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The Art and Impact of Storytelling in Medicine

2024; Lippincott Williams & Wilkins; Volume: 154; Issue: 3 Linguagem: Inglês

10.1097/prs.0000000000011465

1529-4242

A Herman, Kevin C. Chung,

Film in Education and Therapy

In Imperial China's Jin Dynasty (266 to 420 ad) lived a man by the name of Wei Yang-Chi. A member of a lower-class family, his days were occupied with farm work and studies. He was born with a misshapen, cleft lip. All his life, Yang-Chi strove to overcome the physical and social hindrance of his condition. At the age of 18, he learned of a famed physician, living in the governor's mansion in the State of Chu, with the skill to correct his lip. Too poor to afford more than the most basic of travel, he set off on foot carrying the few servings of rice he could afford. On his arrival, the governor, impressed with Yang-Chi's arduous journey, summoned the physician. The physician said to the young man, "I can cure your condition by cutting and stitching the edges together. However, after the operation, it will be necessary for you to rest the affected part for 100 days. During this time, you can ingest only thin gruel and you cannot smile or talk." Wei Yang-Chi replied, "What is 100 days to me when for relief of my condition I would remain silent for half my lifetime?"1 The operation was a success. The governor was so impressed with Yang-Chi's 100 days of dedication, he gave him a job in the provincial government archives. The humble teen gained financial freedom, release from his ailment, and what became a brilliant career. The identity of the physician remains a mystery to this day. The story of plastic surgery dates back to ancient times. Techniques, ideas, and successes have long been exchanged through both oral and written traditions, stories in and of themselves with lessons that have served as the foundation for teaching and innovating the field. From the earliest description of suturing in Ancient Egypt's Edwin Smith Papyrus (1700 bc) to the first account of rotation flaps, advancement flaps, and blepharoplasty in Celsus's De Medicina from the Roman Empire (1 to 100 ad) to the story of Wei Yang-Chi in the Jin Dynasty's imperial historical record (390 ad), medical and nonmedical texts provide detail of the advancements of the day.1 The historical foundation of medicine and surgery is littered with stories similar to these; this story has, almost unknowingly, guided the development of the field. In Being Mortal, Atul Gwande writes, "for human beings, life is meaningful because it is a story."2 Stories affirm who we are. Stories cross time and experiences to unite people who feel vastly different from ourselves. Stories humanize and empower. As surgeons and researchers, we treat people who bring their stories to our offices, hospitals, and operating rooms. We, too, have our own stories. A well-crafted research study might produce significant data, but alone it is often not enough to embolden people to act; but story offers us the ability to prompt our audience to care emotionally, intellectually, and aesthetically.3 When we care, we are compelled to act. When we are compelled to act, our research and medicine influences change within and beyond the walls of the hospital. Influential leaders everywhere are articulate storytellers. As such, leadership development in many industries has focused on the telling of moving stories for persuasion and inspiration. In this article, we introduce principles from other fields, and our own, to develop skills for persuasive storytelling in medicine. By learning ways to exercise the muscle of narrative, we increase the social impact of our work and better capture the humanity of our patients and ourselves. HOW STORIES DO WHAT THEY DO: PRINCIPLES OF SOCIAL IMPACT STORYTELLING When we think of the word "story," it is typically within the context of delight and entertainment. However, human culture is built on stories that teach values and lessons within tales of triumph and tragedy. Story has always held a purpose beyond entertainment. This has been referred to as "serious storytelling," which "progresses as a sequence of patterns […] related to a serious context, and is a matter of thoughtful process."4 In this sense, stories help us identify values for overcoming anxieties about uncertainties we face. In the face of innovative change, fear can hold anyone back from making necessary improvements. Using the following principles of story development and telling (Fig. 1) gives us as researchers the power to face that doubt and hesitancy.Fig. 1.: Using the public narrative model and the 4 truths of storytelling, we can craft stories that acknowledge our audience's emotions of fear and uncertainty, transporting them from the prospect of change to action.Story as "Emotional Transportation" When Peter Guber, now chief executive officer of Mandalay Entertainment and executive chairman of the Golden State Warriors basketball team, wanted to build the first movie multiplex in Manhattan in the 1990s, he was met with resistance because of fear of business cannibalization. In a time where 2-screen facilities dominated the industry, he began by asking potential investors an emotional question: What happens when you go to a food court and 1 option is sold out? The multiplex is just like the food court—when the original picture you wanted to see was not available, you could choose 1 of the other 15 to 20 films currently playing, all without leaving that establishment.5 Consumers would never go hungry for entertainment again. A story is meant to take our minds and hearts on a journey to a place which we were uncertain we could arrive alone. As the passenger, we arrive at our final destination with a new understanding of—and emotional response to—the details. Emotional transportation has roots in creative storytelling. We have all read books or watched movies that moved us. These stories hook audiences with a promise, just like "Once upon a time …" from countless bedtime stories. We enter the story and meet dynamic characters, with whom we find commonality, whose unconscious goals drive their every action. In Shakespeare's Romeo and Juliet, the star-crossed lovers die by suicide rather than choosing to live life without the other. Their love for one another leads them to make choices that are not universally considered correct. The audience, however, identifying with the dedication they feel and the difficulty of separation, believes in Romeo and Juliet's actions as rebellion. At each turn, a story's characters endure conflict that creates anticipation. In Pixar's Finding Nemo, the long-term reality of Marlin's search for Nemo is endangered not only by the vastness of the sea, but also by Dory's short-term memory loss that threatens to lead her and Marlin astray.3 Each scene is story that makes the ending less predictable, leaving us on the edge of our seats. Finally, stories use language to paint the scenery of theme. F. Scott Fitzgerald writes of loneliness in The Great Gatsby. When he writes, "the loneliest moment in someone's life is when they are watching their whole world fall apart, and all they can do is stare blankly,"6 it creates an image that sears into the minds and hearts of the reader, making them at once feel awe and wonder, sadness, and anger. When our stories inspire emotion, we can transport an audience through the fear that lies between their place of comfort and our ideal vision. The Public Narrative Model and the 4 Truths of the Storyteller Barack Obama was driving from Springfield, Illinois, to Chicago when he learned he would be the keynote speaker at the 2004 Democratic National Convention. He wrote the first draft by hand on a yellow legal pad, scribbling notes whenever inspiration struck. He wrote at the countertop in the men's lounge of the Springfield Capitol building. He wrote until 2 in the morning after long senate days. He wrote in his hotel room with the Chicago Bulls game in the background. In an early discussion with his media adviser he stated, "I know what I want to do—I want to talk about my story as part of the American story."7 Stories he heard on the campaign trail flooded his head. He matched them with his own. The 25-minute first draft was awe inspiring, but cuts needed to be made to meet the criteria for the keynote address. With a few anecdotes and biographic elements removed, and some critical lines Obama refused to delete, the team shortened the speech to 17 minutes. When Obama arrived in Boston, he had 3 rehearsal opportunities. Tension built as he struggled to manage the teleprompter, the noise at the convention, and the 3 audiences (the live audience, those watching on the JumboTron, and the TV audience at home).7 On the day of Obama's address, the media buzzed around the young senator, trailing him like a game of follow the leader. That evening, he delivered one of the most moving speeches of modern times. Following a string of "thank you's" and a quick adjustment of the microphone, he began: "Tonight is a particular honor for me because, let's face it, my presence on this stage is pretty unlikely."8 His facial expressions became more animated and his hand gestures more powerful, these telling the story as much as his words. The audience boomed. He paused—for emphasis. "That is the true genius of America, a faith in the simple dreams of its people, the insistence on small miracles,"8 he said. He called on our country to identify and reaffirm its values, measuring them against legacy and the promise to future generations. The stories of people from across the United States were rich with detail. The hope was palpable in his voice, in his words, and in his body—at that moment, Obama became the personification of "the audacity of hope!"8 Obama mobilized a nation that evening. He invigorated young people; old people; and those of every race, ethnicity, and socioeconomic status. He inspired people to make choices to realize a vision, calling on his fellow citizens to access the moral and emotional resources needed to make a change. His speech relied on the 3 pillars of public narrative and exemplified the 4 truths of the storyteller in public narrative9: The story of now asks the storyteller to consider the urgent challenge we face, what happens if we as a collective do not act, and what actions we must take to affect positive change. The story of us helps to define the community, and its aspirations and values to which we appeal. The story of self encourages storytellers to open themselves to vulnerability and demonstrate why they were called to motivate others to join in this action. In telling these 3 stories, Obama radiated integrity and authenticity. The 4 truths10 were the foundation of his speech. He exposed his own vulnerabilities and fear, selling himself and who he is within the narrative as "truth to the teller." He demonstrated "truth to the audience" by leveling with them and placing them as the hero at the center of the action. He expertly navigated the setting in "truth to the moment" by telling a story that was adjusted for the context and using the audience's cheers to direct his emphasis. Finally, Obama showed "truth to the mission" by acknowledging that his story was a values proposition. He asked us all the question "What do you believe in?" and then showed us how we could play a role in his worthy cause. CAPTURING THE HUMANITY IN MEDICINE THROUGH STORY Story is not only a tool used to imbue an audience with passion and motivation—it also has the power to foster empathy and provide healing or treatment. Every encounter we have, both with patients and with peers, is an exchange of bits of information that create a narrative. Our careers are inherently centered around story. Learning about and capitalizing on this reality improves the way we care for patients and provides adjunctive interventions. Developing Narrative Competence The thick of the COVID-19 pandemic had faded when we received an e-mail from the My Life, My Story team at the Ann Arbor Veteran Affairs (VA) Hospital. A patient was interested in participating in the program, and the group was seeking a volunteer to help tell his story. I responded and found myself at the VA later that week to meet this patient. He was a World War II veteran who was hospitalized with late-stage oropharyngeal squamous cell carcinoma and had just been transitioned to palliative treatment days before. I found him sitting quietly in bed listening to his granddaughter recount her most recent soccer game. I introduced myself, and informed him I was there to help tell his story. A smile spread across a face tired with chronic, terminal illness. He nodded and gestured for me to pull up a chair next to his bed. That afternoon we talked for several hours. I learned about his time in the service, his job at Ford, his childhood, his extensive family, and his late wife. The more we talked, the more his granddaughter learned too. We could see the tension ease in his body. The pain was fading just a bit. By the end, he seemed to have regained a bit of strength. My own demeanor relaxed, and I felt the emotional walls built during medical school crumble. I thanked him for his time and rushed home to write the 1000-word story of his life that would live in his medical record and be given to his family. We brought alive his story with words, giving him, his care team, and all of the people who loved him a deeper understanding of who this man was. Programs such as the VA's My Life, My Story show the power of narrative medicine. Developed by Rita Charon and her colleagues in the early 2000s, the concept is rooted in the humanities and the idea that patient-centered care relies on a physician's ability to receive accounts of person. With the rise of the discipline, there is an increased focus on building narrative competence in doctors. This is defined as the set of skills required to recognize, absorb, interpret, and be moved by the stories one hears or reads.11 In learning to hear, tell, and act on patient stories, physicians help heal patients and themselves. Pilot curricula in narrative medicine now exist in medical schools and residency training programs across all specialties. These programs have successfully cultivated a sense of reflection, deeper understanding of patients to be used for medical decision-making and difficult conversation, patient and physician well-being, and the development of professional identity.12–15 Since the inception of My Life, My Story at the VA in Madison, Wisconsin, more than 3600 patient narratives have been written, demonstrating to patients, medical students, residents, and physicians the power of telling and listening to a story. Storytelling as Patient Intervention In the Plastic Surgery Department of MD Anderson Cancer Center in Houston, 7 women who underwent mastectomy and breast reconstruction enrolled in a study to evaluate an expressive writing intervention. These women took part in 4 episodes of expressive writing at home. Many found themselves excited to write their story, with original trepidation fading away as they traveled deeper into their personal journeys. Some women shared their writing, offering glimpses into their psyche during diagnosis, treatment, and recovery, clueing in their loved ones about who they have become during their individual journeys. For all the women, the emotions and pain the writing stirred affirmed their choices, experiences, and how much they had overcome.16 Studied through semistructured interviews and experiential thematic analysis, 3 themes emerged: writing as process, writing as therapeutic, and writing as a means to help others. Through the patients' writing and assessment of the intervention, researchers learned the patient voice. In qualitative research, we collect and analyze nonnumeric data to understand nuanced concepts, opinions, or experiences of people. This type of investigation generates emotions that are inaccessible through other means of research, particularly for marginalized populations. Through this research, we have learned how verbal and digital storytelling reduces stigma around human immunodeficiency virus/acquired immunodeficiency syndrome in impoverished, rural South Africa,17 and increases truth telling, emotional connection, and empowerment among socially deprived Puerto Rican adolescent women.18,19 When we hear the patient voice, we better understand, affect, and communicate their lived experience. We strengthen grant applications by depicting the patients whose lives our research changes. We imbue our own quantitative research with metaphor and imagery to soften the language of science. We eloquently communicate our findings to galvanize the public. We create programming that heals the things our operations cannot. We soothe the scars left below the surface. The story of the first cleft lip repair continues to inspire generations of medical historians to search for the surgeon's identity. With a history being a finicky beast, we are simply left in awe of this person's ability. It is no wonder a story of plastic surgery produces such delight. The specialty is so closely tied to quality of life, it plays a pivotal role in telling the stories of the lives it encounters. Phenomenologist Maurice Merlea Ponty explains that the making of stories "reveals things to us that we know but didn't know we knew."19 Storytelling provides access to depth of information not necessarily available by other means. The lessons discussed above, in our specialty and others, have the power to transform the way our research and practice is received. To be human is to have and share stories. If we see our work as part of our humanity, there is a story there, too. The stories we tell as physicians and researchers have the power to delight, to heal, to teach, to motivate, and to activate the people in our community and beyond to carry out the personal missions of our work.20,21 DISCLOSURE Dr. Chung receives funding from the National Institutes of Health, book royalties from Wolters Kluwer and Elsevier, and a research grant from Sonex to study carpal tunnel outcomes. Alexandra Herman has no financial relationships to disclose. ACKNOWLEDGMENT The authors would like to thank Mike Stokes, staff vice president of communications at the American Society of Plastic Surgeons, for the peer review and edits.