Now and then physician and nursing colleagues, parents, and random e-mailers ask me how to get a book published on a medical topic for a non-medical audience. Since I’ve published two moderately successful books of that sort and have a third one coming out next spring, they think I’ve got some understanding of the process. I think I have some of that.

All of us who work in medicine have a storehouse of stories and experiences from what we’ve seen. Parents of children who have had a lot of medical issues have important first-hand knowledge, too, in how medicine and medical care works. Many believe, as I did when I got started doing this, that other people would be interested in and could be helped by whatever insights we’ve gleaned over the years. They want to write a book about it. If you’re one of those people, great, but here are a few things you should understand.

A good book brings value to the people who buy it — enjoyment, useful knowledge, and, the author hopes, a combination of the two. What a potential author should really, really understand, though, is that book publishing is first a business. Publishers need to make money to stay in business, and profit margins in this business are extremely thin. This means no matter how wonderful your insights or compelling your stories, you need to write a book that people will buy. The prospective author must convince hard-headed business people that the book will make money. Thus what the author is pitching is as much a business plan as anything else.

An author who wants to publish a novel must first write the entire novel before anyone will look at it. Nonfiction, such as a medical book, is different; it is sold on the basis of a proposal. The proposal describes what the book will be and the audience of readers who will buy it. It also contains the author’s credentials to write the book and, very importantly these days, the author’s plan of how to market the book. The proposal ends with one or two sample chapters, typically the first ones, to show the publisher you can write well.

Nearly all people who ask me about these things don’t know that none of the large publishers, and very few of the middle-sized ones, will even look at a proposal if you send it to them. They only consider proposals submitted by literary agents. Small publishing houses often allow authors to submit to them directly, but if, like most authors, you want to reach the largest audience, then you want one of the bigger presses because they have the distribution channels, particularly to book stores.

Finding an agent can be a long and often disheartening process. Agents work on commission. This means they do not charge authors anything. If someone who says she’s an agent wants you to pay them, they aren’t legitimate, and there are many, many shady folks out there claiming to be agents who are happy to take your money. The agent only gets paid if the book sells to a publisher, so for that reason agents are very, very picky about what they take on. Like publishers, agents are asking a simple question: will people buy this book? If they don’t think it will sell, they will reject your proposal, even if they think it is a wonderful book in many ways. Agents reject the large majority of proposals sent to them, often 95% or more of them. Part of being an author is learning not to take these rejections personally.

Before you even send an agent your proposal, though, many of them want you to send them a brief query letter describing the project. If they’re interested, they’ll ask for the full proposal. (Some agents say you can send them the proposal directly with a cover letter.) Expect to pitch your project to many agents before you land one — it took me about 40 queries to get my agent, and many authors I know of queried many more than that. I don’t know how many prospective authors give up before they get an agent, but I suspect it’s the great majority of them. Once you get the agent you’re not there yet; she has to sell it to a publisher, and many proposals don’t sell. When a publisher actually buys your proposal, then you can sit down and write the actual book. It’s not a good idea to write much more than the sample chapters until that happens, because the publisher often wants major changes.

There is a vast amount of information on the internet about this entire process, and some of it is even correct. There are also many books about how to get yourself published. One of the most useful books to me when I began was Thinking Like Your Editor: How to Write Great Serious Nonfiction — And Get It Published, by Susan Rabiner and Alfred Fortunato. The authors are agents and former publishing editors, and they know what they are talking about. It has great advice about how to write query letters and proposals, complete with examples. There are also books that catalog literary agents — who they are, what kind of books they represent, and guidelines for submitting to them. Jeff Herman’s guide is a good one. A great online site about agents is Agent Query.

There are also many, many online sites for writers’ groups where you can get advice, get someone to read your query letter and critique it, and commiserate with other published and aspiring authors. I’m a Super Moderator at one of the biggest of these, AbsoluteWrite (my screen name is ColoradoGuy), so naturally I think that is a good source.

There are also several highly-regarded blogs maintained by prominent literary agents. Several good ones are those by Kristin Nelson, Jessica Faust, Nathan Bransford, and Janet Reid. They are useful and even fun to read, but realize that most of the people who read (and comment on) them are fiction writers. But a nonfiction writer can still learn a huge amount about the publishing industry by giving them a look. Jessica Faust has a good summary of what to put in your proposal here.

It’s interesting and fun to write books of the sort I do. Even if you are successful in getting published, however, don’t expect to make much money doing it. Even so, it’s well worth the effort, I think, and you might even do some good in the process.

I’ve worked in several PICUs over the years. Some were as large as 36 beds (which counts as pretty large in the PICU world), and some were as small as 4 beds. Inevitably, larger PICUs can offer services that smaller ones cannot. This is particularly the case with more specialized services, like some kinds of surgery and access to super-specialists. When I’ve been in a smaller unit, there have been times when I’ve needed to transfer children to a larger one so they could get these more esoteric services. When I’ve been in a larger unit, I’ve received transfers of kids like that. Would these children who needed transfer have been better off going to the larger PICU in the first place?

The dilemma for smaller PICUs is that they can never become as experienced in caring for children with rare conditions, and it is hard for someone working in one of the smaller units to keep their skill levels up. Research has shown, not surprisingly, that physicians who do the same thing a lot are better at doing it than physicians who don’t do it so often. On the other hand, transferring a child from a local, smaller PICU to a bigger one is often hard on families, since often the larger unit is in another city — sometimes in another state. And many PICU problems can be handled just fine in a smaller place, nearer to home.

What to do? As pediatric intensivists, we are sort of feeling our way as we figure this out. Most smaller PICUs have formal or informal relationships with larger units to which they can send children they cannot handle. But these relationships are a patchwork across the nation — we simply don’t know the ideal size for a PICU. When PICUs began several decades ago they were rare, found only in large children’s hospitals. In those days people’s expectations were different about what smaller community hospitals needed to provide. In today’s world, we believe all children should have access to the same life-saving PICU care. So smaller hospitals began to open PICUs to provide that care as best they could. Someday PICU care may be truly regionalized, with formal relationships between big and small units in the region, complete with standardized criteria for appropriate care at one unit or the other. We don’t have anything like that yet.

What parents should realize is that there are differences between what a smaller and a larger PICU can do. If your child has a particularly unusual or difficult problem, it is never inappropriate to ask your child’s doctor if transfer to a larger unit makes sense.