One of the most memorable scenes in Goodfellas occurs early on, when the audience is introduced to most of the crew at the Bamboo Lounge. Henry Hill (Ray Liotta) and Tommy DeVito (Joe Pesci) get into a tense exchange. Tommy seems to get offended after Henry calls him funny. “I’m funny how, Tommy wants to know?” “I mean, funny like a clown? I amuse you? I make you laugh?”

Unknown to the other actors, the scene was being improvised, although it was based on a true incident: A young Pesci was a waiter at a restaurant and told a mobster that he was funny. Needless to say, the wise guy didn’t take this compliment too well. Director Martin Scorsese wanted the dialog between Pesci and Liotta to be improvised because he wanted to capture the unrehearsed reactions of the actors.

Clearly, that is one way to make a story impactful: through improvisation and authentic dialog, i.e., dialogue used to reveal character traits and advance the story. The fun in writing, many people say, is surprising yourself as you write. You begin with an idea, and simply start typing, not knowing exactly where you are going. You pause to reflect or daydream, and suddenly a memory or old lesson pops into your head. This moment of surprising yourself with your own thoughts can translate into words on a blank canvas, and it is at the heart of good writing and even songwriting.

Paul Simon said he trusted his spontaneity when he wrote “You Can Call Me Al.” Simon remarked: “I’m more interested in what I discover than what I invent.” Elaborating on the distinction between discovery and invention, Simon continued, “You just have no idea that that’s a thought that you had; it surprises you; it can make me laugh or make me emotional. When it happens and I’m the audience and I react, I have faith in that because I’m already reacting. I don’t have to question it. I’ve already been the audience. But if I make it up, knowing where it’s going, it’s not as much fun. It may be just as good, but it’s more fun to discover it.”

The title of Simon’s eleventh studio solo album is, in fact, Surprise, and it features a baby’s face on the cover to illustrate the sense of wonder and new discovery found within songwriting and writing in general. Children surprise us all the time with their imagination and insight, challenging our own fixed assumptions and perceptions. In Poetic Medicine, certified poetry therapist John Fox observes: “The statement ‘I had no idea my child thought that way’ is exactly what many adults wanted to hear from their own parents but didn’t.” If you’re someone who “didn’t hear it” from your parents, it’s not too late to unearth your creativity and incorporate the element of surprise in your writing, especially in health narratives, as you discover your true voice.

We often think of “surprise” as a powerful tool to engage readers, keeping them interested, and making the narrative more memorable. But writing health narratives can be a surprising process for the writers themselves due to several reasons:

1. Unforeseen insights. While writing, physicians may discover new insights about a situation, condition, or patient that they hadn’t realized before. This could be a different perspective, a deeper understanding of a medical condition, or a newfound appreciation for a particular treatment approach.

2. Emotional discoveries. Health narratives often involve delving into deep emotional territories. As physicians explore these areas, they might surprise themselves with the depth of their own emotional responses, empathy, or resilience. Writing health narratives has been shown to help clinicians better appreciate the importance of the emotion and intersubjective relation borne of the telling of and listening to patients’ stories.

3. Unplanned directions. Sometimes, a narrative can take an unexpected turn as it develops. A physician might start with an idea or a plan, but as they delve deeper into the narrative, they find it evolving in ways they didn’t initially anticipate. My creative writing instructor told our class that narrative medicine writing “opens the conversation to magic,” meaning the creative direction and nature of the narrative can be limitless. Lewis Mehl-Madrona, MD, PhD, a name synonymous with the narrative medicine movement, observed that physicians may see themselves “as coauthors in the creation of new stories that have uncertain endings, at least while they are being written.”

4. Self-reflection. Writing health narratives can lead to significant self-reflection. Physicians may surprise themselves by uncovering personal biases, strengths, weaknesses, or beliefs that they weren’t previously aware of. Narrative medicine reflective writing has been used to help promote incorporation of diversity, equity, and inclusion training into medical school curricula.

5. New connections. As clinicians delve into the intricacies of health narratives, they might discover surprising connections between disparate ideas, events, or facts. These connections can add depth and complexity to the narrative.

6. Therapeutic impact. Many physicians find the process of writing health narratives to be therapeutic. The act of writing can help them process their experiences, emotions, and thoughts, leading to surprising personal revelations or growth. Some physicians’ careers have been totally revitalized by writing real-life stories about the joys and challenges of practicing medicine in the modern era.

7. Enhanced skills. Through the process of writing and revising, physicians often surprise themselves with the improvement in their writing skills, ability to articulate complex ideas, and capacity to engage readers in a meaningful way. Adopting narrative medicine as an intervention in medical education has played an important role in the professional identity development of medical students.

8. Patient outcomes. Writing about patients’ stories might lead to surprising revelations about patients’ resilience, their responses to treatment, or their coping mechanisms, which can add a new layer of understanding to the narrative.

The element of surprise certainly factored into this essay. I had originally planned to write about rules for writing health narratives, such as “show, don’t tell,” first do background research, and so on. I sat down with that blank canvas, began typing, and my 3-year-old grandson barged into the office and exclaimed, “Bops, how ‘ya doin’ man?” (“Bops” is a neologism for “Pops” and “Bop”-style music.) His surprise attack, coupled with my thinking about the beauty and innocence of children, steered me in a different direction.

“Kids do say the darndest things,” Art Linkletter used to say. Whenever I get stuck at writing, I begin to think like a child again to spur myself on. “It takes a long time to become young,” noted Pablo Picasso.

Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. He is the author of Every Story Counts: Exploring Contemporary Practice Through Narrative Medicine.