I had the pleasure of interviewing author Carol Cassella after I read her bestseller GEMINI, and it was a wonderful experience. Here is our Q&A session:

GTB: Which character did you have the easiest time writing? Who was the hardest?

CC:  Although she might seem to be quite different than myself, Raney was the easiest character to visualize and write. I distinctly heard her voice with a rural accent, akin to the Texas drawl I grew up with. No, Raney has certainly never been to Texas, (and I hope I successfully turned her voice into a rural Pacific Northwest accent), but I spent a lot of time riding horses as a young girl and that meant I spent a lot of time outside the city with kids who’d grown up in smaller towns. And, in ways, Raney reminds me of many of my patients: people who live in much more strained circumstances than my own peer group. One of the greatest privileges of being a doctor is that you get the chance to witness, sometimes intimately, the daily hurdles that millions of Americans who live below the poverty line have to overcome. I’ve taken care of a lot of people whose talents and intelligence might have generated good incomes and stable homes if they had had better examples and opportunities growing up. But I so love Raney’s spunk and independence, and her artistic view of the natural world. We enjoyed being together on the page during the long days of writing the book.

David was probably the most difficult character to bring fully to life. He was the most “evil” of GEMINI’s players, a borderline personality disorder type who could lie not only to others but also to himself; a man with a very poorly developed moral conscience. On the other hand, who among us is purely good or evil? No one, in my experience of the world. We are all born with certain traits and inclinations, but are then much shaped and influenced by the kindnesses and cruelties we experience growing up. I had to make David callous enough to abandon Raney on the highway, but big-hearted enough that she could be willing to marry him, even if it was in many ways a marriage of necessity. I intentionally kept his role in Raney’s accident uncertain; because the police were not able to confirm enough evidence to get a search warrant or prosecute him, I wanted readers to walk that line as well—to suspect David but be unsure how far he would go in a fit of anger. Writing such an ambiguous character is challenging, but also more fascinating than creating someone who could be described as one dimensional.

GTB:  Do you do an outline of the story, or do you just write for hours and let the plot unfold as it will? Do you let the characters create their own voice as you go?

CC:  I have approached each of my three novels differently so far and discovered that outlines do not work for me. I wrote the first draft of HEALER after creating an extensive outline, and ended up with a book that felt forced, the characters driven into actions to match the plot outline rather than motivated by their own personalities as they developed through the writing process. I took another year dismantling and rewriting HEALER so that it worked as a whole. Maybe this is what we are really describing when we talk about “character driven” stories—stories where the plot builds as a consequence of each character’s choices. As I draft scenes I fill in details about each character that often seem to appear out of nowhere—small background conflicts or hobbies or pet peeves that spring onto the page from my imagination and, over time, create a unique individual who might or might not want to follow the plot line I’ve planned. That is when writing gets fun—when you see the characters developing in such a rich and complicated way they begin to dictate their own choices. At that point they do start to speak to me in their own voice, but I have to invest many hours filling blank pages, often discarded, before that spark of life catches fire.

Certainly, though, plot outlines work very well for many writers, and I have friends who depend on them. I think any tool can be used if the writer understands how their own mind approaches story. I begin each novel with a general idea of major plot elements. The central conflict and topic are chosen because I find them interesting questions to research and ponder for the two or three years I’ll spend writing. Then I spend each writing session by starting with a scene I think I’ll need—two characters in a conversation, or some pivotal event that will turn the action. The scenes might be completely unrelated in the novel’s arc, and many of them will end up thrown away, but after a few months I can begin to see what matters—which scenes will form the core of both the plot and the characters’ motivations. I always start the novel thinking I know how it will end, but I am always surprised that things turn out differently than I’d predicted.

GTB:  Is there a possibility in the future to see another book with any of the characters from Oxygen or Gemini? I’d love to see Jake’s story unfold.

CC:  I, too, would love to see Jake’s story unfold. And Marie’s and Joe’s (if he’s alive!). So far, though, I don’t have any plans for a sequel to any of my books. I’m well into the fourth novel now, and don’t yet have a clue about what will follow that. I find that when I’m deeply engaged in writing one novel and one set of characters, I am almost incapable of imagining any other project to follow.

GTB:  Charlotte (and subsequently, the reader) viewed the ethics board and the CPG as “the enemy”. This also served to create tension and make the reader aware of time running out for Raney. What are your thoughts, as a medical professional, on those who decide the fate of comatose patients and deal with ethics, rather than medicine?

CC:  If I have one goal for readers of GEMINI, it is to spark discussions about their own beliefs and personal hopes for the end of life. We are not very good about talking about that tangled, uncertain but inevitable future, either as doctors or as patients. For millennia no one had to ponder such questions except in the most theoretical sense: what an ideal death might look like—quickly felled by infection, or being eaten by a tiger? But in the past few decades, thanks to remarkable advances in medical care, most of us will be offered choices as we grow old and ill. Pacemakers, bypass surgery, dialysis, insulin, stroke prevention, antibiotics, cancer treatment—all of these and hundreds more are giving us many more productive and hopefully happy years before age or disease finally outruns the options available. But the quality of those final months or, sometimes, years, can be very poor. Should more time always be our number one goal? What makes your life worth living?

Given that we must all eventually die, shouldn’t physicians also be helping us approach that end nobly and in keeping with our personal values? Interestingly, hospice care has been proven to extend both the quality and quantity of life in terminally ill patients, and yet access to hospice care is usually offered far too late and too infrequently. I don’t try to give readers answers to any of these questions—they are too personal for any outsider to dictate—but we should all be considering them and discussing our wishes and beliefs with our family members and close friends, who might have to make these difficult decisions for us in our last days. You are quite right, though; I used the ethics board and CPG to impart a sense of urgency and loss of individual (Raney’s in this case) control at the end. While the situation of being an unidentified Jane Doe is unlikely, many, many of us end life without having made it clear what our final wishes are to those who will be caring for us.

GTB: Who do you think had the happier, most satisfying life, Charlotte or Raney?

CC:  Raney had such a free spirit and innate joy for living, a capacity to be happy in the present, I think she had the most important traits for a satisfying life. But economics and the randomness of fate delivered her into a broken family living in hard circumstances. Thank heavens for Grandpa, who gave her love and stability and backbone despite his gruff demeanor. Sadly, in the end, I think poverty and lack of opportunity and education derailed Raney’s chances for a life as happy and fulfilled as Charlotte’s.

Currently half of all school aged children in the U.S. are poor enough to qualify for subsidized lunches. One quarter of our children don’t have enough food to eat. Raney may seem like an outlier, but her life represents a very large number of people who are our neighbors, just a few doors or miles down the road.

Carol Cassella is a practicing physician, speaker, and the national bestselling author of three novels, Gemini (2014), Healer (2010), Oxygen (2008), each published by Simon & Schuster and translated into multiple foreign languages. All three novels were Indie Next Picks.

Carol majored in English Literature at Duke University and attended Baylor College of Medicine. She is board certified in both internal medicine and anesthesiology, and practiced primary care with a focus on cross cultural and underserved populations before becoming an anesthesiologist. Prior to writing fiction Carol wrote for the Global Health division of the Bill & Melinda Gates Foundation, covering their grant projects throughout the developing world. She has been a contributor to the Wall Street Journal as an Expert Panelist in Healthcare, and edits a literary section in Anesthesiology, the journal of the American Society of Anesthesiology. She is a founding member of Seattle7Writers, a non-profit supporting literacy and reading in the Pacific Northwest, and also serves on medical organizations working in Nicaragua and Bhutan. Carol lives on Bainbridge Island, Washington with her husband and two sets of twins. She is currently working on her fourth novel.