Dr. Kelly Luu (biography and disclosures) Disclosures: no disclosures. These suggestions are written in pencil! I continue to learn and experiment with different skills to improve my clinical practice.
What care gap I have noticed
“All he has to do is stop his (insert harmful behaviour).” Sound familiar?
I care for a lot of patients with chronic diseases and often recommend self-education and behaviour change. I became good at collecting and sharing resources: handouts and books I thought would help families understand their problem and what they needed to do about it. As my relationship with these families continued, it was clear that my practice was inadequate.
Evidence shows that the strategy which physicians frequently employ, educating and training, is only the first step in the process of behavioural change. The same way many of us leave a meeting with a financial advisor saturated with information but still asking “what just happened?” I am convinced that many patients leave their doctor’s appointments feeling the same confusion and disempowerment.
Data that answers these gaps
According to the hierarchy of effectiveness model, to achieve behavioural change, a patient must first have an awareness (education), which should then lead to desire which then leads to action. After ensuring that my patients were informed, I felt the need to be more competent at compelling my patients to action. I now use storytelling in my patient encounters to create desire for action (behaviour change), and that is based in feeling.
The stories our patients divulge to us can be much more than a clinical history. Through thoughtful questioning and reflection, it became a clinical tool for me to bring to light my patients’ internal desires and motivations. By exploring stories which spark positive emotions and memories for the patient, we help them connect their experiences to their sense of resilience in achieving their vision of a healthier self.
In the brain, we are stimulating different pathways surrounding the same thought creating neural “stickiness.” As we fire along this cluster of neurons again and again, it starts to feel less like trailblazing and more like an easy hike; this is the moment our actions become a habit. Stories help patients associate their behaviour to as many areas of the brain as possible, strengthening that neuronal connection which helps to make the behaviour endure.
What I recommend (practice tip)
We are already storytellers. We collect, curate, and display our patients’ experiences of illness in a clinical frame. By refining our ability to present our patients’ stories in their best light, we create a more inspiring gallery for everyone.
Ways to become a better storyteller:
- Practice other-focused listening: Listen with curiosity and presence. Listening without putting everything in the context of our own lives and experiences is challenging. However, being engaged and non-judgmental provides patients the security to reflect honestly about their actions. To practice listening with curiosity, I am mindful to keep my inner dialogue separate from the story that my patient is sharing with me, and I ask myself “How do I know that?” to reveal all the assumptions I automatically make about my patients.
Beatrice wants to adhere to her therapy every day and is having a hard time. If my inner voice says “She is not trying hard enough” I might speak with frustration. How can I let go of all my thoughts and truly open up an inviting space for Beatrice to reveal her story?
- Use generous language: This means avoiding the “gotcha moments” which are questions that prompt patients to tell you how they have failed. Asking Beatrice “how many times a week do you miss your medication?” or “why is it so hard?” are really combative questions in disguise and can create a sense of embarrassment and defeat. Focus on what the patient is capable of doing instead of wasting energy on what they have not done or cannot do.
Asking “what can you do to take your medications more regularly?” or “what would make it easier?” allows the possibility of change.
- Create a detailed sensory journey: The more senses you can engage, the more memorable the story becomes. Think about the experiences that have changed you. Are you surprised how well you can visualize the scene, smell the scents or feel the sensations? Celebrate small wins with patients by asking them to elaborate with as much detail as possible. Emotions are great drivers of change.
Beatrice was diligent with her adherence when she first started and felt great. Capitalize on this success and create a storyboard. What was she doing that made it work? How did she feel physically? What emotions did she have? Who was involved?
Stories are already at the heart of medicine and humans are natural storytellers. By helping patients shift their narratives about themselves, we can strengthen their ability to have sustained behavioural change.
References and additional reading
- Ventres W, Gross P. Getting started: A call for storytelling in family medicine education. Med. 2016;48:682-687. (View) PMID: 27740667
- Fantastic review and step by step outline for developing storytelling skills
- Chipidza FE, Wallwork RS, Stern TA. Impact of the doctor-patient relationship. The Primary Care Companion for CNS Disorders. 2015;17(5):10.4088/PCC.15f01840. (View) DOI:10.4088/PCC.15f01840
- Charon R, MyiLibrary. Narrative Medicine: Honoring the Stories of Illness. New York, NY: Oxford University Press; 2006. (View with UBC or request from CPSBC)
- Narrative medicine can be considered a formal practice of storytelling. Rita Charon defines it as “medicine practiced with these skills of recognizing, absorbing, interpreting and being moved by the stories of illness.”
- In addition, UBC VFMP Faculty developing offers an Introduction to Narrative Medicine Workshop (http://facdev.med.ubc.ca/)
- Karia, A. TED Talks Storytelling: 23 Storytelling Techniques from the Best TED Talks. Lexington, KY: Createspace, 2015. (Search with WorldCat, library resource)
- Zak, P. How stories change the brain. GreaterGood. Published December 17, 2013. Accessed May 29, 2017. (View)
- Tippett, K, +Acumen Courses. Krista Tippett on the art of conversation. Udemy. https://www.udemy.com/krista-tippett-on-the-art-of-conversation/. Updated May 2017. Accessed May 29, 2017. (View)
- Cafazzo JA, St-Cyr O. From discovery to design: the evolution of human factors in healthcare. Nursing leadership (Toronto, Ont.). 2012;25 Spec No 2012:24. http:// healthcarequarterly.com/content/22845. Accessed Nov 20, 2017. (View with UBC) DOI:10.12927/hcq.2012.22845
- Kegan, Robert. Immunity to Change Video. British Columbia Organization Development Network (BC OD Network) Learning Portal (http://conversation.bcodn.org). https://www.youtube.com/watch?v=FFYnVmGu9ZI. BCODN. Published on 21 Jul 2012. Accessed Nov 20, 2017.
- Duhigg, Charles. The Power of Habit: Why We Do What We Do in Life and Business. Published: February 28, 2012. ISBN: 9781400069286. (Find in a library with WorldCat)
- Zimmerman G, Olsen C, Bosworth M. A ‘stages of change’ approach to helping patients change behavior. Fam. Phys. 2000;61:1409-1416. (View) PMID: 10735346
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Excellent, brief commentary with excellent references.
Another “resource” that demonstrates the effectiveness of narrative medicine is by Dr. Rachael Naomi Reman in her books:
Kitchen Table Wisdom and My Grandfather’s Blessings
I appreciate the reminder that body-centred experiences through sensory activation/ involvement can be evoked with story telling to enliven the particular learning moment
I enjoyed this article. Thank you!
Another source is the work of Michael White, who developed narrative therapy. He taught patients (and therapists) how to tap into the power of stories to generate more functional patterns of behaviour and belief.
Good article. Great technique to communicate with the pt.
Thank you. Well written and meaningful. The art of medicine and healing stories
Simply superb!! Thank you for the insight…