In a local bookstore, I came across What Patients Taught Me: A Medical Student’s Journey, a memoir by Audrey Young, MD, about how her medical school training in a special University of Washington program facilitated her growth as a person-centered physician. I read the book’s preface standing there by the staff picks. During her rotations and clerkships, Young tells her readers, she regularly sat at night in her student apartment before her “boxy old Macintosh computer with a five-inch screen” trying “to come to terms with a child with cancer, a grandmother with eroding memory.” Later, she created more material by writing regular group emails during her time volunteering in a South African hospital. When one friend, also a medical student, emailed back, “Keep writing. This could be something,” his words became her “spark.” After writing and writing, Dr. Young realized that “the only thing to really make doctoring a human act is the time spent with patients…Their lessons are in this book.” I wanted to find out what lessons the author learned and how she learned them. I bought the book and after reading it, I see a template that others might follow in organizing their thoughts and material for personal stories of growth.

Before I tell you about Dr. Young’s approach to organizing her experience for a book-length memoir, I want to highlight the four staple ingredients I recognized, even from the book’s preface, that all of us who are compelled to write from life experience need to keep on hand:

1. A desire to make a discovery about our lives, to come to articulate an answer to a question our experience has raised for us.
2. A voice we listen to that says, “Yes, write. You have the talent, the right, the ability to fill a niche with felt wisdom for others.”
3. A belief that our experiences are worth recording to mine for our book’s material
4. A willingness to live with our own imperfection and not knowing and write our way to felt answers.

How do we shape our writing toward those felt answers? Can we outline such a shape even before we have started writing a book-length memoir? Or, if we have written a manuscript, how might we find a way to revise the shape of it to heighten our personal discoveries and our readers’ interest?

We must look at our material (written or lived) to see where it can provide a path for us to travel in our writing and a place to start on that path.

In Young’s case, it was the locations of her various rotations and classroom experience that offered her an organization. She was enrolled in the University of Washington’s medical school’s Washington, Alaska, Montana, and Idaho (WWAMI) program and would do her classroom training in Seattle and apprentice with physicians in general practice in small communities in those states. Her book’s chapters are titled for the towns in which she apprenticed and for Seattle, where she did her classroom studies. After she is done telling the story of how she learned what she needed to become the doctor she is today, she offers a postscript about where she lives and works and then a history of the WWAMI program, which she values highly for providing the opportunity to learn from patients.

Here is an outline of how Young’s book uses details of her training to come to insights that support her thesis that patients provided her most highly valued lessons.

1. In Bethel, Alaska, the first place she is assigned, she learns first things first — how to tell a patient’s story to the attending physician in a way that filters what is most important to the diagnosis. She also learns that while she is a student, she will very often not learn the fate of those she helps if the diagnosis is complicated. In her not knowing, she learns to face imagining both the difficult endings their diagnoses may lead to and the hopeful endings that are also possible.

2. In Seattle, Washington  for classroom studies following her time in Bethel, Young is “cooped up with 175 overachievers” and worried, ” she says, “over class rankings and residency letters…I hadn’t seen real patients since the summer before or thought about the day-to-day interactions that turned a medical student into a good clinician.”

3. In Spokane, Washington, she comes to realize that making judgments about patient behavior colors her ability to connect with their best efforts as well as her ability to perceive “that healing happens over months and years, not in the twenty minutes of a clinic visit, and certainly not because of a grand speech from the doctor.”

4. In Pocatello, Idaho, she observes a family, mother, father, toddler and infant, in because of the infant’s breathing problems. Knowing that the attending physician had ordered lab reports to see there were bones broken or healing from abuse, she begins to see a “coiled violence” in the father and looks back at the reports finding no evidence of abuse. She then reports she feels remorse at:

how rapidly I had passed judgment and willingly trusted a stereotype. That mistrust might save one infant’s life but would be a disservice to every other struggling family. Now I wondered if similar suspicions about abuse had caused the original delay in getting Hester’s asthma under control.
The family’s distress over the lack of help for their baby, though their own smoking was exacerbating the experience, made for the “coiled” anger all around. Young sees that as a physician, she will not be able” to alter the overarching reality of lives” but that shouldn’t lead to judgment and misdiagnosis.

5. In Missoula, Montana, Young realizes that she is distracted by missing her family and friends after spending a month back home in Seattle. She questions her ability to stay focused and her decision to leave the city again, but it isn’t long before what she calls “the human story” reasserts itself and sweeps her, she says, to a place she recognizes “immediately as a place of danger and compromise, where I ought to pay close attention and tread with great care.”

6. In Swaziland, South Africa, where Young volunteers for a hospital clerkship, treating adults and infants with AIDS and the effects of dire malnutrition and diabetes in a setting without enough equipment and precautions, she plans to cut her clerkship short and meet a friend who has been in Spain. Before that, however, she accidently sticks her hand with a needle she’d used to drain fluid from a young man who most likely had AIDS. She scrubs and scrubs her hand with antiseptic and when she sits still she realizes that she has become overwhelmed by the “burden of disease and death.” She feels like she lives in an “awake paralysis.” But she chooses to stay and finish the clerkship, a choice she says she later comes to see as something fundamental to being a doctor: “A doctor works because there is suffering and because he or she is able.”

7. In Dillon, Montana, having finished her residency, Young practices as an attending physician. She remembers the many rural doctors she had worked under and what it was like to treat patients over their lifetime. What she knows for sure is what she has been learning all along — the most important information comes from the patients and doctors must listen and be on their team, offering their help in a way they can use it, understanding when their way is different than the doctor’s.

And after finishing her story, she shares two more chapters:

8. Postscript – The doctor is now a teacher at the medical school she trained in. She offers her best tool for teaching the students, based on her experience and insight.

9. A Brief History of WWAMI – Having benefited from the training she received, she fills the reader in on its start and current program.

Throughout her chapters, Young reports what she sees, hears, fears, concludes and is awed by as she watches her attending physicians, does her research to understand patient charts, takes to heart patients’ stories of their lives and illnesses, and recognizes how to work with her own feelings. At its end, What Patients Taught Me is a satisfying read because the author has shown the courage to describe her own vulnerabilities and those of the people for whom she is caring. In her chapters, which take us to the places she worked in the order she experienced them, she shows herself as a new medical student, a more experienced one, and then as an attending physician, always with details of place and people — we feel the ice under her tires as she drives to clinics, experience the camaraderie she shared with other students in the break room and student apartments, the Eskimo community she lived in. Very importantly, we stay tuned to the story because we are interested to know how the author grows from student to doctor, how she thinks as a consequence of her experiences while in training, how that might inform us as we speak with our own doctors.

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 If you’ve been writing a memoir and wonder about the structure of your book or if you are contemplating starting a memoir but are struggling with what material you’d include and why, taking a lesson from Young’s motivation for writing and her organization will prove useful. Like Young’s, your organizational structure may proceed chronologically, but it doesn’t necessarily have to.

Why Will Readers Be Interested in Your Memoir?

Before you can strengthen an existing memoir project or organize the chapters of one you want to start so your book is marketable and of interest to readers, you need to have identified a deep reason for which you are writing your memoir. It is a reason more specific than wanting to deliver the story of a portion of your life. It is a reason that offers you the opportunity to discover something by recounting and reflecting on your past experiences.

To help with this, think about these questions: What in your material is about having made an important decision to do something significant – like starting medical school and deciding to work in rural practices. Did you decide to become a stay at home mother? Become a CEO? Quit corporate life for life on a farm? Enter the field of teaching? Accept a divorce? Come to grips with having experienced a trauma – early childhood or at any other time in your life?

Your reason for writing the memoir is going to be to find out what you learned from your decision. That will also be the readers’ reason for reading your memoir. So the story of your memoir is not only about the decision but also about the result of the decision.

Young decides to enter a special medical school program and as a result she learns person-centered medical practices and comes to believe that learning from patients is a most important part of being a doctor; therefore, she supports the learning model in which she participated. But she doesn’t arrive at this understanding without reflecting on the obstacles she overcame during her time as a medical student: lack of confidence, not knowing if she wanted to be a rural practitioner, overcoming fear of making mistakes, learning to listen, and more.

We learn all kinds of things vicariously from memoir, but what keeps us reading is anticipation — we want to see how someone negotiated obstacles and came out altered and, hopefully in some way, on top. As writers, we want to explore how we did what we did to find out how we are altered.

In addition to identifying the events of overcoming obstacles, a memoirist must remember that stories start when something is about to change. In this way, identifying a decision that underlies your inner reason for writing helps you figure out your story. Were you destined for professional life but decided to own a ranch? Did you decide to expose wrong-doing in your community? Did you decide to take an active role in your own healing from an illness as well as work with the medical community? Did you decide to be a primary caregiver? Your story probably starts with your decision to take on a role.

And your story will be threaded with insights you glean from writing until you reach an ending that portrays when you knew you’d learned all you could and had grown into what you were hoping to become or had the impact on others or a community you set out to have. In the ending is the gem you’ve been writing toward — what you learned from reflecting on your life experience that you would not have retrieved unless you wrote your book.

Write a statement about the decision you came to that impacted your life and add a clause about how making that decision changed you. (For instance, “Deciding to write about how being adopted led to insecurities I struggle with even today, I realized my anger toward my biological parents for abandoning me has dissolved and reconstituted me.”

Then think about the obstacles you overcame — sometimes they are events and circumstances and sometimes they are your own or others’ thinking. List the obstacles. How you introduce them and in what order will be determined by the pattern of organization you choose for your book.

Think About Your Book’s Organization

As you have seen, Young’s book moves by geography as well as chronology, covering her moves for rotations and classes.

What is true for your book? For instance, if it is about the decision to investigate how being adopted shaped your life, and you find that learning family truths is shaping how you look at the personal issues you faced, you might decide to write the book in chapters that are about significant people (both of negative and positive impact) in your life. These people could be arranged in chronological order of when they entered your life, but they could also be arranged in any order that you feel is a good for evoking the issues you’ve been left with in your life in a way that builds to a crescendo of self-knowledge.

So, you might start with a description of teacher from grade school who made you feel empowered to learn, move to a description of working with a therapist you saw as an adult when that empowerment seemed to ebb, move back to memories of a neighborhood bully who stripped you of self-confidence, zip ahead to a description of your spouse who must deal with your lack of confidence, describe raising children and facing perplexing issues for one not raised by biological parents, and then describe the parents who adopted you to show how you are re-seeing them and yourself.

If you are writing about the decision as a girl to play on an all boy football team, you might be writing about how that experience created the confidence to keep on making unusual decisions. You might order your book by football terminology: the coin toss, the kickoff, first penalty, etc., to introduce your unusual decisions by what they meant to you. Or, perhaps you’ll work on a book arranged by a description of being a girl playing football on a boys’ team and then descriptions of other unusual decisions and adventures, which may go in chronological order.

If you are writing about what you’ve learned as a person who decided to volunteer in areas following natural disasters, you might order your book by the documented disasters. The disasters can go in chronological order if that seems right or they might go in the order of types: earthquakes, flooding, famine, and epidemics, for instance.

Consider Your Book’s Preface

You may be thinking that you will sit down and write your preface before you start on your chapters. To write it meaningfully for readers, you need to consider these questions: What does the reader need to know to step into chapter one? Should that be chapter one? Can the reader figure out what is necessary from the details of the story as they go along?

Most likely, the preface is best written after you have finished your book because then you’ll know what you want readers to be thinking as they begin the book. That might even be knowing what you were thinking as you began the book.

I have found that people write a preface thinking they are setting up the book but they are actually giving away information that belongs in the story. Even though the reader will read the preface first, only after you have finished your story do you have a completely correct platform to offer readers. Often, a preface even tells something of the writer’s current life because that will inform the reader’s thoughts as they begin the story.

Collect Your Memories, Thoughts and Information

Figure out a plan for gathering the material you’ll need for writing. Keep files or a journal to remember details from memories, letters, old journals of yours and others and record images from interviewing people, visiting particular sites, reading and researching on your topic.

Some people are beginning to experiment with a software program call Scrivener. It is a way to keep research, drafts and revisions in an orderly way for retrieval.

Identify Your Spark

Plan to send off writing as you create it to a trusted reader or community of readers. That will help keep you writing. Some people start a blog, others keep copies of their email, and still others send hard copy of what they have written. You might start a Google Circle to disseminate the writing to your readers.

Always remember that you are writing to real people who want to know your story. Tell them you are pleased to be sending these vignettes, essays, chapters, and thoughts their way and very much appreciate that they are reading them. These readers are good for you exactly because they are interested in what you have to say, not in critiquing it (your writing group will help you work on how you say it). All you need from your first trusted community of readers is to know they are reading what you write. When they tell you to keep going, (and they will), listen! Keep words of endorsement and encouragement near you in your writing area. Always read them when you sit down to write.