bigger medical ones. As a resident this picked up speed and finally I started in on my first book-length manuscript. As with many writers this first novel-length extravaganza was a roman á clef aka thinly veiled autobiography. It was about a conflicted gay surgeon who finds love and liberation. Along its 600 pages it veered into action adventure, there might have been a murder, boy met boy, lost him and then found him again, I seem to recall a hurricane in Mexico where my main characters formed an impromptu medical response team, and it was all tied up with a happy ending that involved an unexpected inheritance and beach-front property. I see you wincing, and please bear with me.

When I'd completed this masterpiece, there was no fanfare. No patting myself on the back. It was just done and I was off and running trying to think about what to do next. Send it to publishers? Find an agent. So when I told my then therapist I'd finished my book and he said, "Congratulations". I stopped dead.

Right, I thought, I've just achieved something I've always wanted, something big, and yet I didn't take a millisecond to stop and recognize the moment. What was that about? And I realized a couple important things. First, my ambition as a writer is far more about the process than the product. How do I become the best writer possible? How do I continue to get published and reach a bigger audience? It's a constant striving toward what comes next. Like deciding to do a blog, if even in the beginning no one reads it. There's nothing wrong with any of that. Yet, there's something equally important on the other side of this forward movement. The moment itself.

Over the years, as I've become successful in my two careers--author and psychiatrist--this theme repeats. This week my ninth book under my own name arrived in the mail--VULTURES AT TWILIGHT (Severn). There was no fanfare. A UPS truck dropped off my author copies in a brown cardboard box in front of the garage. I went out, saw the box, wondered if it was something I bought on eBay or Amazon, and then I spotted the address from my publisher. It was the new book.

I took it inside, ripped off the tape and got my first look at something I started writing over ten years ago. This particular book has been through many incarnations on its long road to publication. I examined the glossy cover, which has a beautiful image of a misty cemetery and my name in bold letters over the title. I read the inside jacket, the back blurbs--not a wrong note anywhere. It's a lovely book. I opened the cover and saw the dedications to my grandmother, great Aunt, and my mother in law--three women filled with love and light. I felt dueling impulses--pride at the achievement and the opposing Puritanical voice--"And pride goes before a fall." "Shut up!" I told that second voice. I held the new book, and reveled in the moment. "Congratulations, Charles. It's a beautiful new book. Congratulations."

2012-02-08T04:57:00.000-08:00

Overcoming Addiction

Charles Atkins, MD

"Wouldn't it be great if youcould love me first and let the bottle wait?"

--Dolly Parton

"They tried to make me go torehab, I said, ‘No no no.’"

--Amy Winehouse

You know it’s killing you. The alcohol, cigarettes, pain pills, illegal drugs whatever the habit isthat you’ve tried to change—repeatedly—but without success. Your conversations with yourself are familiaras a favorite tee shirt, “I’ve got to stop…I’ll do it tomorrow.” And then tomorrow comes, and with it the urgeto drink/smoke/use illicit drugs and despite your best intentions you give in. “Okay, tomorrow then. I’ll really stop tomorrow.” So what’s wrong with us that we persist inbehaviors that harm us? And mostimportantly, how does someone finally make the needed change?

As a psychiatrist who works withpeople with drug and alcohol dependence I spend a lot of time on these questions. While the answers can be complex, I’m drawnto some basic truths. First, thedestructive habit--whatever it is--serves a purpose, at least initially. The "why" someone begins to drinkor use drugs varies from person to person. Alcohol provides a sense of relaxation and well being. For people who are anxious or sociallyawkward it helps lubricate their tongues and makes them feel at ease in socialsituations. Opiates (pain pills toheroin) induce a state of euphoria and relieve not only physical pain, butemotional suffering, as well. It’s nocoincidence that so many survivors of abuse and trauma become addicted to heroinand prescription opiates.

For teens experimentation with drugsand alcohol has become a passage rite. Thenot-fully wired adolescent brain doesn't register the danger in the behavior,and it’s during these young years where most pick up habits that turn ugly intime. The magnitude of this is followedby annual surveys that monitor high-risk behavior in teens. In 2009 24% of high-school students engagedin binge drinking, nearly ten percent had driven in the past month when they'd hadalcohol, roughly 30% had been passengers in a car where the driver had beendrinking, 20% smoked cigarettes, 20% had used prescription drugs without adoctor's order, over six percent had tried cocaine and/or Ecstasy, and 2.5% hadtried heroin.

Once established, negative behaviorstake on a rhythm and turn into a habit. A smoker hears the phone and lights up, the morning cup of coffee isaccompanied by a smoke, and every work break includes a quick cigarette or two. A drinker anticipates the weekend, or the endof the workday as the time for the first beer or cocktail. Passing a liquor store they think aboutwhether or not there's enough booze in the house, or who they’ll meet up withfor drinks at a favorite watering hole.

Depending on the drug of choice,problems start to develop and can damage any and all aspects of a person'slife--physical and/or mental health, relationships, job, finance. An arrest for Driving under the Influence(DUI) starts a cascade of losses and legal problems. Physical effects of excessive drinkingemerge, and dependence--the body's need for the continued presence of asubstance--takes hold. An opiate addictno longer gets the euphoric high, but instead is chased by the physical andemotional agony of withdrawal “Jonesing" that turns her life into anunending search for the next fix. Thealcoholic becomes shaky in the morning, starts to drink throughout the day, hasunbearable anxiety, poor sleep, and somewhere around the 20-year mark of heavydrinking heads into serious alcohol-related diseases such as cirrhosis and certaincancers. A dangerous and potentiallyfatal withdrawal syndrome--delirium tremens (The DTs)—traps the drinker andtheir ability to “just go cold turkey” is no longer a safe option. As for cigarettes, there’s little doubt thatthey represent the number one cause of preventable death in this country fromheart disease, cancer and stroke.

What's remarkable is that even in theface of terrible losses--job, health, family--the destructive behavior persists. Deceit and minimization of the problem iscommon, and attempts to quit or cut back are frequent and short lived. Motivation to do something about the behavioris mercurial, changing from moment to moment.

Yet people can and do change. And just as the reasons why someone starts adestructive habit are varied, the paths that lead someone to put down a badhabit are particular to them. At somepoint there is an awakening and with it a call to action. "This is killing me and I've got tostop." For others it may be anexternal force, a spouse threatening to leave, a child who can no longer bearto see you drunk and cuts you out of their life, an illness or serious legalproblem that's a direct result of the addiction. Regardless, something in the equation shiftsand motivation moves into action: throwing away the cigarettes, dumping thebooze down the drain, checking into a detoxification program, attending a12-step meeting. Again, there are manypaths and depending on the behavior, the severity of the addiction and theperson these vary from “going cold turkey” on your own to intensive treatment. Some will require the services of medicalprofessionals to get them through potentially dangerous withdrawals (alcoholand certain Valium-family drugs), and many will turn to rehabilitationprograms, drug counselors and well-established self-help groups such as AA andNA. The first days are the hardest aswell-worn patterns of behavior, and cravings have to be resisted andchanged. This is where familiar slogansfrom 12-step groups such as AA become life savers, “One day at a time”. “Today I’m not going to drink or drug, I’lldeal with tomorrow when it comes.”

What is clear for everyone who has successfullyput aside a destructive habit is that they’ve transformed a desire to changeinto action. In time, the olddestructive behavior is replaced with newer and healthier ones. As I often tell my patients, putting down abad habit is both easy and hard. The hardpart is “just don’t drink” and the easy part is, “just don’t drink”.

2012-01-30T15:11:00.000-08:00

On Creativity and Howto Vanquish Writer's Block

Charles Atkins

Writer's Block--a sort of creative constipation--is littlemore than negative self talk. It's asuseful as a jar of marshmallow fluff added to the laundry. And the good news is, it's completely fixableand here I speak as both a psychiatrist and published author.

So here's the deal, and how I learned about nurturingcreativity and the opposite--stomping it out like the swarm of roaches who'vefound the fluff in the laundry. When Iwas a psychiatric resident, one of my year-long rotations involved providedpsychotherapy to articulate students at an Ivy League university. Here, I observed something interesting. The Grad students who were zipping throughtheir theses had both internal and external positive regard. They had mentors and peer networks thatsupported their work. Their sparks ofideas got bellowed into roaring flames by doctoral supervisors who providednecessary critiques, but were quick to underscore what was good and what worked.

On the flip side I sat through many an hour with distraught,anxious and depressed pre-docs whose degrees hinged on shipwrecked theses. This crew had ponderous self doubt. Some was entirely self generated, but forothers they had problematic relations with their faculty supervisors. My patients would complain that they'd go inwith idea after idea only to have it shot down and leave their mentoringsession feeling aimless, discouraged and hopeless.
Because this was therapy, both they and I explored all of this negativity,where it came from, and more importantly, how to get rid of it. As might be expected we found long historiesof intense self doubt and internal criticism. We learned about withholding fathers and mothers for whom a single 'B' onan otherwise perfect record was not good enough. These now internalized voices, especiallywhen fueled by external criticism, made forward movement nearly impossible.

These observations on what feeds creativity and what shut itdown led me to a series of realizations. The kernel of which comes down to the following--writer's block is inyour head, and to get rid of it all you have to do is shut down any negativeself talk and doubt. It's that simple...andit's that hard.

Around the same time I was doing this clinical work Iattended my one and only writing seminar. It was with the Canadian author/writer Barbara Turner-Vesselago. Entitled "Freefall" it was allabout diving into one's writing and shutting down these negative thoughts. Beyond this she encouraged participants toleap into the heart of resistance. As apsychiatrist I completely understood this. Because those things we don't want to look at, talk about, or God forbidwrite about, are gold mines of intense emotion. And Ms. Turner quickly proved that our fears and anxieties can bebottomless wells from which we draw sensually luscious writing. You just need to take a deep breath and divein.

A connected point to all of this--again from personalobservation--is that my creative juice is not to be messed with. As a writer I know that letting doubt creepin will shut things down. To get aroundthis--and why I never get writer's block--I have some quick fixes. Most of these run through my brain in theflash of a heartbeat, others require more definitive actions. Here they are:

When faced with a slowdown in writing, I askmyself the following: "What don'tyou want to write about?" I thenproceed to write about that very thing. If negative thoughts intrude, I tell myself I can always rip it up later. As a sidebar, when I'm doing fiction, I'llask the question from the perspective of my character. What is she/he most resistant about or scaredof? Let's go there now.

Editorial automatic thoughts. These are fleeting thoughts we can all fallprey to. "Thisis no good." "Yourargument doesn't hold water.""Geez! Will you ever stop making run-onsentences?" These Idismiss by reminding myself--there's always time to edit, but at the moment Ijust want to write and get mythoughts on the page.
Distraction. While different from the negative self talk I've been discussing,writer's--and everyone else--have all kinds of things to distract us from thetask at hand. Here, it's a matter ofsticking to what I'm about, and reminding myself that the laundry, changing thekitty litter, shopping, 'Words with Friends' etc. will get done after I finishmy day's writing.
Negative outside influences. Similar to my example about mentors, andothers, who can pour acid on our creativity we sometimes find ourselvespartnered with people where the creative juices do not mesh. Sadly, my take here, is best to cut yourlosses and move on. Your/my creativityis too precious to engage in this kind of head butting.
Necessary criticism: Here, I want to briefly touch on vitalcritiques that aid in the editorial process, and for those of us who care aboutsuch things--getting published. I'll usethe example of my own agent, the legendary Al Zuckerman. Al starts each of his critiques with at leastone genuinely positive comment--'Charles, you have many wonderful storyelements here.' Soon to be followed by,'and this is why this manuscript is not working in its current form...' Yes, my ego takes a little bruising--'What do you mean? Isn't all my writing wonderful?' To remedy this I let his comments fermentovernight. I then start in the morningwith a mental reframe--Al, wants the workto be strong and saleable, he's absolutely right that there are too manycharacters being introduced too fast. And you wrote this once, just start in on the rewrite, do it page bypage and it'll be done before you know it.
Take a break, do something physical and comeback to the writing. Some of my bestideas have come on the elliptical--including this essay. I also find that if there's something missingfrom a piece, the answer magically appears in the midst of an hour'scardio. I don't know why; it justhappens.

So that's it. Whenfaced with writer's block, the key to forward movement is learning how tosilence negative thoughts. Whether theseare purely internal or fueled by those around us, with practice you can learnhow to push these away and let your creativity flow.

Motivation is a Crock: How to Create Healthy Habits and Lose the Bad Ones

2012-01-24T02:15:00.000-08:00

Motivation is aCrock:

How to CreateHealthy Habits and Lose the Bad Ones

CharlesAtkins, MD

Question:"How do you get to Carnegie Hall?"

Answer:"Practice."

I'm a dualcareer psychiatrist and author. And as Ibounce from being the white-coated Dr. Atkins to Charles Atkins the writersitting in sweats at his computer every morning I've discovered several thingsthat help with both professions. Here'sone--Motivation is a crock.

If I waited toget motivated to write; there'd be little on the printed page. Similarly I've noted with my patients--andmyself--when it comes to positive behavioral change like exercising, giving upcigarettes, creating healthy eating habits, ending a bad relationship etc. ifwe relied on motivation little would happen. Especially if the desire is to create a sustainable new behavior that isdone--or not done (smoking, drinking, overeating etc.)--in an ongoing way.

Yet somehow there'sa magical notion that we can make important changes when 'we feel likeit'. And yes, we all get bursts ofmotivation:

· Today'sthe day I stop smoking.

· Withoutfail my diet starts on Monday.

· Swearto God I'll never drink again.

Truth ismotivation--our desire to do something--is fickle, or maybe a better metaphoris it's like the temperature that goes up and down. An alcoholic who wakes at eight with ahangover swears, "I'll never drink again". By noon after a few aspirin the hangover isgone, motivation plummets, craving and maybe some subtle--or not so subtle--withdrawalsymptoms pick up and by four p.m. he's in the liquor store getting his favoritebottle. It's not that the morning'sdesire to quit was a lie, it's just like most thoughts, it was fleeting.

So here's thedeal about change and creating sustainable positive habits. It's simple and it's hard. And the folks at Nike summed it up with theirfamous snapline--"Just do it". If you want to be a writer you need to sit your butt down in a chair,every single day and write. It might behard at first, but if you stick to it, it gets easier. Somewhere I read that Stephen King writes tenpages a day. That explains a lot, in 30days he has the rough draft of a novel. My own writing habit varies on whether or not I'm going in to seepatients. If it's a home day, and I'mworking on a new book I write between 5-10 pages. If it's a work day, I get up early and writeat least 2-3 pages. I've done this foryears. As a result, I've written quite afew books. Yet on at least half thosedays as I'm climbing the stairs to my office I don't feel like writing; themotivation is not there. And here's anobservation, the reluctance to get the work done, passes quickly once I startto type. For writers, this is one of thefew truisms that holds water--"Writers write," and most of us do itdaily, whether we feel like it or not.

So too, knowingthat daily exercise decreases depression and anxiety, controls weight, lets yousleep better at night and keeps your bones and muscles healthy, is useless informationif you don't do it. Again, on most daysbefore starting to exercise, 'I don't feel like it'. After the fact I feel great--accomplished,ready to face whatever comes next etc. But if I waited for motivation, it wouldn't happen. And if I stopped exercising all the gainsI've made would vanish.

A lot has beenwritten about motivation and it's ephemeral nature. In behavioral science we look at the work ofProchaska, Norcross and DiClemente who developed stage of change theory. And how motivation can be the catalyst foraction. How we take a motivational wishand turn it into steps toward real change is where most get stuck. "I know I need to lose weight, I try butI just can't do it." Really? Let's break it down. What are you actually doing to get thatweight off? Have you worked thesechanges into your daily routines? Areyou taking in a prescribed number of calories? Are you portioning your food correctly? Are you bringing your own lunch to work? Have you stopped drinking sugared sodas and juices? If the weight's not coming off, chances areyou've not made the changes you thought you had. This is where programs like Weight Watcherscan be so beneficial. They give people wantingto lose weight, clear information and guidelines, that if followed in anongoing way, will help.

For those withdrug and alcohol problems 12-step programs such as AA and NA can be life savers. Their mission is crystal clear, people comingtogether with unified goals--don't drink or drug. To this end there is a very matter-of-factbehavioral plan laid down--don't use, show up to meetings, call your sponsor orget to a meeting when you get a craving and so forth. And of course their famous mantra, "OneDay at a Time." Yup, maintainingchange is about managing the behavior one day at a time.

The good news isthat over time the energy expended in creating behavioral change takes root. This makes tremendous sense, practice makesperfect. My desires to write, maintainhealthy eating habits or exercise turn from wishes into concrete habits, withdaily practice. Yes, I still get theimpulses to screw off and play Words withFriends instead of finishing the next chapter. But my mind has been trained that this is thetime to write, and so I do.

2012-01-15T12:34:00.000-08:00

This week I've asked my friend and book doctor/editor extraordinaire Liz Fitzgerald to weigh in with...

Confessions of a Book Doctor: Five Things that Every Writer Must Know

Liz Fitzgerald

I’ve worked as an editor and book doctor for a number of years, both with a publishing house and more recently as a freelance editor and book doctor. As an editor faced with a towering slush pile I can tell you what is likely to survive the process and make it to publication in a tremendously competitive industry. What follows are the bits of advice I find myself repeating most often to new authors…and even to some who have been around for awhile and need a reminder.
    Point 1: Be professional, you must know the rules of the publishing game. Don’t think—especially as a new author--that you can take short cuts, use cute stationary, or assume that your 1200 page opus on your cat is appropriate for a publisher that handles romance novels of between 300-400 pages. Publishers have guidelines—follow them. Do not deviate. Most guidelines can be obtained on-line
    You also need to understand that there is etiquette around submissions. Again, follow the guidelines, if they want an outline and three chapters that’s what you send. If they want it with a paperclip versus a staple, that’s what you do. Increasingly, more publishers and agents are accepting electronic submissions—some still do not—find out what they want.
    Once you’ve got the etiquette down, which includes knowing the basics to double space, use a proper heading etc. let’s talk about the writing.
Point 2: To get a book done, most authors write daily. Most find a regular time and work it into the fabric of their life. In my experience what separates wannabe writers from those who eventually get published, is that they write every day, usually at the same time of day and for a set period of time. Many authors set quotas for a specified number of pages or words a day. If you find yourself blocked, bored or distracted, write something anyway even if it isn’t your main project.
Don’t’ be married to every word; there are always more. I find that with many new authors—and even some who’ve been around for quite a while—it’s difficult to have the editorial discipline necessary to prune and even excise extensive bits of prose. Sometimes writing that is exquisite and lyrical is unnecessary or weighs down the story—it must go. There may be ways to soften the blow, tell yourself you can use it somewhere else. But the cleaner your prose the less it will be edited by others, and the more likely it is to get a green light.
Point 3: Show don’t tell. Everything should take place on the page. The reader needs to be there at all important events. Don’t tell them about it but use sensual detail to show them. Set the scene including your character’s visceral responses to the action. How they feel, what they see, smell taste and hear.
    In the following example we can see how sensual detail amps up tension and sets a scene.
    “Come on, Beth.” His fingers entwined in her hers, flesh on flesh, holding tight. “I want to show you something.”
    “What?” she asked, laughing, and followed him down the granite stairs that led to the dissection rooms and the hospital morgue. Careful not to trip on her gown, she didn’t think about the stench of death and formalin that curtained the air.” –The Cadaver’s Ball, Charles Atkins (St. Martin’s Press/Leisure Books).
    By comparison, “They found themselves in the morgue,” falls flat. It’s a common pitfall to leave lush detail and action out of a scene. This doesn’t mean it’s free season on purple prose, but if it’s not on the page, no one will read it.
Another mistake that new authors---especially fiction writers fall into is that too much of what occurs becomes internal. You need to take what is in the character’s head and turn it into observable action. There are different ways to do this. If your character is cerebral and conflicted, give him/her a friend, confidant…or even dog to whom they can bare their soul and reveal their motivation—what they want—as the story progresses.   Perhaps the most hackneyed example of this is the villain who at the very end of the book reveals why he/she did all the evil things they did—“I suppose you’re wondering why I called you all here this evening.” It’s more satisfying, and in keeping with contemporary literature, to reveal early in the book the motivations of all the major characters. This doesn’t mean that there can’t be secrets and surprises—there should be. Your reader needs to walk in step with your characters and get to know them—just as we get to know real people—as they, and the story, develop.
    Point 4: It is important to develop a couple of literate friends whose opinions you trust. Now this is where—just as with editing—you will need to table your ego, and that surging bad feeling authors can get when faced with criticism. Honest and informed critiques are a sort of mirror that can show you the strengths and weaknesses of a particular piece. Writers often become myopic around their work, especially when they’ve read and reread the same chapters. Outside eyes are crucial. Choose one or two people—more than that can be confusing—and take what they say to heart. Avoid people who are overly negative, or positive.
    If you find yourself in arguments with your trusted critic, saying things like, “Oh, you don’t get what I was trying to do there.” You need to stop, and rethink a couple of my earlier points. Why did they not get the rich narrative running through your head? It’s probably not on the page. Why are they not feeling it emotionally? Chances are good you told them what was happening instead of showing with rich sensual detail.
    Point 5: The final point is perhaps the most important. If you want to be a published author, perseverance is everything. Even the most wonderful books and already established authors will receive rejection from agents and editors. To quote Dorchester Publishing (Leisure Books) acquisitions editor Don D’Auria, “it’s getting the right book, to the right editor or agent at the right time.” In other words the rejection may have nothing to do with the quality of the piece you sent, it just wasn’t what that particular editor or agent needed at that moment.
    No doubt there is pain that comes with rejection letters. There’s no getting around this and the best I can say is that for most writers this lessens over time, especially if the rejections are interspersed with acceptance letters.
However not all rejection is bad, and when you receive one that is not a form letter, read it carefully because an editor has found something in your work on which they want to comment. Pay attention to suggestions they make and if they leave the door open for further submission, consider sending them something else that is more in line with what they need.
Weathering rejection is a critically important step for any author. Because what I’ve witnessed over the years, is that some of the most brilliant authors will never make it to publication because they cannot get past the rejection. I like the approach that my friend and author Charles Atkins takes towards rejection, “you look at the letter and see if there’s anything in it that can help the writing. If there is, fix it. If there isn’t, or it’s a form letter, figure out who you need to send it to next, and get it out in the morning mail.”
-The End-
Bio—Liz Fitzgerald was an editor and publicist for Donald I. Fine, Inc. She currently works as a freelance editor and book doctor. She can be contacted at efitzge203@aol.com.

2012-01-07T10:14:00.000-08:00

A Road Well Traveled: The Physician-Author and the Continuum of Story

Charles Atkins, MD

“Thereis no more difficult art to acquire than the art of observation, and for somemen it is quite as difficult to record an observation in brief and plainlanguage.”

--William Osler

It’sno accident that there are so many physician authors, from Somerset Maugham andArthur Conan Doyle to modern best-sellers like Robin Cook, Tess Gerritson,Michael Palmer, Michael Crighton and F. Paul Wilson. As I pursue dual careers of author andpsychiatrist I realize that this connection is logical and rooted in ourprofession’s reliance on stories: hearing them, using them and tellingthem. How we get from one end of thestorytelling spectrum to the other is a well-trod road that takes us from theclinical record through authoritative non-fiction to the mainstream novel.

Itstarts with the doctor’s training. Welearn to take a history. “So, whatbrings you in today?” It’s thesimplicity of an open-ended question that invites any response. “I’ve had a cough that won’t go away,” “I gotthis rash after I came back from Vegas,” “Every time I walk up a flight ofstairs I feel heaviness in my chest.” The answers come with emotion and body language; we observe it all: thepain, the fear, the embarrassment. Weshape the story, and even enter it, as our attitude and willingness to listenhave a strong bearing on whether our patient will trust us enough to give usthe truth, the whole truth and nothing but the truth. The more interested, relaxed andnon-judgmental we are, the greater the chances of getting the information. We generate hypotheses about the cough, therash, and the heaviness. We ask morequestions, “How long have you had the cough?” “What happened in Vegas?” “Tell me about the feeling in yourchest.” We’re careful not to jump tooquickly to a diagnosis, as missteps in the gathering of a history lead to wastedtime and bad treatment. A cough could bethe common cold, or the only symptom of a malignancy. The rash could be from the detergent used onthe hotel’s sheets or a psychosomatic concern over an extramaritalliaison. Is the chest pain indigestion,angina, panic? Ultimately, it’s thephysician’s skill in taking and interpreting a history that is our singlemost-important tool. It’s all aboutgathering the data, interpreting it, and putting together a story that makessense.

AsI think back through medical school and residency, I can see that I was taughtbasic truths about the nature of story that have helped me both clinically andas a writer:

Common things are common; when you hear hooves, don’t think zebras.
Consider all angles, who, what, when, where, why?
Don’t jump to conclusions; generate a differential.
Consider your reader.

Oncewe’ve fleshed out the story, it’s time to write it down. As medical students and trainees we learnedhow to present and write up a case. Iremember how as a med student I would be assigned a patient in the emergencyroom, work them up, and then, with little or no sleep, present them to a roomfull of other trainees and a Chief of Services who delighted in grilling us. He wanted the whole story and he wanted itwith multiple possible endings. “So Dr.Atkins, please enlighten us with the story of your patient, Mr. Jones…”

Ipresented in the time-honored way. It’sclinical, it’s dry as dust, but it is a story. “Mr. Jones is a 42 year old never-married Caucasian man who presentswith three days of sub-sternal chest pain that he describes as, ‘crushing, likesomething is sitting on me’. It’s worsewith exertion, is relieved with rest and radiates to his jaw, but not down hisarm…”

Learningto obtain a history and present a case—in both written and oral fashion--lays muchof the groundwork for the doctor-writer. Obviously, there’s a difference between what and how we write in amedical record and what’s likely to become a blockbuster novel, but similarskills are required for both. I’ve cometo view these different approaches to story as points on a continuum. On one end we have the most-objectiveclinical reporting and on the other, personal narrative and finally fiction.

Similarto popular non-fiction and fiction, the medical record as a repository of storyserves multiple purposes and has multiple readers. All of which must be considered when leavinga note in a medical record. Thehistories we write lay out the clinical data upon which we arrive at ourdiagnostic impressions and conclusions. Our notes reflect why we’re prescribing various treatments and whether,and how, they’re working. Our chartsmust meet criteria for ‘medical necessity’ as defined by various insurers,Medicare and Medicaid should we wish to get paid and not get hauled into courtfor fraud. We need to remember the JointCommission reviewer who will look at what we’ve written to see that we’restaying current, are avoiding confusing abbreviations and are cognizant of allaspects of the human being—as defined in their hundreds of published standardsof care. What we write needs to be clearso that a colleague covering in the middle of the night knows what is goingon. Should there be a bad clinicaloutcome, the chart is a legal record where the written story is all thatmatters, ‘if it’s not in the chart, it didn’t happen’.

Justas when writing a novel or non fiction book, I need to consider my readerswhenever I document in a chart. Assomeone who teaches clinical documentation I stress the importance of imaginingeveryone who could one day read your note standing over your shoulder: theinsurance reviewer, the attorney for a patient wishing to sue you, the hospitalrisk manager, the patient’s mother, the patient, your colleagues, and ofcourse, you.

Themedical record requires a particular type of storytelling. It must be factual and free fromeditorializing. Judgment-laden words andphrases like, patient is manipulative,non compliant, difficult, should be eliminated. Just stick to what happened, what was observed. Or as they say in writer’s lingo “show, don’ttell”.

Evenwith this attention to the facts, the medical record is highly subjective. When teaching, I’ll give a class of studentsthe data from a single patient and instruct them to write up their formulationand present the case aloud. If there areten students I’ll hear ten different stories.

From the case presentationor case study we come to the jumping off point that separates clinical writingfrom narrative and fiction. Forphysician-authors this leap is not far or difficult. Take the following examples of a standardHistory of Present Illness, which is then rewritten as a personal narrative (itcould also be viewed as the inner monologue of a character in a novel).

Case 1: Case Presentation:

Patientis a 48 year old Caucasian man brought by ambulance to the emergency roomfollowing a near fatal suicide attempt by carbon monoxide poisoning in thecontext of multiple recent stresses—loss of job, separation from spouse andchildren and severe financial difficulties. For the past four weeks the patient has experienced worsening symptomsof depression including diminished sleep with difficulty falling asleep, earlymorning awakening and mid-night arousal, feelings of worthlessness andhopelessness and increased thoughts of suicide with a plan to kill himself,which he attempted earlier today. Clientwas discovered by a neighbor who was concerned by the sound of the car enginein the closed garage.

Case 1: Personal Narrative:

It’sso hard to find words. Everything insideme feels dead. I don’t want to writethis, or think. I’d like to go away andbe done with everything. I’m sosorry. I’ve screwed up everything; mylife…Peg’s the kids. I can’t shake this,and they’ll be better off without me. Ishould be looking for a job. John toldme the layoff wasn’t anything to do with my performance. Others got laid off—I know this--but how doyou not take it personally? I feel likea total failure. Like everything I’veworked for all of these years didn’t matter. You’re with a company for 20 years and they tell you it’s not personalwhen you have two weeks to say goodbye, clean out your desk, and go for jobcounseling, which was pointless. I can’tsleep. I lay there, the same thoughtsover and over through my head, everything is coming undone. Two month’s of not paying the mortgage. I don’t have the money for the taxes. No one’s going to hire me, not for anythingclose to what I was making. I’m almostfifty. My whole life is unraveling andthere’s nothing I can do to stop it. Iget up and even the television is too much. I can’t focus. I hear Leno tell ajoke, I used to think he was hysterical; it’s not funny, even though I hear theaudience laugh. I used to laugh all thetime. People would come up to me andtell me what a happy person I must be because I’m always smiling. Every day, every hour I think about the carand how easy it would be to do this. Theweird part is that thinking about killing myself doesn’t feel bad, more like a relief, just bedone with it. I think that’s what I’lldo. I’ll do it in the morning.

Once across thisdivide, how far we go as writers is limited only by our interest, perseverance,talent and skill. My interest as anovelist has been to take psychiatric and forensic topics and explore them infiction. I picked the mainstream genreof the psychological thriller, ‘A’ because I like to read these, ‘B’ becausethey’re commercially viable and ‘C’ because as a psychiatrist I know somethingabout human nature and why we do the things we do -- even bad things. The medium of novels is ideal for in-depthexploration of complex subject matter.

For the would-bedoctor-writer, there aren’t a lot of absolute rules, but there are some helpfulhints. Go with your expertise and writewhat you know. Beyond that most of theprinciples of clinical writing continue to apply, you need to think of yourreader, and pay attention to the conventions of whatever genre you’vepicked. Just as you consider theMedicare, Managed Care and Joint Commission reviewers when writing in a chart,think about who’s going to read your book and give them what they want.

In novels thefirst goal is to entertain—why else would someone purchase one? Because I write thrillers they need togenerate tension, suspense and fear; they must snag the reader at the firstpage and not let up. Beyond that I wantto educate, both the reader and myself about topics I find interesting,confusing and important. This is whereclinical skill and experience can inform fiction.

For instance, inmy first book, THE PORTRAIT (St. Martin’s Press 1998) I wrote a thriller thathad a hero with a serious mental illness, in this case an artist with Bipolar Disorder(manic depression). I wanted to createan insider’s view of what it’s like to have a serious mental illness, to becomepsychotic, paranoid and even suicidal. Ichose a first-person narrative so that the reader could have this voice insidetheir head.

“It was funny, the times I had beenin the hospital; they didn’t seem quite real, that this, my real life, would bea memory, like a trick done with mirrors. So many ghosts followed me—quick friendships on locked wards, endlessmouth checks with hard-faced nurses. Theghosts filled my paintings, worlds populated with earthbound saints andtormented devils. My own Faustiandilemma became a little clearer each year. If I took the pills, so I was told repeatedly, I could avoid thehospital. I could also kiss paintinggood-bye. So I juggled.”

When I came to mysecond book, it was at a time when I was working with troubled teenagers whowere coming for evaluations at the request of the court, the schools, orparents faced with an out-of-control kid. RISK FACTOR (St. Martin’s Press 1999), allowed me to demonstrate infiction the process by which a child grows up to become a sociopath. I relied heavily on the theory ofexperimental psychologist John Bowlby, combined with what I was seeing in myclinical practice. I created situationsand a cast of characters that allowed me to show many sides of AttachmentTheory. My protagonist was a singlemother of two working with troubled teenagers in both inpatient and outpatientsettings.

In a sense, thenovel can be a delivery system for information. Material that might otherwise be dry and conceptually difficult can bebrought to life in ways that are crisp and evocative.

More recently, inthe wake of 911, Hurricane Katrina and some personal tragedies, I took thetopics of Trauma, PTSD etc. and wove them into a thriller, THE CADAVER’S BALL (St. Martin’s Press 2005/Leisure Books 2006). I wanted to demonstrate through multiplecharacters how life-threatening events change us, how some people recover andothers are destroyed by the experience. In this case my protagonist is a psychiatrist who has been severelytraumatized.

“After a year of intensive therapy,I know this. I feel it claw at mysanity. Oh, God, make it stop!

My fingers claw at smolderingsteel, as black smoke burns my eyes, “come on, Beth!” I can’t see, I can’t breathe. The smell of gas. Help me! Somebody help me! She’s notmoving, her hair caught in the shoulder strap? I smash the window, but I can’t get the door. She’s not breathing. I suck in and put my head through shatteredglass, my mouth over hers, tasting her lipstick. Headlights come through the fog. I stagger into the road. My hands wave, “stop!” The whites of a man’s eyes stare through thedarkened glass. “Please stop.” He slows and I grab for the closed window;it’s cold against my blistering palm. Why isn’t he stopping? I bang myhand against his window. “She’s dying!Help me!” My palm print, smeared inblood, slips away; he’s speeding up. Iscream. A blue sparks turns to flames; it’s in her hair. Help me!

I startledand blinked as a hand tapped my shoulder.

“DoctorGrainger. Peter, are you okay?”

Icoughed and fought back the nausea that always comes. “I’m fine,” I said, not knowing where I was,wondering how long I’d been gone.

While thecharacters are products of my imagination, what they go through is real. This is what I find most-exciting aboutfiction; we can get to truths about mental illness and human nature and presentthem in ways that are easily understood by the reader.

When physicians spanthis continuum of clinical storytelling, from the medical record and casepresentations to narrative and fiction, something has been completed. It’s taking what we’re taught in our trainingand in our clinical practice and giving it life. It’s a practical fusion of the science we learnas medical professionals and the art of being both a doctor and a writer. Beyond that, pushing clinical material intothe realm of fiction offers endless opportunities to gather insight into thewonderful complexity of being human. Forphysicians, this is a well-trod path that’s worth the trip. Our training as doctors starts us on theroad; should we choose to follow, it brings us to the whole story, the wholeperson and the bigger truth.

2012-01-01T13:24:00.000-08:00

The Wall of Unwanted Books

CharlesAtkins

" I have learned, that if one advances confidently in thedirection of his dreams, and endeavors to live the life he has imagined, hewill meet with a success unexpected in common hours."

--HenryDavid Thoreau

Do all authorshave a drawer of unpublished books? Oris this just me? As I hit the finalpre-release weeks of one-such manuscript that will finally be published, thereare numerous lessons to be learned. Butas so much with writing it's more about the showing than the telling. So here's the story of how VULTURES ATTWILIGHT, which I wrote over a decade ago as a charming Connecticut cozy withtwo older female protagonists (for those not used to the term "cozy"it refers to a not-terribly gory murder mystery often set in a small town--AgathaChristie's Miss Marple is the archetype), will now come out as my first lesbian-themednovel.

How does thishappen? Well, in the late 1990's Iachieved a major score--or more accurately my agent did--by landing a two-bookdeal with St. Martin's Press. My firstnovel--THE PORTRAIT--did well and so I set about crafting a follow upbook. My editor at St. Martin's was RuthCavin--a legend in the field--who at the time was in her early eighties. I was also working as a geriatric psychiatrist.My thought--write what you know--was todo a mainstream mystery but this time have heroines in their late seventies andearly eighties. I set the book in afictional Connecticut town that thrives off the systematic fleecing of itsolder residents as they downsize and die. It was a theme I knew well from my day job, and so I constructed adarkly comic mystery where the local antique dealers were getting bumped offone by one. I finished the manuscript,had a few people read it, did a rewrite or two, then off to my agent whosubmitted it to Ruth at St. Martins...who hated it. Her rejection letter was scathing. This was not going to be the second book inthat contract. And therein lies one ofthe many lessons I've learned--read your contracts carefully. A multi-book deal does not mean that thepublisher is obliged to print whatever you send. Ruth did not care for the book, and so it wasnot going to press, at least not then and not with St. Martin's.

My then agent, shoppedit around a bit, but clearly I needed to get back to the drawing board and comeup with something to fulfill my contract and so VULTURES AT TWILIGHT--at thetime it was actually named DOILIES UNDER GLASS--landed in a drawer. To be fully accurate this is more of a shelfthat over the years has taken on the look of a brick wall made out of tightlystacked manuscript boxes with titles of the enclosed, often with dates, writtenon the side in black sharpie. Timeelapsed I came up with two more books for St. Martin's, which they did publish. Between books I'd dust of VULTURES ATTWILIGHT, give it a rewrite, send it out, read the rejection letters and thenslide it lovingly back into my wall of unwanted books.

At one pointthere was a near hit with a small specialty publishing house--they will gounnamed. They had a series of professionalreaders review the manuscript, it looked promising. They held onto VULTURES for eighteen monthsas an exclusive submission, before ultimately rejecting it. At least here, I could read the critiquesfrom their readers, and came away with the conviction that indeed this book waspublishable. I gleaned anything of valuefrom the reviews and I re-worked the manuscript yet again. But with no likely buyers in site the optionswere limited. Do I self publish? Or...back onto the shelf?

Here, I was a torn. Self publishing has become increasingly acceptableand affordable. Yet part of me clings tothe notion that if no one in the "real" publishing world is ready togive it a go, maybe it needs to stay on the shelf. And while the differences betweenself-publishing and having a publisher bring out a book have become fewer thereare still some big hurdles that the self-published author must consider. Most notably, how do you get a self-publishedbook reviewed in the bigger publications? Not to mention I really do like that initial advance check.

So VULTURES saton the shelf until I got a call from my agent Al Zuckerman--and any authorshould be so lucky to have an agent like Al. He'd just had lunch with the editor at a gay-themed publishing house,and he'd brought up my name. He wonderedif I was interested in writing a mystery or thriller series with a gayprotagonist. Looking back at my wall ofunwanted books, I spotted my very first manuscript--a rambling six-hundred pagestory of a conflicted gay surgeon. It'spart love story, part action adventure, part mystery, part buddy book and totalmess. It's quite possibly the worstthing I've ever written. So I told himI'd think about it, and while I was deep into another project gave it seriousthought. Which is when it hit me. What if...What if the two women protagonistsin VULTURES fell in love with another? They were already the best of friends, was it such a leap? As it stood, the book had no love line andthis made tremendous sense. Indiscussing it with a gay friend of mine she thought it would work, but I'd needto make them a bit younger--and so I did. It took a solid two months to get a strong rewrite, and what emerged is abook that is a tremendous amount of fun. However....

By the time itwas ready to be submitted to the gay-themed publishing house, they'd gonethrough radical restructuring and the editor I'd written this for, had left. So back to the shelf...or so I thought. And this is where we get our happy ending, ormaybe a fresh start. Unbeknownst to me,my agent had forwarded the new gay-themed VULTURES AT TWILIGHT to Severn House,a British independent who's published my last two hard covers. Sure enough they wanted it, but only as aseries. If I could commit to at least a secondbook with my two heroines--Lil and Ada--it was a go. And now VULTURES AT TWILIGHT will be releasedin January 2012 in the U.K. and later this year in the U.S. with the e-versionto follow a few months later. And themoral of this story, which is old and worth revisiting, persistence does pay,and often in unexpected and wonderful ways.

2011-12-30T14:15:00.000-08:00

Pearls to get You Puiblished

As I prep for the release of my latest mystery--VULTURES AT TWILIGHT (Severn House)I came upon the following that I wrote for the now defunct Byline Magazine. It's all about the circuitous route to getting published. For me, this is all about the journey. The product is great, but how we get from point "A" to "B" is endlessly interesting--at least to me.

Furrballs & Pearls
Published in Byline Magazine as “Pearls that Get you Published”
Charles Atkins, MD

At four-thirty on Monday morning my cat throws up on The Chicago Manual of Style. This is not an omen, I reassure myself while cleaning it up and moving on to the morning’s writing.

This time in the dark, while the rest of the world sleeps is when I work on novels, map out marketing strategies, answer emails from my agent, publisher, and publicist and hammer out the next column or article. These are words written when my brain is sparking to life under the kindling effects of the day’s first cup of coffee. I never know where the words will lead me, but that’s the excitement of writing while half asleep. At seminars when people ask me how I do it, I tell them that the secret is one of trusting the process and trying not to think too much. Don’t think . . . write.

The Chicago Manual of Style, from here on marred with a small brownish stain, was a concession to my first agent who harangued me about my ignorance of the comma, “Buy a book, learn this and move on,” she instructed me after receiving a three-hundred page manuscript with the same comma error repeated several hundred times,

My path to becoming a writer, and now a published author, is constructed of thousands of such mornings. I’d always wanted to write a book, but I’d never had the discipline, at least that’s what I’d thought. Then came medical school, internship, and residency. Like eight years of boot camp they trimmed away all of my self-defeating habits with endless chapters to memorize followed by sleepless nights on-call. As a writer this discipline gives me the stamina to start a book on one day and finish it two to three months later. It’s easy; each day is a thousand words, and don’t skip days.

For the past couple years I’ve taken that writing to the market place. It’s like jumping hurdles; each one brings me further along on the road. Pearls of wisdom, like luminous guideposts, help steer the process. It’s a path that others have been down, but it’s obscured and like those three-D images that appear when your eyes have sufficiently lost focus, the way to publishing is not always clear.

So what are the pearls?

The first is the basic, “writer’s write.” If you don’t make time on a regular basis, it’s not going to happen. The book won’t get written, the screenplay you’ve been carrying around in your head won’t make it to the printed page, and that groundbreaking article on the perfect orgasm will never make it to Cosmo. All of the successful writers I’ve encountered have a writing habit. It’s best to put something down on paper everyday. Beyond that, like other habits, it’s helpful to set up a regular time and place. The “when” is unimportant, but it should be daily.

The next pearl has to do with creativity, and how to avoid writer’s block. My understanding of creative process is what allows me to sit down at my computer and have perfect faith that what I’m going to write will make sense, and have a beginning, a middle, and an end. As a psychiatrist, I have years of experience in seeing what shuts down creativity. The number-one killer of the muse is criticism. More often than not, it’s internally generated. When I worked at Yale providing counseling to graduate students, I mentally divided them into two groups, those that whizzed through their theses without a problem and those that stalled out. I found that the stymied pre-docs were critiquing their work as they tried to create it. Invariably, they found it wanting; it wasn’t good enough, or important enough, or what their supervisor wanted. These self-critical messages made it impossible to maintain the creatively mushy brain state that allows for interesting writing. This phenomenon was articulated for me at a creative writing seminar where the instructor encouraged us to write without editing. You can always edit later, but when it’s time to do a rough draft—for me at least—the goal is to get it down on the page. If it’s horrible I can always come back later and burn it.

So once you have a book written, how do you take it to market? The first piece of advice I received about publishing was from another physician author. He said, “Publish something small first, like a short story. It’ll help build your credentials.” He was right, but this also falls under the category of easier said than done. This became my introduction to rejection letters. Like most authors, I have received many of these. But rejection is not all bad. In amongst the form letters that assure me it’s not my writing but simply, “does not meet our requirements at this time,” are often helpful hand-written lines and paragraphs that let me know the real reason. Sometimes they steer me in the direction of another publication, and sometimes they clue me in to some key element that I need to incorporate. Maybe it’s not a rejection letter after all, but a request for me to redo the piece in a manner more in keeping with the needs of the publication.

The first novel I wrote, a medically based-action-adventure-gay-themed-romantic-comedy thriller—now safely buried at the bottom of a drawer--received the following comment scrawled in the margin of a quarter-sheet form letter, “this is very unprofessionally formatted!!!!” I overlooked the three exclamation marks, told myself it was written by someone with the emotional maturity of a seventh grader, but I did take the message to heart. I bought a book on manuscript formatting. Sure, I’d double-spaced and laser printed, but my headers were wrong and all of the other conventions that separated the pros from the amateurs hadn’t been observed. It was a great, albeit snotty, rejection letter, that helped me clear a hurdle.

A rejection letter, and the emotions it can fuel inside of us, is a potential pitfall for many would-be authors. I often hear people talking about the one or two times they submitted something and had it returned. They feel devastated and defeated. For some, they never clear this hurdle. Rejection has an annoying way of finding deep resonance within us. This is where some careful reminders can help us stay on track. Rejection is not personal and more often than not, the piece we sent really isn’t right for the publication, or they have no space to print it, or they just ran a similar piece, or…When I started submitting articles and essays, I told myself that I was doing well if one in ten were accepted. That’s now down to about one in three. Rejection letters are part of the business of writing, not to be confused with the art of writing; it’s important to keep these separate. When I receive a rejection letter, I read it, file it in a folder, and forget about it—unless of course there’s something handwritten that is useful. They’re not something to stew over. And as another author told me about rejected pieces, “don’t let them sit longer than twenty-four hours in the house.” What he meant was, look the piece over, revise it if necessary, and then send it somewhere else.

The next step is critical; if you want to get a book published you need an agent. When I started I wasn’t certain that this was necessary—haven’t we all read such success stories? But then I met the ex-owner of a publishing house at a conference. He set me straight with two sentences, “Sure we read unsolicited manuscripts. But in the twenty years I ran **** Press we never once published one.” It was a pearl not to be overlooked. I refocused my efforts, bought a book on the subject, wrote a succinct query letter, and got an agent.

Once I had representation the quality of rejection changed. No longer were manuscripts getting returned from editorial assistants, but they now came back with letters from senior editors and vice presidents. And then, wonder of wonders, we got a nibble, and then another, and then a two-book deal.

Now that I’ve entered the realm of the published—my first book came out last year and I have another coming out this fall--I face a new series of hurdles. But as before the pearls are dropping and I’m just the little piggy who’s going to pick them up.

I now spend considerable time on marketing and publicity—a subject that fills many books and more in-depth articles. What I’ve learned is that I am ultimately responsible for how my books sell. New authors, in the age of cost-conscious, downsized publishing houses, must not depend on the marketing department. They will provide some basics, but on beyond that you’re on your own. But here again, there’s a road. I do a lot of talks, charity events, and every television and radio interview I can land. An author friend of mine refers to it as being a “publicity slut”, where she’s been on Oprah seven or eight times, I’m not about to argue.

As I look back through this article, I can’t help but think, “what an awful lot of work this is.” And that’s the truth. I write because I have to, because it’s a passion--a labor of love. As a psychiatrist, I am all too aware that most people move through life with no passion. So I pay attention to those things that nurture my craft. I practice daily, and listen to the wisdom of those that are further down the path; I find this works.

Bio—Charles Atkins is a practicing psychiatrist and author. He has written both fiction and non-fiction. His latest mystery--VULTURES AT TWILIGHT (Severn House) will be released in the UK in January 2012, and May 2012 in the US.