How to Write a Thought Piece

1. September 27, 2013 How to Write a Thought Piece Louise C. Walter, MD Professor of Medicine Division of Geriatrics

2. What is a Thought Piece? • Manuscripts that articulate a new idea/perspective in a meaningful way • Develop an intellectual framework that challenges existing paradigms • Address any important topic in clinical medicine, health policy, research methodology, public health, etc. • Making your case in words for what you believe—important in medicine • Thought pieces are scholarship—can have large impact on moving your field forward and helping your career

3. Where to Start? • We all have conceptual frameworks for our research • “which outline possible courses of action or present a preferred approach to an idea or thought” • We all can point to things in medicine that bug us—we know things could be done better • Few take time to clearly articulate their argument for why it is important to think differently about a problem • That is the role of a thought piece

4. How Are Thought Pieces Different? • You have a thesis (an argument) • Unlike data driven articles or systematic reviews which are suppose to be objective without a preformed conclusion... • Focus is not on generating new data • Like a legal brief: Argument use data to support argument • Unlike data driven pieces find argument that supports your data • Not merely opinion (not an editorial or opinion piece) • Grounded in existing data/evidence

5. Publishing • Journals publish these under many different names/article types • JAMA: Commentary (1500w), Special Communication (3000w) • NEJM: Perspective (1200w), Sounding Board (2000w) • Ann Intern Med: In the Balance (1500w), Academia & Clinic (4000w) • JGIM: Perspectives (2500w) • Choose based on target journal (audience) and word count • Look at examples of thought pieces

6. Examples: A New Conceptual View of a: • Clinical Problem • Seligman HK, Schillinger D. Hunger and Socioeconomic Disparities in Chronic Disease. NEJM 2010. • Hulley SB, et al. Should We Be Measuring Blood Cholesterol Levels in Young Adults? JAMA 1993 • Grenon SM, et al. Can I take a space flight? Considerations for doctors. BMJ 2012 • Health Policy • Bibbins-Domingo K, Fernandez A. BiDil for Heart Failure in Black Patients: Implications of US FDA Approval. Ann Intern Med. 2007 • Wojcicki JM, Heyman M. Let’s Move—Childhood Obesity Prevention from Pregnancy and Infancy Onward. NEJM 2010. • Williams BA et al. Balancing punishment and compassion for seriously ill prisoners. Ann Intern Med. 2011 • Research Methodology • Bach PB, et al. Resurrecting Treatment Histories of Dead Patients: A Study Design That Should Be Laid to Rest. JAMA 2004

7. Outline of Talk We now know what a thought piece is • Why write a thought piece? • What is the process for writing a thought piece? Will answer these questions using two of my thought pieces as examples

8. My First Thought Piece:Cancer Screening in the Elderly • Came about because questions about when to stop cancer screening arose frequently in my outpatient clinic • Ex. 80 y/o woman who hikes Mt Tam. • Ex. 80 y/o woman who had severe dementia • Mammography? Colon cancer screening? • Told to do decision-analysis • Cost-effectiveness based on stopping age • Approach did not address the issues which I felt were more conceptual • How to think through a screening decision

9. Why a Thought Piece vs. Data Driven Article? • Approach to cancer screening bugged me—one-size-fits-all based on age • Decision analyses produce a number for the “average 80 year-old”—So preventive care should be similar for my two patient examples? • It was a conceptual problem more than a quantitative problem—How would you actually use “life years saved” to make decisions? • So I told my residency program directors that I wanted to write a thought piece • Told thought piece was waste of time • “It won’t get you promoted” • I disagree...I think thought pieces are an important part of your research portfolio

10. Wrote as a fellow • Most cited work • Made me an expert in this area—national reputation (helped get me promoted)

11. Steps for a Thought Piece • Choose your audience • Clearly articulate the problems and limitations of current approaches • Clearly articulate the new paradigm • Determine domains of new paradigm—these provide the structure to piece • Give specific examples/figures/tables to illustrate domains—make it practical • Recommend what needs to be done to accomplish new paradigm

12. Step 1 • Choose your audience Who needs to hear what you are saying? ---Clinicians, Patients, Policy Makers, Researchers, etc.

13. Cancer Screening in the ElderlyThe Audience • Conceptual view of a clinical problem • Guidance on how to think through a screening decision in older patients • Audience—practicing clinicians • General internists; Family Medicine • Geriatricians • Nurse practitioners

14. Step 2 • Choose your audience • Clearly articulate the problem and limitations of current approaches Why is it important to think about things differently? What needs to change?

15. Cancer Screening in the ElderlyArticulate the Problem • Guidelines based on age cutoffs and were conflicting Mammography Guidelines (until 2002) • USPSTF: Stop mammography at age 70 • American College of Physicians: Stop at age 75 • American Geriatrics Society: Stop at age 85 • American Cancer Society: Never stop • “One-size-fits-all” approach to screening based on age does not work in the diverse elderly population • Variation in life expectancy/health/preferences

16. Step 3 • Choose your audience • Clearly articulate the problem and limitations of current approaches • Clearly articulate the new paradigm What is your thesis (your argument) for how to think about a problem?

17. Cancer Screening in the ElderlyArticulate the New Paradigm • Need framework to guide how to think through screening decisions in elderly • Incorporates individual characteristics (health/life expectancy) and preferences • Key Messages of Framework: • Benefits/harms of screening should be considered in context of individual’s health/life expectancy, not age alone • Estimates of benefits/harms should be weighed with qualitative judgments of individual’s values/preferences

18. Step 4 • Choose your audience • Clearly articulate the problem and limitations of current approaches • Clearly articulate the new paradigm • Determine domains of new paradigm—these provide the structure to piece What are the important components of the new paradigm?

19. Cancer Screening in the ElderlyWhat are the Domains? • Estimate life expectancy • Determine potential benefits of screening • Determine potential harms of screening • Weigh potential benefits and harms according to an individual’s values and preferences

20. Step 5 • Choose your audience • Clearly articulate the problem and limitations of current approaches • Clearly articulate the new paradigm • Determine domains of new paradigm—these provide the structure to piece • Give specific examples/figures/tables to illustrate domains—make it practical Can you give practical illustrations or case examples to support concepts?

21. Illustrate Great Variation in Life Expectancy for People of Similar Ages Life Expectancy for Women Years Age (years) Walter LC. JAMA 2001;285:2750-2756

22. Illustrate Theoretical Concepts—Ground piece with evidence and examples To support your argument: • Use existing data in a new way • Reference the literature • Tables and Figures are helpful to illustrate concepts • Use case examples

23. Cancer Screening in the ElderlyUse Case Examples Mrs. A: 80 y/o woman with severe dementia Mrs. B: 80 y/o woman hiking Mt Tam. • Estimate life expectancy • Mrs. A has severe dementia and functional dependency, so life expectancy < 5 years • Mrs. B is probably in upper quartile of life expectancy for her age, so likely to live > 13 years • Probability of benefit • Mrs. A unlikely to benefit since life expectancy < 5 yrs • Mrs. B has reasonable likelihood of benefit given her substantial life expectancy

24. Use Case Examples—Cont. • Probability of harm • Mrs. A has severe dementia so tests may cause distress and if asymptomatic cancer identified likely is unimportant • Mrs. B understands and accepts risks of tests • Values and preferences • Mrs. A has avoided doctors and becomes agitated if anything interrupts her daily routine • Mrs. B worries about her health and wants a mammogram and FOBT • Screening recommendations • Recommend AGAINST screening Mrs. A • Recommend screening Mrs. B

25. Step 6 • Choose your audience • Clearly articulate the problems and limitations of current approaches • Clearly articulate the new paradigm • Determine domains of new paradigm—these provide the structure to piece • Give specific examples/figures/tables to illustrate domains—make it practical • Recommend what needs to be done to accomplish new paradigm Offer solutions—No one wants to hear just a litany of problems

26. Cancer Screening in the ElderlyMake Recommendations • Need to reimburse clinicians for complexity and time requirements of these screening discussions • Need to improve cancer screening quality assessment systems...

27. Where Things Fit • Choose your audience • Clearly articulate the problems and limitations of current approaches • Clearly articulate the new paradigm • Determine domains of new paradigm—these provide the structure to piece • Give specific examples/figures/tables to illustrate domains—make it practical • Recommend what needs to be done to accomplish new paradigm Introduction Body Conclusion

28. Why Write a Thought Piece? • Thinking through thought piece helped me figure out the domains I wanted to tackle with my research • Better estimating life expectancy/prognosis • Harms/Downstream consequences of screening • Led to collaborations to study patient preferences for screening • Helpful in grant writing • Reviewers do not criticize my conceptual framework

29. Example 2:Thought Piece about Policy Problem • In 2002, SF VA clinicians frustrated • Our colorectal cancer screening rate of 58% failed to meet national target goal: 65% • Clinicians told to screen more patients • Failure to increase rates  financial penalties • We decided to assess whether this “quality indicator” reflected quality

30. Background: VA Quality Indicators • Based on chart review by external auditors who compute % eligible patients who received timely colorectal cancer screening • Eligible patients: > 52 yrs who did NOT have cancer of liver, pancreas, esophagus, or life expectancy < 6 mos • Over-sampled patients with specific comorbid illnesses, such as CHF and ischemic heart disease • We reviewed medical charts of the 229 patients previously reviewed by auditors to compute the 2002 colorectal cancer screening quality indicator

31. 229 Patients Not Tested N=81 Tested N=148 Diagnostic N=57 Screening N=91 Results of Our “Audit of the Audit” Patient too Sick to Benefit N=25 Refused Test N=38 Failed to Complete Test N=10 No Valid Reason For Not Tested N=8 Walter LC. JAMA 2004;291:2466-2470

32. Why Write a Thought Piece? • Small single-site study • Written as traditional data study would not have large impact • Discovered problems with national VA policy that had generalizable lessons for US healthcare • Decided to write thought piece to try to reach broader audience

33. Step 1: The Audience • I wanted to change policy—target audience was policy makers in quality improvement • ...and clinicians (give voice to their concerns)

34. Steps 2&3: The Problem/The New Paradigm • Quality indicators often based rigidly on rewarding high cancer screening rates rather than encouraging individualized decisions • Do not account for when risks > benefits • Do not account for patient preferences • Quality indicators should encourage patient-centered care

35. Steps 4&5:Domains/Illustrations • Target Population for quality measures: Does severity of illness matter? • VA case example: age and severity of illness of patients audited for screening • Target Screening Rates: Are Higher Rates Always Better? • Harms of screening frail elders—prior literature • Measuring Performance: Should Patient Preferences and Clinical Judgment be Considered? • VA case example: flow diagram to illustrate how often these were ignored by measures

36. Step 6: Make Recommendations • Findings resulted in VA making several improvements to the performance measure • Auditors no longer focus on screening in ill elderly patients (e.g., random sample) • Still need to develop measures that go beyond equating good care with high screening rates • Reward for not doing something when not doing something is good care Walter LC. JAMA 2004;291:2466-2470

37. Risks of Thought Pieces • Thought pieces risky....challenge existing paradigms • Reviews unpredictable • Sample reviews of my policy thought piece: • “For all its simplicity and humility this article raises extremely important questions about the state of the art of quality measurement.” • “Conclusions are overreaching and opinionated. Strikes a tone of harsh overstatement. Paper needs to be more tactful and careful regarding its criticism and interpretation because of the potential repercussions.”

38. Anticipate Who You Might Upset • I thought I might upset the VA so I tried to assuage them by saying: • “VA funded this project; attests to the commitment of the VA for moving the science of quality measurement forward; VA is a leader in quality improvement” • The VA PR person writing the press release thought the article was a positive piece about the VA...

39. Final Advice/Tips • Best not written alone • Need mentor who is very invested in project—help effectively communicate ideas • A lot of work; not a side project—Articulating thoughts in a meaningful way is very challenging—30 drafts of first piece • Junior faculty perfect to write these (new eyes on a problem) • Important to articulate why the way we think about a problem is wrong—move the field forward • Can be high impact—cited often • Think about what new paradigms need to be articulated in your areas of research