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4-step process to write about EMS, health care policy

The “Madman, Architect, Carpenter, Judge” technique is a useful process to convey complex ideas to field personnel, agency leaders and community stakeholders

It’s said words and ideas can change the world, but I’d argue that’s only possible when those ideas are effectively conveyed. So while anyone can put pen to paper — or fingers to keyboard — not everyone can do so in a way that brings about any real or lasting change.

Given the dynamic nature of EMS, being able to adequately communicate ideas to field personnel, agency leaders and community stakeholders is an invaluable skill. And like other EMS skills, it takes time to develop.

Those who have the most trouble writing likely run into the same pitfalls of writer’s block, boredom and frustration that I’m all too familiar with. But given my profession as a health services researcher, writing is traditionally the best way for academics to disseminate and translate ideas, so I have no choice but to work through any negative emotions.

While the process may be painful at times, seeing the final product that perfectly illustrates ideas which previously only existed in my mind is strangely satisfying and what allows me to start new projects even when the finish line seems a bit out of reach.

I write differently depending on the audience and context, but here are some of the rules I apply regardless.

1. Read
The research is relatively unequivocal here, reading and writing are intertwined [1]. Good writers read a lot. And they don’t just read the same type of material they are publishing, but vary in their pursuits and interests. If I spent all day reading EMS1 news on community paramedicine or the most recent peer-reviewed health care publications, I would burn out.

So some days I kick back with a novel or my favorite nonfiction. On other days when there’s not as much time to sit down with a book, I will scan my Twitter feed for interesting news articles. I use social media to find multiple perspectives on current events, since it gives me access to a wide variety of authors and publication sources.

EMS is not an island, so understanding what is happening in the industries that are directly and indirectly connected to prehospital care can also help with your comprehension and analysis of how we fit into the bigger picture.

Occasionally I’ll break out of my millennial mold and browse to a handful of bookmarked sites (see a list of the websites I visit regularly). My favorite non-EMS websites are:

2. Take your time
Regardless of what I am writing, the process I use tends to follow a systematic trajectory. Developed in the late 1970s by Betty S. Flowers, “Madman, Architect, Carpenter, Judge” has become a reliable way of going from ideas to a finished product [2]. With this model, it is important to give what has been written time to ferment between each stage along with recognizing that various parts of any manuscript can be in different stages in the process at any given time.

The Madman
The Madman, wrote Flowers: “He’s full of ideas, writes crazily and perhaps rather sloppily, gets carried away by enthusiasm or anger, and if really let loose, could turn out ten pages an hour.”

Grammar and spelling don’t matter in this stage. It’s all about word vomit ― just get the words on the page. This is the stream of consciousness, let it all out, what-brilliant-rants-are-made-of phase. But don’t worry, because half of what you write in this phase will be changed or deleted before the final version.

The Architect
“Her job is simply to select large chunks of material and to arrange them in a pattern that might form an argument. The thinking here is large, organizational, paragraph-level thinking,” wrote Flowers.

If you had an outline before you started, it can come in handy during this stage. Here is where you cut and paste large chunks, making sure the generic idea behind each paragraph is contributing to the overall thesis. You don’t have to delete sections you’re unsure about, just move them to the end of the document. You never know what may come in handy later.

The Carpenter
“The carpenter nails these ideas together in a logical sequence, making sure each sentence is clearly written, contributes to the argument of the paragraph and leads logically and gracefully to the next sentence,” wrote Flowers.

Now that the individual paragraphs are aligned in a logical order, this stage is designed to apply those same rules at the sentence level. The carpenter isn’t necessarily looking for perfect grammar or spelling, but instead makes sure that each sentence flows within the individual paragraph and adds value to the final argument.

The Judge
Flowers described the role of the judge as, “Punctuation, spelling, grammar, tone — all the details which result in a polished essay become important only in this last stage.”

This stage is the hardest to ignore, especially for the Type-A perfectionists out there. Although intentionally placed at the end so as to not bog the writer down during the creative process; it takes time to learn to ignore the voice in your head telling you to immediately fix run-on sentences and misspelled words as soon as you notice them. Once you learn to ignore the Judge until the end, it’s weirdly liberating.

3. Ask for and provide feedback
A fresh set of eyes can be a terrible thing to waste. Ask for help and offer it in return. One of the best ways to improve your own writing is to help others develop theirs.

Not only can they help you with the more generic ideas and content flow, but more often than not they are the ones that will catch those small grammar mistakes that you’re too entrenched to notice.

4. Know your own style
What do you like to write about? I love writing about anything relating to EMS, which is a big category from the perspective of those reading this article, but on my end, it’s only a small part of what I read and research on a daily basis. If you love the topic, it’s easier for the words to start to flow.

Repetition matters
In EMS, it’s well known that skills like intubation, starting an IV or performing a physical examination take time and countless repetitions to develop. Writing is no different: it’s a skill that needs to be nurtured and practiced so that you don’t lose what you’ve learned.

1. A Relationship between Reading and Writing: The Conversational Model

2. Madman, Architect, Carpenter, Judge: Roles and the Writing Process by Betty S. Flowers

Catherine R. Counts, PHD, MHA, is a health services researcher with Seattle Medic One in the Division of Emergency Medicine at the University of Washington School of Medicine. She received both her PhD and MHA from Tulane University School of Public Health and Tropical Medicine.

Dr. Counts has research interests in domestic healthcare policy, quality, patient safety, organizational theory and culture, and pre-hospital emergency medicine. She is a member of the National Association of EMS Physicians and AcademyHealth. In her free time she trains Bruno, her USAR canine.

Connect with her on Twitter, Facebook, or her website, or reach out via email at