Dr. Christine Horner’s path to becoming an author was "a little unusual." Before becoming an author, she was a plastic surgeon whose mother had breast cancer and went through conventional treatment, which seemed to work.
"Then, five years ago, she had a metastasis to her bone in her leg and gave up," Horner says. "Nine months later, she was dead."
As Horner dealt with this personal trauma, she saw the population of women coming in for reconstructive breast surgery after mastectomy get younger and younger, until she found herself working on breast cancer survivors in their 20’s.
Horner soon came to the conclusion that something wasn’t working in the way the medical community diagnosed and treated breast cancer. So she dove into the literature and was shocked at what she found.
"I found thousands of studies about things we weren’t doing in our culture to protect against breast cancer," she says. "The more I was learning, the more upset I got about how we practice medicine."
Horner wanted to spread what she was learning, and she was soon contributing regular segments to a local TV station while still working at her practice. But the workload quickly became overwhelming, and she knew it was time to take the next step.
"One day, I woke up and quit my practice and took some time off," Horner says. "I thought I was going to write a book."
The resulting book, Waking the Warrior Goddess, was published by Basic Health Publications in Laguna Beach, Calif. Norman Goldfind, her publisher, says the book has been a great success for his company, and they’ve returned to press several times.
The book has been good for Horner as well. She has been on multiple national TV programs, done hundreds of press interviews for major media, and has spoken before hundreds of audiences all around the country.
But as Horner learned along the way, publishing a book is a labor of love that requires skills doctors don’t naturally cultivate. And even with national media exposure and multiple print runs, it doesn’t necessarily pay the bills.
What advice would Horner give to aspiring authors? She laughs and, without hesitation, offers: "Don’t quit your day job."
Pick a topic that you know
Dr. Rosalind Kaplan is the author of The Patient in the White Coat, published by Kaplan Publishing in 2010. Her book fits into the emerging genre of what she called "narrative medicine," or books that blend memoir and prescriptive passages.
Kaplan is perfectly suited to write narrative medicine - she experienced the medical system as a patient firsthand after contracting hepatitis C from an accidental needlestick.
"People do best at writing what they know," Kaplan says. "I think that’s really important for doctors."
Judging from the number of books published last year (almost 1 million, including self-published titles), it seems that just about everybody in America wants to write a book.
But before the first word hits paper, it pays to do some homework, according to Jeanne Fredericks, a literary agent who owns the Jeanne Fredericks Literary Agency in New Canaan, Conn. Fredericks represents both Drs. Horner and Kaplan.
"The first thing to do is to check the competition," she says. "See whether there is another book on the subject. If there is, is the book old or out of date? Do you have the opportunity to bring fresher information? Or is this a topic people don’t buy books about?"
Write the proposal
Once you have a topic in place, you can write a book proposal. The vast majority of nonfiction books are sold on proposal. A book proposal is a very specific document, Fredericks says, and must include a few elements, including a table of contents, a sample chapter and a marketing plan that shows how you plan to sell your book.
It also helps to work with a reputable literary agent. Today, many of the largest publishing companies won’t even look at proposals unless they are submitted by legitimate literary agents like Fredericks. Agents screen proposals and only sign authors who seem to have mass sales potential. The authors, in turn, benefit from that agent’s contacts in the publishing world.
But the value of having an agent goes beyond his or her Rolodex. Agents also negotiate contracts, handle foreign and subsidiary rights, act as the author’s advocate and career guide in the complicated publishing world, and help authors build their marketing platforms, often before publication.
This last piece can’t be underestimated. Publishers are increasingly interested in signing authors who have a built-in sales channel, whether it’s a busy speaking schedule, TV appearances, or even a large Web following.
"I recommend an author building a platform locally and regionally first, so they get used to speaking in front of an audience," Fredericks says. "Another easy way to build a platform is through the
Internet. Successful authors often have a website or Twitter account before they publish, so they can approach a publisher and say, ’I have X-number of thousand of followers.’"
Prepare for rejection
Even with a platform, a polished proposal and a reputable agent, there is no guarantee your book will sell once it’s sent to publishers. This part of the process can be the most painful, as authors frequently spend months or even years in a wilderness of rejections and almost-sales.
This was definitely the case for Horner, who quickly amassed a pile of rejections - until one week when seven publishers suddenly announced their interest almost simultaneously. A book auction was quickly arranged, with all the interested publishers bidding against each other for the right to publish her book. Fredericks handled the auction and guided Horner throughout the process.
Ultimately, Fredericks recommended that Horner choose Basic Health Publications, a relatively smaller publisher than some of the big, mainstream companies. At Basic Health, Horner got the personal attention of the publisher, Norman Goldfind, and she felt thoroughly supported during publication.
Kaplan faced a different road to publication, one that is depressingly familiar to industry insiders. She contracted with an agent relatively quickly, but her first agent was unable to sell the manuscript. The agent left the literary agency, so Kaplan was orphaned. Around the same time, she received a "really damning" rejection from a university press she’d submitted her book to.
"I took it very badly," she remembers. "I stuck the thing in a drawer and said forget this."
But she didn’t stop writing or attending writer’s conferences - and finally, she took the manuscript out again and started to rework it. This draft attracted the attention of yet another agent, but Kaplan says, "We were like oil and water. She wanted me to do crazy things to the book that as a physician who works five days a week and sees patients, and who wants to remain credible, I refused to do."
Finally, Kaplan met Fredericks, who would become her third agent and the one who finally sold her book.
Most nonfiction books aren’t actually written - or at least finalized - until they are sold. But this doesn’t mean they are first drafts.
When she first sat down to write her book, Horner approached it like a surgeon: She wrote from 6 in the morning until 10 at night and finished a rough draft in less than three weeks. But ultimately, that draft wasn’t the book that made it to market.
Attend a writer’s conference
Her advice for other doctors who are facing down a blank page? Go to a writer’s conference.
Horner attended a writer’s conference in Cape Cod that was specifically aimed at doctors writing books. The conference was a combination of publishing 101 and networking opportunities. It was there that she sharpened her proposal with the language that would eventually sell the book, and where she made the connections that would eventually lead her to Fredericks.
Not all doctors, however, are cut out to write their own books. As a result, ghostwriters and book doctors are an important part of medical publishing.
"Ghostwriting is quite common in the industry, especially when celebrity authors are involved," Fredericks says.
Ghostwriters are either paid by a flat fee or through a profit-sharing arrangement with the doctor. The exact fee or sharing arrangement depends on the writer’s role in the project. Ghostwriters typically cost between $10,000 and $35,000, but can cost much more, and collaborators typically command anywhere from 20 percent to 50 percent of advances and royalties.
As for which approach works better, Fredericks says, "Agents tend to prefer that an author get a share of the royalties. We want everybody on the same team so everybody has a share in the success of the book."
Should you self-publish?
It’s no exaggeration to say that publishing seems to be on the verge of the biggest upheaval since Johannes Gutenberg invented the printing press. The introduction of print-on-demand technology makes it possible to cheaply produce print books, and the growing popularity of ebooks makes it easier than ever to publish your own book with almost no overhead.
Better yet, ebooks can be sold through all the major online distributors (Amazon, iBooks, BarnesandNoble.com) at no competitive disadvantage and much greater profit to the author. All of this means that, for the first time, self-published authors can compete with big publishers on almost-even turf. Even the traditional stigma against self-publishing is beginning to fade.
Yet as exciting as this dawning era promises to be, there are still compelling reasons to seek out a traditional publisher. The most important is distribution - self-published print books are not nationally distributed by the chain bookstores, including Borders, Barnes & Noble and Books-A-Million, so your book will end up in front of fewer people.
Ebooks, meanwhile, are still less than 10 percent of the total market, so even very successful ebooks sell much less than traditionally published books. This may change in the future, but most publishing experts predict that print books will still be around for years to come.
The second advantage to traditional publishing is editing. Self-publishers are responsible for all of their own editing, which usually means hiring expensive freelance editors and learning their peculiar language.
"In the recent past, there have been periods in publishing when we thought some technology was going to change publishing, but the public wasn’t ready," says literary agent Jeanne Fredericks. "The difference now is that I think the tipping point has been reached…. But it’s a huge job to write something and sell it. I believe that people should ask themselves what they’re good at, and how much they want to do."
Market your book - and yourself
Neither Horner nor Kaplan had any illusions about how hard it is for a book to succeed in today’s competitive marketplace - especially when marketing a book competes with the demands of a full-time practice, as it does for Kaplan.
Kaplan’s marketing plan includes the typical steps - keep a blog, network among friends, rely on her publisher to set up events - but she only has so much time to devote to book promotion.
"Obviously, I have to prioritize. The good news is that a lot of book marketing these days is word-of-mouth and digital."
Kaplan planned to tap her extensive network of friends and colleagues in Philadelphia, as well as reach out to the large societies of hepatitis patients and physicians.
"It should be fun," she says. "I turn 50 [soon], so I’m having a huge book-launch bash that will bring all my friends and family together."
Once Horner’s book came out, she hit the road. She traveled all over the country giving talks. She put up a professional website with podcasts and testimonials. She gave interview after interview. She even partnered with a nutraceutical company to introduce a supplement that contained ingredients said to aid in the prevention of breast cancer.
As a result, she got access to the company’s public relations team, which landed her spots in national media and organized two whirlwind weeks in New York doing press.
But throughout all this - as her profile rose and books started to move off the shelves - Horner came up against the other worst-kept secret in publishing: It’s nearly impossible for anybody but a handful of authors to make serious money in books.
"The only thing most unpublished authors see are announcements of huge sums paid for a few books every year," Goldfind says. "That’s not the norm."
In fact, Basic Health’s average advance ranges from $2,000 and $5,000, while large publishers might pay between $35,000 and $50,000, says Fredericks. No royalties are earned until the book "earns out" its advance, meaning that the book sells enough copies that the author is entitled to royalty monies beyond the advance.
It’s also unusual for any author to get much marketing support for their book, beyond the publisher’s effort to place the book in bookstores and get good distribution. This means the burden of marketing generally falls on the author.
"For the first two years, I was on the road constantly," Horner says. "I’d come home to wash my clothes and leave. When I broke even, people in publishing would say, ’That’s amazing,’ but I felt like I was killing myself for no profit."
Don’t give up
Despite the challenges, Horner hasn’t given up. She is just now preparing another book proposal, and she recently hired a publicist to help her develop a TV career.
"Believe me, I’ve had my moments when I thought I should be waitressing," she says, laughing. "I’ve had my meltdowns. But it’s just like being a surgeon. People say don’t do it because it’s an insane path. But I’m one of those people who muscles my way through. I heard that 1 percent of books make a profit, and that was enough for me."
Jon VanZile is a medical writer and editor. He lives in South Florida.