1. Relevant to stakeholders
2. Redefines rigor
3. Replicability
NIMH = National Institute of Mental Health; PBRN = practice-based research network; PHQ-9 = 9-item Patient Health Questionnaire; RE-AIM = Reach Effectiveness–Adoption Implementation Maintenance.
Health care transformation needs the full benefit of research to inform decision making and discover new options. The research community owes it to its “customers” and the public to evolve its standards and methods for health care research. The 5 R’s are offered as a next step in the developmental trajectory of an evolving field—a framework for a much needed discussion and adjustment of criteria for what is considered high-quality research.
As is the case for other models—for example, the Reach Effectiveness–Adoption Implementation Maintenance (RE-AIM) evaluation model, 52 , 53 the Chronic Care Model, 54 and the Institute of Medicine 6 quality aims 55— the effect of the 5 R’s model comes not from doing separate R’s or even 2 or 3 of them, but from doing them all in an integrated fashion whereby each reinforces the others. The 5 R’s are proposed to work together across stages of the research and dissemination process. Table 2 shows a research “preflight” checklist.
Questions to Apply the 5 R’s at Each Stage of the Research and Dissemination Process
Stage of Research | Bold Standard 5 R’s | ||||
---|---|---|---|---|---|
Relevant to Stakeholders | Rapid and Recursive | Redefines Rigor | Reports on Resources | Replicability | |
Design | End users of this research identified? Stakeholders who need to be involved identified? Plan in place to engage their perspectives? Plan in place to gather stakeholder questions and what is important to them? | Rapid cycle measurement and assessment built into the design? How? Approach in place to allow early discoveries to shape the study? | How is study systematic and pragmatic about concepts, measures, data collection procedures, and analysis plan? Multiple methods used? How? Internal and external validity balanced? How? | Intervention costs (monetary and other) measured? How? A standard vocabulary for reporting on resources in place? What? | Study designed to inform implementation and reinvention in different settings? How? Likely relevant settings for this research identified? |
Implementation | Stakeholders involved in ongoing refinement? How? Changes they suggested along the way recorded? Changes suggested implemented? Which ones? | Short-cycle learning taking place to refine design and measurement? Is learning influencing the study? How? | Systematic approach being followed to concepts, tools, data collection, measures, procedures, analyses? Checks for bias and superfluous connections in place? Clear description of what is being done recorded? | Cost data gathered on an ongoing basis? Using a consistent vocabulary for different kinds of costs? | Contextual factors documented that are important to understanding what happened (and why) in the study setting? |
Reporting | Diverse stakeholders involved in interpreting and reporting findings? Their different interpretations reported? | Emergent findings shared on an ongoing basis throughout the study? Have adaptations made been reported? | Study methods reported transparently and thoroughly? Reported how study checked for potential biases and superfluous connections? Reported how conclusions are justified by standards of evidence? | Study reports useful cost data using a defined vocabulary for different kinds of costs? Estimates made for costs under different conditions? | Contextual factors relevant to reinvention in new settings reported, including variation across settings or within settings? |
Dissemination | Target audiences, stakeholders, or likely users involved in next steps? Findings expressed in language and context that mean something to different stakeholders? | Guidelines provided for adaptation and customization/tailoring for future use? | Description included for how internal and external validity findings support wider use? | Intervention cost data discussed as a factor in dissemination? | Data-supported suggestions included about the contexts for which program or intervention is relevant or reproducible? |
There is little doubt that implementing the 5 R’s on a meaningful scale will require continued changes in thinking and infrastructure pointed out in literature on the separate R’s. Table 3 summarizes such changes.
Challenges and Changes for Routine Implementation of 5 R’s
Challenges | Changes to Address Challenges |
---|---|
Decision-maker needs outpace current speed of review cycles: grant review; funding decision; IRB approval and modification processes Study implementation time frames Publication cycles not amenable to “just in time” decisions; slow review and release of findings (see more below on dissemination) Low priority assigned to designs that can speed research | Harness stakeholder interest in timeliness to drive a cultural shift to shorten what is considered “rapid” or “timely” compared with present custom Implement a variety of technical changes to research processes already suggested in literature , , , , Use rapid-cycle testing of hypotheses, allowing ineffective ideas to “fail fast” and successful innovations to spread quickly Link social media with traditional communications vehicles |
Funding agencies offering calls for proposals Grant application reviewers Researchers “Customers” of research (stakeholders who use the findings) | Among all parties, build awareness of and comfort with a broader “palette” of research designs, so that research design is driven by the questions, rather than research questions driven by designs Use professional meetings/training events to more clearly articulate features, pros/cons of different designs—their appropriate or promising scope of application |
Skill and interest in stakeholder involvement in generating questions, articulating ultimate use of study findings, study design, implementation, reporting, and dissemination Awareness of and respect for political as well as scientific concerns of stakeholders such as policy makers Skill and comfort in building relationships with clinicians and clinics—consultative, cooperative, problem solving Experience and confidence with the broader “palette” of research designs, including rapid learning in real-world experiments | Propose an enhanced “job description” for research teams—a checklist of skills, interests, and relationships required for specific studies Beyond essential methodologic, data-gathering, and analytic skills, include “softer” skills and methods such as shown in left column Build up those skills through examples, conferences, and training among both existing and new researchers |
Negative experiences or preconceptions about feasibility or practical value of doing research in the practice Few or no current relationships with researchers Unfamiliarity of working with researchers to turn practice concerns and curiosity into researchable questions Unfamiliarity with building research data gathering into routine clinic systems rather than being an effortful “add on” Not connecting research with more familiar quality improvement, rapid-cycle learning | Provide examples and assistance through professional venues and practice facilitation or technical assistance that help clinicians and researchers adjust mindset, methods, and interactions to create practical research partnerships along the lines described in the literature , , |
Limited researcher and reviewer expectation that data on resource use of interventions or on context information relevant to transportability or reinvention in new settings be gathered systematically or reported Space limitations and/or customary priorities in journals that reduce additional context and resource data reporting | Adjust research announcements and grant review guidelines to ask for greater reporting on context and resources required; accompany by explanation of why For publication in limited space, consider other methods such as web supplements to access detailed context and resource use data if not in standard published article |
Limited readiness to publish replications of key findings in original or new contexts or to publish negative results of replication Reaching those stakeholders who want to make research-based decisions at the time and place decisions are made Limited dissemination in publications or forms in which stakeholders are already engaged, knowing that different forms of publication/dissemination reach different stakeholders | Publish replications (successful or not) in places where stakeholders will find them Reward researchers via funding and career paths for key replications, not only for new positive results Create a stakeholder map—which stakeholders need what information from the study, in what form, and where it is most likely to be read Create stakeholder-specific versions of core journal publications to increase reach of the information |
IRB = institutional review board; RCT = randomized controlled trial.
Although many of these changes are under way in different places in different ways, considerable challenges remain. We believe that emerging stakeholder interests align well with the 5 R’s and will drive such change. For example, the 2014 Academy Health report on improving the evidence base for Medicare policy making 56 interviewed leaders in health policy and care delivery for their most pressing health services research needs over the next 3 to 5 years; it was research that (1) aims at understanding the performance of new organizational forms such as accountable care organizations and Medicare Advantage plans; (2) uses comparable data sets for performance of physician practices and new organizational arrangements; (3) engages with the promises and pitfalls of electronic data, rapid cycle research, and comparative effectiveness research; (4) understands how the politics of evidence and policy affect research relevance and usefulness; and (5) builds relationships between researchers and policy makers, with study findings available at the time decisions were made—even if “best available” rather than “best” evidence. Although this study was focused on Medicare, we believe its lessons can be much more broadly taken.
In addition, we solicited feedback from a convenience sample of 8 stakeholders on the importance of research for practical decision making and on the 5 R’s. Participants were balanced across practitioners, other implementers, and administrators. Responses indicated that relevant was the most important R, with rapid a close second, followed by other R’s—none of which were considered unimportant. The most important role for research in practical decisions was testing viability of approaches in their own settings and available resources. Suggested reasons why research is often not useful were lack of relevance, rapidity, or good relationships with researchers. The 2 facets identified as making research more helpful were “faster turnaround” and building better relationships between researchers and clinicians; as one clinician put it, “Relationship is so important, you should put a 6th R in there!”
Admittedly aspirational, we do not expect every study to comprehensively address all 5 R’s. We do not expect, for example, all epidemiologic research or basic mechanism studies to address all of them. Studies having as their long-term goal achieving translation to real-world settings or making a population impact, however, would benefit from considering each R, reporting on those most relevant, and discussing implications for the others. Examining the implications of all 5 R’s should be useful in the vast majority of research studies, from efficacy to effectiveness to implementation and dissemination, not just for a few community translational “T4” studies, which are investigations of practice intervention effects on population health. This strategy would help align the pipeline of potential interventions with real-world pragmatic requirements.
Practitioners often experience research as interfering with practical procedures or believe that researchers just want study participants to address their own questions and further their careers. On the other hand, researchers often experience clinicians as not interested in research, resistant to research protocols, or not being ready to implement evidence-based findings. This is not a perceived relationship between researchers and practitioners or other stakeholders that will carry us into a successful future. The 5 R’s proposed embody the terms of a new and more transparent win-win partnership between researchers and stakeholders with important questions that research can help answer.
This new standard (and its implicit partnership between stakeholders and researchers) is especially important for students and those early in their careers, whether clinicians, researchers, policy makers, or others wishing to develop or use research evidence. The 5 R’s are offered as teaching tools as well as research tools—helping all stakeholders wear constructive “hats” with each other when addressing important questions. Over time, this approach may lead to an improved relationship between the research and health care enterprises—on behalf of the public they both serve.
Conflicts of interest: authors report none.
Funding support: This project has been funded in whole or in part with federal funds from the National Cancer Institute, National Institutes of Health, under contract No. HHSN261200800001E. Dr Stange’s time is supported in part by a Clinical Research Professorship from the American Cancer Society.
Disclaimer: The content of this article does not necessarily reflect the views or policies of the National Cancer Institute or the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US government.
What's the Story #06
“The Essayist at Work” is our first special issue. The cover is different, and although it is our habit to center each issue around a general theme, the essays and profiles in “The Essayist at Work” are narrower in scope. In the future, we intend to publish special issues on a variety of topics, but this one is especially important, not only because it is our first, but also because it helps to launch the first Mid-Atlantic Creative Nonfiction Summer Writers’ Conference with the Goucher College Center for Graduate and Continuing Studies in Baltimore, Md., a supportive and enthusiastic summer partner. Many writers featured in “The Essayist at Work” will also be participating at the conference – an event we hope to continue to co-sponsor with Goucher for years to come.
The writers in this issue represent the incredible range of the newly emerging genre of creative nonfiction, from the struggle and success stories of Darcy Frey (“The Last Shot”) and William Least Heat-Moon (“Blue Highways”) to the master of the profession, John McPhee. From the roots of traditional journalism to poetry and fiction, Pulitzer Prize-winner Alice Steinbach, poet Diane Ackerman and novelists Phillip Lopate and Paul West, have helped expand the boundaries of form and tradition. Jane Bernstein, Steven Harvey, Mary Paumier Jones, Wendy Lesser and Natalia Rachel Singer ponder the spirit of the essay (and e-mail!), while I continue to reflect on and define the creative nonfiction form.
From the beginning, it has been our mission to probe the depths and intricacies of nonfiction by publishing the best prose by new and established writers. Creative Nonfiction provides a forum for writers, editors and readers interested in pushing the envelope of creativity and discussing and defining the parameters of accuracy, validity and truth. My essay below, “The 5 Rs of Creative Nonfiction,” is dedicated to that mission. It will appear in “More than the Truth: Teaching Nonfiction Writing Through Journalism,” which will be published in the fall of 1996 by Heineman.
It is 3 a.m., and I am standing on a stool in the operating room at the University of Pittsburgh Medical Center, in scrubs, mask, cap and paper booties, peering over the hunched shoulders of four surgeons and a scrub nurse as a dying woman’s heart and lungs are being removed from her chest. This is a scene I have observed frequently since starting my work on a book about the world of organ transplantation, but it never fails to amaze and startle me: to look down into a gaping hole in a human being’s chest, which has been cracked open and emptied of all of its contents, watching the monitor and listening to the rhythmic sighing sounds of the ventilator, knowing that this woman is on the fragile cusp of life and death and that I am observing what might well be the final moments of her life.
Now the telephone rings; a nurse answers, listens for a moment and then hangs up. “On the roof,” she announces, meaning that the helicopter has set down on the hospital helipad and that a healthy set of organs, a heart and two lungs, en bloc, will soon be available to implant into this woman, whose immediate fate will be decided within the next few hours.
With a brisk nod, the lead surgeon, Bartley Griffith, a young man who pioneered heart-lung transplantation and who at this point has lost more patients with the procedure than he had saved, looks up, glances around and finally rests his eyes on me: “Lee,” he says, “would you do me a great favor?”
I was surprised. Over the past three years I had observed Bart Griffith in the operating room a number of times, and although a great deal of conversation takes place between doctors and nurses during the long and intense surgical ordeal, he had only infrequently addressed me in such a direct and spontaneous manner.
Our personal distance is a by-product of my own technique as an immersion journalist – my “fly-on-the wall” or “living room sofa” concept of “immersion”: Writers should be regular and silent observers, so much so that they are virtually unnoticed. Like walking through your living room dozens of times, but only paying attention to the sofa when suddenly you realize that it is missing. Researching a book about transplantation, “Many Sleepless Nights” (W.W. Norton), I had been accorded great access to the O.R., the transplant wards, ethics debates and the most intimate conversations between patients, family members and medical staff. I had jetted through the night on organ donor runs. I had witnessed great drama – at a personal distance.
But on that important early morning, Bartley Griffith took note of my presence and requested that I perform a service for him. He explained that this was going to be a crucial time in the heart-lung procedure, which had been going on for about five hours, but that he felt obligated to make contact with this woman’s husband who had traveled here from Kansas City, Mo. “I can’t take the time to talk to the man myself, but I am wondering if you would brief him as to what has happened so far. Tell him that the organs have arrived, but that even if all goes well, the procedure will take at least another five hours and maybe longer.” Griffith didn’t need to mention that the most challenging aspect of the surgery – the implantation – was upcoming; the danger to the woman was at a heightened state.
A few minutes later, on my way to the ICU waiting area where I would find Dave Fulk, the woman’s husband, I stopped in the surgeon’s lounge for a quick cup of coffee and a moment to think about how I might approach this man, undoubtedly nervous – perhaps even hysterical – waiting for news of his wife. I also felt kind of relieved, truthfully, to be out of the O.R,, where the atmosphere is so intense.
Although I had been totally caught-up in the drama of organ transplantation during my research, I had recently been losing my passion and curiosity; I was slipping into a life and death overload in which all of the sad stories from people all across the world seemed to be congealing into the same muddled dream. From experience, I recognized this feeling – a clear signal that it was time to abandon the research phase of this book and sit down and start to write. Yet, as a writer, I was confronting a serious and frightening problem: Overwhelmed with facts and statistics, tragic and triumphant stories, I felt confused. I knew, basically, what I wanted to say about what I learned, but I didn’t know how to structure my message or where to begin.
And so, instead of walking away from this research experience and sitting down and starting to write my book, I continued to return to the scene of my transplant adventures waiting for lightning to strike . . . inspiration for when the very special way to start my book would make itself known. In retrospect, I believe that Bart Griffith’s rare request triggered that magic moment of clarity I had long been awaiting.
Before I tell you what happened, however, let me explain what kind of work I do as an immersion journalist/creative nonfiction writer, and explain what I am doing, from a writer’s point-of-view, in this essay.
But first some definitions: “Immersion journalists” immerse or involve themselves in the lives of the people about whom they are writing in ways that will provide readers with a rare and special intimacy.
The other phrase to define, a much broader term, creative nonfiction, is a concept that offers great flexibility and freedom, while adhering to the basic tenets of nonfiction writing and/or reporting. In creative nonfiction, writers can be poetic and journalistic simultaneously. Creative nonfiction writers are encouraged to utilize fictional (literary) techniques in their prose – from scene to dialogue to description to point-of-view – and be cinematic at the same time. Creative nonfiction writers write about themselves and/or capture real people and real life in ways that can and have changed the world. What is most important and enjoyable about creative nonfiction is that it not only allows, but encourages the writer to become a part of the story or essay being written. The personal involvement creates a special magic that alleviates the suffering and anxiety of the writing experience; it provides many outlets for satisfaction and self-discovery, flexibility and freedom.
When I refer to creative nonfiction, I include memoir (autobiography), and documentary drama, a term more often used in relation to film, as in “Hoop Dreams,” which captures the lives of two inner-city high school basketball players over a six-year period. Much of what is generically referred to as “literary journalism” or in the past, “new journalism,” can be classified as creative nonfiction. Although it is the current vogue in the world of writing today, the combination of creative nonfiction as a form of writing and immersion as a method of research has a long history. George Orwell’s famous essay, “Shooting an Elephant” combines personal experience and high quality literary writing techniques. The Daniel DeFoe classic, “Robinson Crusoe,” is based upon a true story of a physician who was marooned on a desert island. Ernest Hemingway’s paean to bullfighting, “Death in the Afternoon,” comes under the creative nonfiction umbrella, as does Tom Wolfe’s, “The Right Stuff,” which was made into an award-winning film. Other well-known creative nonfiction writers, who may utilize immersion techniques include John McPhee (“Coming Into the Country”), Tracy Kidder (“House”), Diane Ackerman (“A Natural History of the Senses”) and Pulitzer Prize winner Annie Dillard (“Pilgrim at Tinker Creek”), to name only a few of the many authors who have contributed to this burgeoning genre.
Currently, many of our best magazines – The New Yorker, Harper’s, Vanity Fair, Esquire – publish more creative nonfiction than fiction and poetry combined. Universities offer Master of Fine Arts degrees in creative nonfiction. Newspapers are publishing an increasing amount of creative nonfiction, not only as features, but in the news and op-ed pages, as well.
Reading, ‘Riting, ‘Rithmitic – the 3Rs – was the way in which basic public school education was once described. The “5 Rs” is an easy way to remember the basic tenets of creative nonfiction/immersion journalism.
The first “R” has already been explained and discussed: the “immersion” or “real life” aspect of the writing experience. As a writing teacher, I design assignments that have a real-life aspect: I force my students out into their communities for an hour, a day, or even a week so that they see and understand that the foundation of good writing emerges from personal experience. Some writers (and students) may utilize their own personal experience rather than immersing themselves in the experiences of others. In a recent introductory class I taught, one young man working his way through school as a sales person wrote about selling shoes, while another student, who served as a volunteer in a hospice, captured a dramatic moment of death, grief and family relief. I’ve sent my students to police stations, bagel shops, golf courses; together, my classes have gone on excursions and participated in public service projects – all in an attempt to experience or re-create from personal experience real life.
In contrast to the term “reportage,” the word “essay” usually connotes a more personal message from writer to reader. “An essay is when I write what I think about something,” students will often say to me. Which is true, to a certain extent – and also the source of the meaning of the second “R” for “reflection.” A writer’s feelings and responses about a subject are permitted and encouraged, as long as what they think is written to embrace the reader in a variety of ways. As editor of Creative Nonfiction, I receive approximately 150 unsolicited essays, book excerpts and profiles a month for possible publication. Of the many reasons the vast majority of these submissions are rejected, two are most prevalent, the first being an overwhelming egocentrism; in other words, writers write too much about themselves without seeking a universal focus or umbrella so that readers are properly and firmly engaged. Essays that are so personal that they omit the reader are essays that will never see the light of print. The overall objective of the personal essayist is to make the reader tune in – not out.
The second reason Creative Nonfiction and most other journals and magazines reject essays is a lack of attention to the mission of the genre, which is to gather and present information, to teach readers about a person, place, idea or situation combining the creativity of the artistic experience with the essential third “R” in the formula: “Research.”
Even the most personal essay is usually full of substantive detail about a subject that affects or concerns a writer and the people about whom he or she is writing. Read the books and essays of the most renowned nonfiction writers in this century and you will read about a writer engaged in a quest for information and discovery. From George Orwell to Ernest Hemingway to John McPhee, books and essays written by these writers are invariably about a subject other than themselves, although the narrator will be intimately included in the story. Personal experience and spontaneous intellectual discourse – an airing and exploration of ideas – are equally vital. In her first book, “Pilgrim at Tinker Creek,” which won the Pulitzer Prize, and in her other books and essays, Annie Dillard repeatedly overwhelms her readers with factual information, minutely detailed descriptions of insects, botany and biology, history, anthropology, blended with her own feelings about life.
One of my favorite Dillard essays, “Schedules,” focuses upon the importance of writers working on a regular schedule rather than writing only intermittently. In “Schedules,” she discusses, among many other subjects, Hasidism, chess, baseball, warblers, pine trees, june bugs, writers’ studios and potted plants – not to mention her own schedule and writing habits and that of Wallace Stevens and Jack London.
What I am saying is that the genre of creative nonfiction, although anchored in factual information, is open to anyone with a curious mind and a sense of self. The research phase actually launches and anchors the creative effort. Whether it is a book or essay I am planning, I always begin my quest in the library – for three reasons. First, I need to familiarize myself with the subject. If it is something about which I do not know, I want to make myself knowledgeable enough to ask intelligent questions. If I can’t display at least a minimal understanding of the subject about which I am writing, I will lose the confidence and the support of the people who must provide access to the experience.
Secondly, I will want to assess my competition. What other essays, books and articles have been written about this subject? Who are the experts, the pioneers, the most controversial figures? I want to find a new angle – not write a story similar to one that has already been written. And finally, how can I reflect and evaluate a person, subject or place unless I know all of the contrasting points-of-view? Reflection may permit a certain amount of speculation, but only when based upon a solid foundation of knowledge.
So far in this essay I have named a number of well-respected creative nonfiction writers and discussed their work, which means I have satisfied the fourth “R” in our “5R” formula: “Reading.” Not only must writers read the research material unearthed in the library, but they also must read the work of the masters of their profession. I have heard some very fine writers claim that they don’t read too much anymore – or that they don’t read for long periods, especially during the time they are laboring on a lengthy writing project. But almost all writers have read the best writers in their field and are able to converse in great detail about the stylistic approach and intellectual content. An artist who has never studied Picasso, Van Gogh, Michelangelo, even Warhol, is an artist who will quite possibly never succeed.
So far we have mostly discussed the nonfiction or journalistic aspects of the immersion journalism/creative nonfiction genre. The 5th “R” the “riting” part is the most artistic and romantic aspect of the total experience. After all of the preparatory (nonfiction) work is complete, writers will often “create” in two phases. Usually, there is an inspirational explosion, a time when writers allow instinct and feeling to guide their fingers as they create paragraphs, pages, and even entire chapters of books or complete essays. This is what art of any form is all about – the passion of the moment and the magic of the muse. I am not saying that this always happens; it doesn’t. Writing is a difficult labor, in which a regular schedule, a daily grind of struggle, is inevitable. But this first part of the experience for most writers is rather loose and spontaneous and therefore more “creative” and fun. The second part of the writing experience – the “craft” part, which comes into play after your basic essay is written – is equally important – and a hundred times more difficult.
Vignettes, episodes, slices of reality are the building blocks of creative nonfiction – the primary distinguishing factor between traditional reportage/journalism and “literary” and/or creative nonfiction and between good, evocative writing and ordinary prose. The uninspired writer will tell the reader about a subject, place or personality, but the creative nonfiction writer will show that subject, place or personality in action. Before we discuss the actual content or construction of a scene, let me suggest that you perform what I like to call the “yellow test.”
Take a yellow “Hi-Liter” or Magic Marker and leaf through your favorite magazines – Vanity Fair, Esquire, The New Yorker or Creative Nonfiction. Or return to favorite chapters in previously mentioned books by Dillard, Ackerman, etc. Yellow-in the scenes, just the scenes, large and small. Then return to the beginning and review your handiwork. Chances are, anywhere from 50 to 80 percent of each essay, short story, novel selected will be yellow. Plays are obviously constructed with scenes, as are films. Most poems are very scenic.
Jeanne Marie Laskas, the talented columnist for the Washington Post Magazine, once told me: “I only have one rule from start to finish. I write in scenes. It doesn’t matter to me in which order the scenes are written; I write whichever scene inspires me at any given time, and I worry about the plot or frame or narrative later. The scene – a scene – any scene – is always first.”
First and foremost, a scene contains action. Something happens. I jump on my motorcycle and go helter-skelter around the country; suddenly, in the middle of July in Yellowstone National Park I am confronted with 20 inches of snow. Action needn’t be wild, sexy and death-defying, however. There’s also action in the classroom. A student asks a question, which requires an answer, which necessitates a dialogue, which is a marvelously effective tool to trigger or record action. Dialogue represents people saying things to one another, expressing themselves. It is a valuable scenic building block. Discovering dialogue is one of the reasons to immerse ourselves at a police station, bagel shop or at a zoo. To discover what people have to say spontaneously – and not in response to a reporter’s prepared questions.
Another vehicle or technique of the creative nonfiction experience may be described as “intimate and specific detail.” Through use of intimate detail, we can hear and see how the people about whom we are writing say what is on their minds; we may note the inflections in their voices, their elaborate hand movements and any other eccentricities. “Intimate” is a key distinction in the use of detail when crafting good scenes. Intimate means recording and noting detail that the reader might not know or even imagine without your particular inside insight. Sometimes intimate detail can be so specific and special that it becomes unforgettable in the reader’s mind. A very famous “intimate” detail appears in a classic creative nonfiction profile, “Frank Sinatra Has a Cold,” written by Gay Talese in 1962 and published in Esquire Magazine.
In this profile, Talese leads readers on a whirlwind cross country tour, revealing Sinatra and his entourage interacting with one another and with the rest of the world and demonstrating how the Sinatra world and the world inhabited by everyone else will often collide. These scenes are action-oriented; they contain dialogue and evocative description with great specificity and intimacy such as the gray-haired lady spotted in the shadows of the Sinatra entourage – the guardian of Sinatra’s collection of toupees. This tiny detail – Sinatra’s wig lady – loomed so large in my mind when I first read the essay that even now, 35 years later, anytime I see Sinatra on TV or spot his photo in a magazine, I find myself unconsciously searching the background for the gray-haired lady with the hatbox.
The frame represents a way of ordering or controlling a writer’s narrative so that the elements of his book, article or essay are presented in an interesting and orderly fashion with an interlaced integrity from beginning to end.
Some frames are very complicated, as in the movie, “Pulp Fiction”; Quentin Tarantino skillfully tangles and manipulates time. But the most basic frame is a simple beginning-to-end chronology. “Hoop Dreams,” for example, the dramatic documentary (which is also classic creative nonfiction) begins with two African-American teen-age basketball stars living in a ghetto and sharing a dream of stardom in the NBA and dramatically tracks both of their careers over the next six years.
As demonstrated in “Pulp Fiction,” writers don’t always frame in a strictly chronological sequence. My book, “One Children’s Place,” begins in the operating room at a children’s hospital. It introduces a surgeon, whose name is Marc Rowe, his severely handicapped patient, Danielle, and her mother, Debbie, who has dedicated her every waking moment to Danielle. Two years of her life have been spent inside the walls of this building with parents and children from all across the world whose lives are too endangered to leave the confines of the hospital. As Danielle’s surgery goes forward, the reader tours the hospital in a very intimate way, observing in the emergency room, participating in helicopter rescue missions as part of the emergency trauma team, attending ethics meetings, well-baby clinics, child abuse examinations – every conceivable activity at a typical high-acuity children’s hospital so that readers will learn from the inside out how such an institution and the people it services and supports function on an hour-by-hour basis. We even learn about Marc Rowe’s guilty conscience about how he has slighted his own wife and children over the years so that he can care for other families.
The book ends when Danielle is released from the hospital. It took two years to research and write this book, returning day and night to the hospital in order to understand the hospital and the people who made it special, but the story in which it is framed begins and ends in a few months.
Now let’s think about this essay as a piece of creative nonfiction writing, especially in relation to the concept of framing. It begins with a scene. We are in an operating room at the University of Pittsburgh, the world’s largest organ transplant center, in the middle of a rare and delicate surgery that will decide a dying woman’s fate. Her heart and both lungs have been emptied out of her chest and she is maintained on a heart-bypass system. The telephone alerts the surgical team that a fresh and potentially lifesaving set of organs has arrived at the hospital via helicopter. Suddenly the lead surgeon looks up and asks an observer (me) to make contact with the woman’s husband. I agree, leave the operating room and then stop for a coffee in the surgeon’s lounge.
Then, instead of moving the story forward, fulfilling my promise to Dr. Griffith and resolving my own writing dilemma, I change directions, move backwards (flashback) in time and sequence and begin to discuss this genre – immersion journalism/creative nonfiction. I provide a mountain of information – definitions, descriptions, examples, explanations. Basically, I am attempting to satisfy the nonfiction part of my responsibility to my readers and my editors while hoping that the suspense created in the first few pages will provide an added inducement for readers to remain focused and interested in this Introduction from the beginning to the end where, (the reader assumes) the two stories introduced in the first few pages will be completed.
In fact, my meeting with Dave Fulk in the ICU waiting room that dark morning was exactly the experience I had been waiting for, leading to that precious and magic moment of clarity for which I was searching and hoping. When I arrived, Mr. Fulk was talking with an elderly man and woman from Sacramento, Calif., who happened to be the parents of a 21-year-old U.S. Army private named Rebecca Treat who, I soon discovered, was the recipient of the liver from the same donor who gave Dave’s wife (Winkle Fulk) a heart and lungs. Rebecca Treat, “life-flighted” to Pittsburgh from California, had been in a coma for 10 days by the time she arrived in Pittsburgh; the transplanted liver was her only hope of ever emerging from that coma and seeing the light of day.
Over the next half-hour of conversation, I learned that Winkle Fulk had been slowly dying for four years, had been bedbound for three of those years, as Dave and their children watched her life dwindle away, as fluid filled her lungs and began to destroy her heart. Rebecca’s fate had been much more sudden; having contracted hepatitis in the army, she crashed almost immediately. To make matters worse, Rebecca and her new husband had separated. As I sat in the darkened waiting area with Dave Fulk and Rebecca’s parents, I suddenly realized what it was I was looking for, what my frame or narrative element could be. I wanted to tell about the organ transplant experience – and what organ transplantation can mean from a universal perspective – medically, scientifically, personally for patients, families and surgeons. Rebecca’s parents and the Fulk family, once strangers, would now be permanently and intimately connected by still another stranger – the donor – the person whose tragic death provided hope and perhaps salvation to two dying people. In fact, my last quest in the research phase of the transplant book experience was to discover the identity of this mysterious donor and literally connect the principal characters. In so doing, the frame or narrative drive of the story emerged.
“Many Sleepless Nights” begins when 15-year-old Richie Becker, a healthy and handsome teen-ager from Charlotte, N.C., discovers that his father is going to sell the sports car that he had hoped would one day be his. In a spontaneous and thoughtless gesture of defiance, Richie, who had never been behind the wheel, secretly takes his father’s sports car on a joy ride. Three blocks from his home, he wraps the car around a tree and is subsequently declared brain dead at the local hospital. Devastated by the experience, but hoping for some positive outcome to such a senseless tragedy, Richie’s father, Dick, donates his son’s organs for transplantation.
Then the story flashes back a half century, detailing surgeons’ first attempts at transplantation and all of the experimentation and controversy leading up to the development and acceptance of transplant techniques. I introduce Winkle Fulk and Pvt. Rebecca Treat. Richie Becker’s liver is transplanted into Rebecca, while his heart and lungs are sewn into Mrs. Fulk by Dr. Bartley Griffith. The last scene of the book 370 pages later is dramatic and telling and finishes the frame three years later when Winkle Fulk travels to Charlotte, N.C., a reunion I arranged to allow the folks to personally thank Richie’s father for his son’s gift of life.
At the end of the evening, just as we were about to say goodbye and return to the motel, Dick Becker stood up in the center of the living room of his house, paused, and then walked slowly and hesitantly over toward Winkle Fulk, who had once stood alone at the precipice of death. He eased himself down on his knees, took Winkle Fulk by the shoulder and simultaneously drew her closer, as he leaned forward and placed his ear gently but firmly between her breasts and then at her back.
Everyone in that room was suddenly and silently breathless, watching as Dick Becker listened for the last time to the absolutely astounding miracle of organ transplantation: the heart and the lungs of his dead son Richie, beating faithfully and unceasingly inside this stranger’s warm and loving chest.
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Last updated at April 16, 2024 by Teachoo
In order to Save Environment from harmful effects of plastic,we should use 5R Principal
This means that we should use less.
For Example
Reusing means using the same thing again and again.
This means we should collect items like plastic, paper, glass, metal and use these materials to make new products, instead of using new plastic, or new metals.
It means converting waste into resources
Example - Waste plastic bottles can be used to make boat
We can use cups without handles to grow plants
We can refuse to use products which are harmful to the environment
Example - We should say no to single use plastic bags
CA Maninder Singh is a Chartered Accountant for the past 14 years and a teacher from the past 18 years. He teaches Science, Economics, Accounting and English at Teachoo
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Last Updated: Aug 28, 2024
By Mike Sims, BARBRI President
You’ve figured it out already. Most, if not all, of your first-year grades will depend on your performance on your final exams. And, if not all, of your finals will consist of essay questions….but law school essay questions are different than what you’ve previously experienced.
It’s not about how much law you’ve memorized. Instead, your job is to solve the problem presented in your essay question. You are being tested on your ability to apply the facts to the rules of law you have learned and explain how you arrived at a reasonable solution and solve the problem.
So what should you start doing NOW to learn the material and position yourself well for final exams?
Always try to get the reading done even if it feels like you don’t understand everything (or anything!).
The most important thing is that you learn what the professor thinks the case said – not what you think the case said.
These are all previews for what will likely be on the final exam.
Try a daily review – quickly take 5-10 minutes at the end of each day to jot notes about what the professor said was important in class that day while it’s still fresh.
A periodic review at the end of every major topic in each course is a must.
Don’t worry too much about the specific number of practice questions you do, but make sure you do some.
Be consistent with these practices and they’ll pay off big time as you approach final exam time. Click here for more law school final exam tips.
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COMMENTS
The 5 Rs are Refuse, Reduce, Reuse, Repair, and Recycle. Though the list can often continue with even more Rs, like Resist, Rot, Repaint, Repurpose, Reclaim, and Refurbish. Photo credit: Good Good Good. We've created a breakdown of these, along with simple tips to help you get started: .
The 5 R's: Refuse, Reduce, Reuse, Repurpose, Recycle
The 5 R's of Zero-Waste Living. The journey towards zero-waste living can be broken down into five actionable steps, known as the 5 R's: Refuse, Reduce, Reuse, Repurpose, and Recycle. These steps are designed to be followed in order, prioritizing the prevention of waste creation before considering disposal. Let's dive into each of these R ...
The 5R framework for reflection was developed by Bain et al. in 2002 and guides students and teachers in reflecting on their experiences. The 5R framework represents Reporting, Responding, Relating, Reasoning, and Reconstructing the experience to present it in an engaging reflection. Brian works to achieve two important purposes through this model.
The Importance of the 5Rs of Waste Management
The 5 R's: Refuse, Reduce, Reuse, Repurpose, Recycle
The Five Rs are guiding principles for reducing the waste we produce, and they follow a specific order. Here's the hierarchy in order of importance, and more information on each of the Rs: Refuse: This is the first and leading principle that tells us to refuse anything we don't really need. Even if it's free, if you don't really need it ...
In today's world, where the consequences of unchecked consumption and waste generation are becoming increasingly apparent, adopting sustainable practices is of paramount importance. The 5 Rs of sustainability—Refusing, Reducing, Reusing, Recycling, and Repurposing—provide a practical framework for individuals, businesses, and communities ...
Published Friday Sep 22, 2023. Let's revisit a topic that you're probably familiar with: reduce, reuse, and recycle. Now let's add rethink and refuse to that list, and there you have the basics of sustainability. The five R's: reduce, reuse, recycle, rethink, and refuse are a great way to implement small changes into your daily life and ...
The Five Rs are a hierarchy of actions. They stand for Refuse, Reduce, Reuse, Repurpose and Recycle, in that order. In other words, recycling is the last option. For every purchase decision you make, you can follow the hierarchy of the 5 R's to minimize your carbon footprint and therefore the impact of your purchases on the environment.
You have probably heard of the 5Rs of sustainability at some point. But do you really know what they refer to and how important their application is for our planet? Today, we want to talk to you about the basic ecological rules of reuse, reduce, repair, recycle, reject and recover . So that you can put them into practice and thus contribute to ...
Five actions should respectively be taken if possible before recycling any products. These R's include: refuse, reduce, reuse, repurpose and finally, recycle. This is an important methodology for businesses to follow to ensure they can reduce waste and boost their recycling efforts. This ultimately lessens the amount of waste that will end up ...
Conclusion. The 5Rs of waste management - refuse, reduce, reuse, repurpose, and recycle - hold significant importance in driving environmental sustainability and creating a more sustainable future. By implementing these principles, businesses can make a positive impact on waste reduction and contribute to a cleaner and healthier planet.
The 5 R's: "Refuse what you do not need; reduce what you do need; reuse what you consume; recycle what you cannot refuse, reduce and reuse; or transform the rest." - Bea Johnson. Bea Johnson is the author of Zero Waste Home, a book launched in 2013 telling the story of Johnson and her family and how they switched from a hyper-consumerism lifestyle to a minimalist and sustainable one.
The Five Rs are guiding principles for reducing the waste we output, and they follow a specific order. Here's the hierarchy and more information on each of the Rs: Refuse: This is the first and leading principle that tells us to refuse anything we don't really need. Even if it's free, if you don't really need it, say no to knick-knacks ...
The new, simple, yet effective waste management mantra is the 5R principle: "refuse, reduce, reuse, repurpose, andrecycle". These powerful concepts are essential for reducing waste and encouraging a more sustainable way of life. So, let's take a look at each of the 5R of waste management. Prepare to start on a waste-reduction journey that ...
Environment. 5 Rs to make your life more sustainable. There are small actions that can reduce your ecological footprint. After the 3 Rs - Reduce, Reuse and Recycle - there are two other behaviors - Refuse and Rethink - that help to cut unnecessary expenses. Learn how to apply the 5 Rs in your everyday life.
The 5 Rs: Refuse, Reduce, Reuse, Repurpose, Recycle. UK Recycle Week - 16th-22nd October 2023: Small steps we can take at home this week and beyond. Reduce Sustainability Recycle Editor's Pick Reuse. When it comes to recycling, many of us are already doing our best to be more conscientious when it comes to our purchasing and disposal decisions.
These 5 R's are only the initials of some words that determine actions to mitigate our impacts: It is transforming materials already used in raw materials for others or the same product. We can make the separation of our waste for recycling encouraging this action. The beer or soda can is a classic example. It is a way to avoid going to waste ...
An emerging standard for research, the "5 R's" is a synthesis of recommendations for care delivery research that (1) is relevant to stakeholders; (2) is rapid and recursive in application; (3) redefines rigor; (4) reports on resources required; and (5) is replicable. Relevance flows from substantive ongoing participation by stakeholders.
The 5 Rs. Reading, 'Riting, 'Rithmitic - the 3Rs - was the way in which basic public school education was once described. The "5 Rs" is an easy way to remember the basic tenets of creative nonfiction/immersion journalism. The first "R" has already been explained and discussed: the "immersion" or "real life" aspect of the ...
R ecycle R epurpose (or Recover) R efuse Reduce This means that we should use less. For Example Save Electricity by switching off un-necessary lights and fans Save water by repairing leaky taps Do not waste food Reuse Reusing means using the same thing again and again. So, Instead of throwing papers, we can reverse it and use it again ...
What is the 4R principle? Q. The three R's which can help us to conserve natural resources for long term use are : (a) recycle, regenerate, reuse. (b) reduce, regenerate, reuse. (c) reduce, reuse, redistribute. (d) reduce, recycle, reuse. Q. Question 7. The three R's that will help us to conserve natural resources for long term use are.
Bill and his guests continue their conversation after the show.
Try a daily review - quickly take 5-10 minutes at the end of each day to jot notes about what the professor said was important in class that day while it's still fresh. A periodic review at the end of every major topic in each course is a must. The end of every roman numeral in the syllabus is an excellent way to gauge the end of a topic.