Submitting an article to a journal and having it accepted is always, for me, an energizing experience. Rejections may be harder to take, but my philosophy and practice has always been to wait, think, consider, and resubmit elsewhere. Surely, I think, some group of people somewhere would benefit from reading a piece that I wrote (assuming that it i not terrible), and that is also something that I try to communicate to my graduate and professional students: “you have done the work, thought it through, and even if you need to change it, a “community” out there–somewhere–would benefit from reading the piece.” My record number of rejections (I should think of them as “non-acceptances”!) is 5, until that article was accepted in the medical journal with the largest circulation in the world. I somehow knew that the piece would be interesting somewhere.

I have recently begun writing pieces in narrative medicine, based upon my own experiences, as a patient, or a medicine-watcher, or member of “the teaching team.” I feel more riding on these pieces. They are not the result of objective analysis, but are parts of me, and who I am, and what I have experienced. That does not mean that they are interesting, or worthwhile, or appropriate for the journal to which I have submitted–but the closer relationship to “self” seems to matter to me. So can I apply the same strategy to my narratives? “Yes,” I am convinced.

My friend Tom Koch, who had a background in journalism before he became a medical geographer-epidemiologist-ethicist-gerontologist,and who still writes in large circulation media, told me recently that you are really writing for one person: the editor. The editor is the person who needs to be convinced that the piece should be published. I still am trying to assimilate the thought, and while I am not sure that I agree, it is true that without the editor’s endorsement, the piece will not be published.

I recently wrote a piece on my mother’s death, and the decisions leading up to final discontinuation of life support in a medically futile situation. I went through 12 drafts, and sent it to a health journal that has a wonderful section on narrative medicine. And unsurprisingly, in a statistical sense, it was not accepted. So what am I going to do next?

The very act of writing the piece was technically challenging and worthwhile. The writing was worth doing. And it is a piece that I had been wanting to write for 17 years. I could not quite do it, and it took determination and frankly courage to write it, and revise, and revise. Having just heard from the first journal, what will I do next?

Since there are no comments from referees, I can’t read the comments and consider the issues that the comments raise. And I am not going to put the piece to sleep. So I’ll give it a rest for a week, reread it, and (yes), send it to the next journal. This time, it may not be a health care or medical journal, or it may be to one that specializes in narrative medicine. In the end, though, no matter how disappointed I was with the decision to not publish, the very act of writing and wrestling with the issues was worth it. Yet on a daily basis, as I learned when I headed up the Clinical Ethics Consult Service at one of the Seattle hospitals, families deal with these end of life issues. What to do? How aggressive to be? What is futile? And indeed, in one way or another, “what are my values?” And, more to the point, “what are my loved one’s values? What did she express when we talked about this kind of situation?”–I cannot urge loved ones strongly enough to discuss end of life issues even when it may seem so easy to postpone–no immediate health problems, or nothing that is life threatening. That is exactly when end of life preferences need to be discussed, however painful they may be, because we all die, and presumably we want to die as we wish to die. My beeper used to go off in the middle of the night all the time because such discussions had not occurred, or because Dr. so and so did not agree with the wishes of the patient or the family, or, even more difficult, when family members did not agree with each other, and when nobody was considering what Mom or Dad had indicated or stated–if there had been any discussion. In those situations, discussion had usually *not* taken place, and health care documents, such as an advance directive to physicians (“living will”) either did not exist, or could not be found–or were not considered.

So back to my piece. I will resubmit it, and maybe I will even exceed my previous record of rejections! (oops, non-acceptances)–but it will see the light of day, because I have a story to tell, and others say that they benefitted from reading it.