On Thursday, March 24, apenndx had the opportunity to interview Dr. Sara Manning Peskin – author of A Molecule Away from Madness: Tales of the Hijacked Brain.
Sara Manning Peskin, MD, MS, is an assistant professor of clinical neurology at the University of Pennsylvania. She received her undergraduate degree in biochemistry from Harvard University, where she graduated magna cum laude prior to moving to Philadelphia. She attended medical school and received a master’s degree in cellular and molecular biology at the University of Pennsylvania, where she also completed her neurology residency and a fellowship in cognitive and behavioral neurology. Her writing has appeared in the New York Times, the Washington Post, and Boston Globe Magazine, among other publications.
Below is an edited transcript of the conversation. Dr. Sara Manning Peskin along with Dr. Jonathan Reisman along will lead a panel about writing in medicine on 3/31 from 12-1pm. Register here
Joshua
Your book, A Molecule Away from Madness: Tales of the Hijacked Brain, was a fantastic look at how powerful and yet delicately equilibrated our brains really are! What was your inspiration for writing the book, and what did you hope your readers would come away with?
Dr. Manning Peskin
I mostly wanted to take readers into the lives of people who have these really dramatic personality-altering diseases! We often think of the example where a couple drifts apart, and they go to a therapist and say – “This isn’t the person I married.” I wanted to capture these diseases where people are literally not the people they used to be, not because everyone drifts apart or because everyone changes, but because there’s been this molecular change and they are now a different person. I wanted to capture what life looks like for them and for their families. Then when I started doing the writing, I realized that the history behind these diseases is totally fascinating. I trained in neurology, but I didn’t know most of these stories. There are all these scientists who were totally shunned and most of them went out on a limb and really risked their careers. Some of them spent all their money in order to get us the knowledge we have now, knowledge that we take for granted. So, I think I also wanted to be a bit of an entertainer with those stories.
Joshua
Your work (both your book and your New York Times article series on dying) spends a lot of time unpacking the emotions, symptoms, and experiences surrounding death. How has writing impacted your conceptions of death and dying, and what about the subject makes it a recurring feature in your work?
Dr. Manning Peskin
That’s so funny; I don’t think anyone’s ever pointed out that it’s recurring, but I guess it is! The first piece I wrote about dying was when I was an intern. My grandfather, who I am pretty close with, had been ailing for a while and passed away in the spring of my intern year. We were with him for the last few days, and I had just no concept of what dying is like. As an intern you are often with patients for two seconds as they are passing away. There are people passing away in the hospital, and you go and check on them every little while – but that’s totally different than watching someone you love slowly pass away over those final days and hours. And I think I was totally struck by how totally unprepared and surprised I was by the experience, considering that I had medical training. So that’s what sort of inspired those pieces. I think I’ve always been interested in palliative care and end of life issues. And, how do we think about that final time, which is sort of surreal? Those interests are definitely related to cognitive neurology because most of the patients I see who have neurodegenerative diseases––there isn’t a cure, and so part of my job is guiding them along the path of degeneration, and also talking to their families about what to expect and how things are going to go and making sure that when they are close to passing away, getting them in hospice and getting them on services that have support for that kind of passage. So, I suppose [death] has always been something that I’ve been interested in. It’s less present in what I do now than in my direct pieces about death, but it is certainly present. All the people that I’m talking to now are people who are scared of an early death.
Joshua
Do you think writing those pieces help you as you have conversations with patients who are suffering from neurodegenerative diseases?
Dr. Manning Peskin
It’s definitely cathartic writing about those experiences with patients. I think the other thing is that writing about the scientists that discovered these diseases changes how I practice. [I] Learned about what Dr. Alzheimer really discovered [and how] that story unfolded. Now when I diagnose people with Alzheimer’s disease I tell them [the story]. I think it’s useful. People don’t know what the difference is between dementia and Alzhemier’s disease. Explaining it from a historical perspective using narrative is a lot more effective than saying “Oh [in] Alzheimer’s disease we find these proteins.” Telling them a story is more effective for teaching them about their own disease.
Joshua
You describe the book as connecting a patient’s narrative to the molecules causing the problem. This process involved numerous interviews with patients and family members. How did you approach these interactions balancing the desire to accurately understand the individual’s experience with the emotional burden discussing disease and even death can have?
Dr. Manning Peskin
For the book, most of those people were not my personal patients when I interviewed them. So, that was kind of nice. It wasn’t like I was limited to 30-60 minutes, I had as much time as I wanted, or as much time as they would give me. I think with those interviews people were generally really open. I didn’t feel like I had to limit the questions, and the goal was to get something emotionally evocative and to be honest about what their experience has been like. In the clinic, on a long-term basis there is some distance that you have from your patients. But even just yesterday there was a young woman with early-onset Alzheimer’s disease, and there are always patients that get under the skin that you’ve built up. But that’s also what makes you come back to work, that these are conditions that really pull at the heartstrings and make you feel. There’s a reason I never went into surgery; I would not be good at it!
Joshua
How do you respond when you have a patient that gets under the emotional defenses that clinicians build up?
Dr. Manning Peskin
I go home and I talk about it to my husband. Yesterday in particular, there were a few patients in a row that were just really struggling. And for me, talking about it is the way that I process it. And it makes me feel closer to my own family. You end up saying, life is very short, you have these things that come out of nowhere. Being purposeful about the time I have with my own family is quite helpful.
Joshua
Part of being a public facing medical writer is translating the jargon that fills practical medicine and making it both readable and accurate for lay readers. Your book discusses complex aspects of neurology; Pick bodies and NMDA-encephalitis are things we just talked about in our neurology block. How do you balance creating something accessible and welcoming to readers while also not shying away from scientific and clinical complexity?
Dr. Manning Peskin
Basically I had an enormous amount of readers that were not medically trained. And eventually I hopefully got rid of all the jargon in the book. There is some criticism that you say that it makes it difficult for [readers] to discuss the topic because they don’t have the language, and I can hear that as a criticism. But the more I push, the more I realize people learn through narrative. That’s what’s emotionally evocative; that’s what gets them to learn information. There’s a reason people don’t read biology textbooks for fun! So, the goal was to take out all of the jargon and get to the root of the concepts, and the concepts for these medical issues are actually relatively straightforward! You don’t need someone to understand all of neurology when you are trying to explain a particular patient’s issue. I tried to narrow the focus and remove the jargon…I never wrote a scientific explanation and tried to translate it. It was alway in every draft trying to peel away more [jargon]. I had more than 10-15 drafts of each chapter, and each one had more and more [jargon] pulled away. Even now I look back at the book and realize I didn’t need to use that technical word.
Joshua
What was your actual process for writing the book?
Dr. Manning Peskin
I started writing when I was an intern, and thought maybe I’ll write a book. I started doing interviews in 2016, and then I published some smaller articles over time. In 2017, I got an email from an agent who had read one of my articles and asked me if I wanted to write a book proposal. I wrote the proposal with him. Then you shop it around to publishers and get a book deal and start writing most of the book. I signed the book deal in the spring of 2018, and I remember telling [the publishers], “I’m sure I’ll have it done in a year”. And I didn’t finish it until the middle of 2021. So it takes a long time. One big thing I don’t think I realized is that it is much easier to get a book deal if you have a big social media platform. I have no social media and no desire for it, but I think that is a bit of a hindrance.
Joshua
On your website you have articles dating back to 2016 talking about issues as diverse as the doctor-patient relationship and your honeymoon in the Amazon. When did you begin writing and prompted you to put your work into the public square?
Dr. Manning Peskin
[In] doctoring class during 4th year you have to write something. And I didn’t turn it in and [administration] said they wouldn’t let me graduate until I finished this project. So I ended up writing this piece about my grandfather, who was still living then, and publishing that. In retrospect it was a horribly written piece, and I’m quite embarrassed about it. But that was the first thing I ever published. I had been an MD/PhD and quit my PhD after a year and a half. I was sort of lost. So many people did research and I wasn’t sure what I wanted to do. I ended up deciding on neurology and intern year there was a lot of night shift. My husband was just starting a company at that point, and so I ended up writing some blog posts for his company. It was an immigration software company so it was writing about immigration, which I know nothing about! But it was interesting, it was writing about immigrants and I did a few profiles about immigrants. That was interesting just learning how to interview and how to write. That sort of was the beginning. My husband’s aunt is a young adult author and suggested that I write about my honeymoon. I submitted one thing to [the New York Time’s] Modern Love [series] that got rejected, and then I wrote the honeymoon piece and that got accepted. Then the dying pieces sort of evolved over time. Now I’ve sort of shifted. My goal is to write about neurology and medical things rather than personal narrative. Although some people do both, I’m trying to be a little bit more focused.
Joshua
There are many students (including myself) who are interested in writing and getting our work published. However, it can be a really intimidating and difficult process to break into a publication. What was your process of getting your articles published and selling the vision of the book
Dr. Manning Peskin
So [for] Modern Love there is just a submission channel. I think [that piece] was helpful because when I submitted other stuff I could say “Here’s my other piece.” Even though it’s totally unrelated it gives you a leg-up, because it is a known outlet. For the dying pieces, I emailed the person who edits [the] Well [section of the New York Times] and I didn’t get a response. And then I emailed her again and she put me in touch with another Well editor and that’s who I worked with on those pieces. Some of it is just total luck. Some of it is just submitting a lot of pieces. I’ve submitted a bunch of stuff to JAMA’s A Piece of my Mind and never gotten anything into it. So there’s a lot of rejection behind every acceptance. I think part of it is just submitting a lot. The other [thing] is just emailing editor’s directly. Most of them you can find their emails online, and emailing them with your 1-3 paragraph pitch and a few links to other stuff you’ve written. I don’t know if that’s the right advice, but that’s what I did.
Joshua
How do you think being a physician-writer has affected your clinical practice?
Dr. Manning Peskin
I think the biggest thing was not talking to patients in as much jargon. I had no idea how I was talking. I’m talking to them in a more narrative form about their disease and explaining things in a more narrative way. It has changed the way I talk to patients. And it is neat to diagnose people with something that I know the history of the disease. It’s just more interesting.
Joshua
Secondly, how have you found time to write while balancing your professional and personal responsibilities? What does your writing process look like? For comparison, Dr. Jason Han, a CT resident at Penn has a very streamlined writing process that he says allows him to produce a finished piece in 2 hours.
Dr. Manning Peskin
I’m 80% [clinical] time, and 20% of my time is writing. And that is not paid for by Penn. Friday’s I have isolated for writing, although half of it ends up being child care. So part of it is just having time carved away. It took me 6 years to write my book, and it’s not very long. And the NYT dying pieces I worked on for half a year. One thing that is nice is that there are so many types of technology to use. Most of the time I write stuff on the computer, but I’ll use Google Docs so I have it on my phone. Oftentimes I’ll be editing in bed, before I go to bed or when I wake up in the morning. Then your mind is really fresh and seeing it with different line breaks and backlight makes you think about it differently because it’s not exactly the same format. I have a Kindle that I got two years ago. I ended up editing the last round of the book on the Kindle, which was so helpful. I picked up so many things that I never would have realized. [In reference to Dr. Han], I’m probably the opposite end of the spectrum. I can’t think of anything of good quality that I’ve ever written in two hours.
Joshua
How integrated is writing into your academic professional career. Is it something institutions like Penn see as equivalent to teaching or research, or do you have to push writing to the side while also pursuing more traditional academic responsibilities?
Dr. Manning Peskin
I couldn’t get them to see it as equivalent. They have been very supportive. When you are a Neurology resident you have to do a project, and writing a book was my project. So they were very supportive of that. But in terms of actual faculty positions, nowhere that I spoke with was going to pay me and give me one day a week off for writing. It also gets into intellectual property stuff, because if they are paying you to write, then it becomes a little complicated about who owns it. So for me [working] the 80% time is helpful. There are all these programs that have medical humanities programs and then you can be faculty in those things but unless you do that I don’t know how to [integrate] it.
Joshua
How did you convince Penn to give you Friday’s off?
Dr. Manning Peskin
They aren’t paying me [for Fridays]! I had the book deal by then, so financially I can make some money as a writer. So it doesn’t feel like Fridays are a total financial loss, it’s just a different source of funding. Penn was interested in being flexible. This stuff is good for them; it’s free publicity for them. But it’s not the same currency as research grants. That being said, whenever I write stuff, they publicize it, so they benefit me for sure.
Joshua
Finally, what advice would you give to other physicians or medical students that want to make writing and patient narratives a part of their careers?
Dr. Manning Peskin
They need to just start writing and start submitting. Oftentimes there’s a block on submitting. You just submit and most of it will be rejected, and that’s normal. But eventually something get through. The other piece for me that’s been so helpful is having a writing group and having lots of readers. A Molecule Away from Madness was mostly a community effort. When I think about where it started and where it ended. Most lines in that book I can say “Oh this person suggested this and that person suggested this,” so it was really a community effort. And that’s how I’m learning to become a better writer. So at least for me those are the things that have been the most helpful – having a low threshold to submit and getting a lot of outside input.
Joshua Anil is an MS1 at the Perelman School of Medicine.
