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Jackanory: narrative education in medical communication

The power of storytelling, the importance of the individual and the start of a radical shift in pharma
Jackanory: narrative education

Boston, 2013, and a bunch of agency types collect in a rather cramped and faintly dismal hotel function room for an afternoon of whatever it was the meeting agenda said. Into this arena of postprandial apathy steps Dr Rita Charon, foremost exponent of narrative medicine, and it appears she has forgotten her slides. Nothing appears on the screen behind her save for an artistic abstract featuring, as I recall, purple lines and black rectangles.

With nothing on the screen to stimulate the senses, a confused audience turns its attention to the quietly spoken senior woman occupying stage front. She is talking, clearly though not loudly, and with little, if anything, that could be described as so vigorous as a gesticulation. All I could think (given the piscatorial attention span of the average agency executive) was that I hoped the gags were good. There were no gags.

Dr Charon told stories. Individual patient stories recounted with depth of feeling and detail no one had witnessed before and, unexpectedly, the audience was rapt. These weren't case studies as beloved by clinicians (49-year-old man with three-year history of X, had lab results Y so I gave treatment Z) or patient pictures (photo of healthy looking smiley person with something chronic and life-shortening) as beloved by the more naïve end of the pharma marketing community. These were stories that put disease, healthcare and treatment in their proper place within the context of individual human lives: narrative medicine.

The point here is that it is impossible to understand the impact of an illness on an individual without understanding the individual's story. The effect on a person of being diagnosed as HIV positive is quite different depending on his or her marital status, his or her age, his or her culture and, most significantly, a myriad of factors particular to him or her. This is the 'data' you need in order to act for that individual; this is the patient story. The art of the good doctor is to understand the narrative so as to be able to understand the disease and target therapy appropriately. Good medicine is narrative medicine, but narrative medicine is also, I would propose, good education. Dr Charon, in describing the narrative of a patient with a rare disease, indelibly imprinted the memory of its signs, symptoms, treatment and outcome in the memories of one hundred people who, up to that time, had lived in happy ignorance of any such disease.

Yes, stories are powerful but it's really a bit glib to leave it at that. Storytelling, story appreciation and story learning are hard-wired into our brains. We humans consume and repeat stories rapaciously all across our lives. From gossip down the pub, to jokes, to news stories, we frankly can't get enough. We absorb stories to the extent that we can completely suspend reality in pursuit of story enjoyment. When you turn on Coronation Street you (probably) know it's not real; it's being displayed on a flat screen for one thing, it's shot in a studio, the actors appear in the papers. But none of this interferes with your appreciation of the story. It gets more bizarre still – theatre-goers watching Shrek (the stage version, naturally) rapidly forget their own presence when sat in rows in front of the acting ranks to absorb a story about an eight-foot ogre. The truth of the story does not impact their appreciation or indeed their memory of it, and that latter fact is the crux of the medical educational opportunity that good storytelling represents.

The obvious opportunity in storytelling is to educate about disease, treatment and outcomes through the prism of individual patient stories as evidenced by Dr Charon. Good case studies told well on the congress stage can get part way there as they recount the triumphs and tragedies of a diagnostic conundrum, but they lack the medically irrelevant human details they need to make them good stories. Good storytelling needs that characterisation to make you care about the outcome and a good plot to surprise and dismay you along the way. Us humans like a structure to our stories, a set-up, a series of crunch points, a climax, a resolution. If you are Quentin Tarantino you might get away with mucking with plot structure but lesser mortals shouldn't bother.

Storytelling, story appreciation and story learning are hard wired into our brains

A good patient narrative, in effect an anecdote, is a Trojan horse for knowledge that our brains are unlikely ever to be suspicious of, but we must avoid confusion with anecdotal evidence. Patient stories should represent tested evidence and medical fact or give pertinent lessons on the unusual and be clearly labelled as such. This missive is not a plea for Daily Mail medicine.

Of course, such thoughts could be seen as a bit drippy in the hard evidence-based medicine world we live in today; narrative education as I'm describing here is hardly mainstream. What's wrong with explaining medical matters in blocks of prose with umpteen graphs and a slug of stats? What do you mean you can't remember it? Thing is though, underneath all the bluster your top KOL/external expert/therapy area expert (the names vary - the gist is the same) is just the same story-loving beast as the rest of us even where medicine is concerned. Telling the tale of your new medicine's development, the characters, the failures, the blinding insights and the dumb mistakes can be an intriguing cocktail if told well. It has the useful spin-off that for many an healthcare professional it provides the first realisation that there are one or two steps for pharma before selling a drug. 

While training on storytelling recently, I got into an in-depth discussion of whether storytelling could ever impact on that most sacred of objects, the clinical paper. Do they have to be quite so dull and unmemorable? I know we all (well 'piscatorians' at least) read the abstract and only carry on if there is something positive but it still seems like a wasted opportunity. 

Wouldn't it be cool if you wanted to pick up a clinical paper for the pleasure of reading the story within it rather than as a necessary drudge to find the interesting bits? More seriously, when reading clinical papers is such hard work is it any wonder we naturally ignore those that hold only negativity and non-significance. There are patient consequences to positive bias as our friend Dr Ben Goldacre has recently been explaining, but unlike him I suspect the issue is grounded more in human disinterest in the uninteresting than pharma malevolence.

Patient stories should represent tested evidence and medical fact or give pertinent lessons on the unusual

The structure of a story, its characters and plot is one thing, but above all a story needs a storyteller. Stephen Fry I suspect could read a train timetable and keep us fixated. Harry Potter would have passed unnoticed into oblivion if his many exploits were described in an standard operating procedure. Execution is critical and herein pharma has created its own demons by spending too long supporting too many mediocre medical story-tellers to speak on its behalf. 

Times are a changing and, I suggest, it's about time. Pharma is equipping itself and its medical teams for a radical shift that will involve it speaking more for itself about the medicines it develops, the research it does, the lives it improves and (yes) the profits it makes. The shift is barely underway and will be painfully slow, but as we break ground let's not forget the whole flaming point of what we do when we speak for ourselves – the patient and his or her story.

Article by
Dr Nick Broughton

medical director, at Havas Lynx Medical. Email him

9th October 2014

From: Marketing

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