Thursday, August 16, 2012

Writing persuasive public health narratives - Part 1 of 2

PSA screening is back in the news, with an analysis just published in the New England Journal of Medicine suggesting that the test could benefit some men and harm others, depending on the values they place on (less likely) extended life versus (more likely) disabling side effects of testing and treatment. The fatal flaw in this analysis is that it assumes that the result of the ERSPC study, which was the only one of 5 randomized trials to find that PSA screening reduced prostate-cancer mortality, represents the "true" effect of screening. If that were the case, then the PIVOT trial, published in NEJM last month, should have found that surgery for localized prostate cancer reduced mortality compared to watchful waiting. It did not.

It never ceases to amaze me how proponents of PSA testing manage to totally disregard the evidence that the test does not work. That they do, and continue to get away with it, seems to me to be not only a failure of science, but a failure of leadership. Along those lines, thanks to Johns Hopkins University Bloomberg School of Public Health's Ann-Michele-Gundlach for inspiring me to write the following essay (slightly updated and divided into Part 1 and Part 2) for her leadership survey course last summer.


Public health leaders must often tell people things that they don’t really want to hear. “Stop smoking.” “Eat a healthier diet.” “Exercise for at least 30 minutes each day.” To motivate people to heed these messages, leaders construct simple narratives to communicate the potential harms of undesired health behaviors and the benefits of desired ones. Who wants to spend their golden years tethered to an oxygen tank for every moment of the day? Who doesn’t want to live long enough to play catch with their grandchildren?

Some health messages, however, are more challenging to communicate. For example, contrary to the beliefs of most laypersons and good intentions of health professionals, screening for cancer does not always lead to better health outcomes. This narrative is considerably more complex, and if poorly constructed, can be self-defeating. In November 2010, I resigned my position as a researcher and medical editor at the federal Agency for Healthcare Research and Quality (AHRQ) to protest the politically-motivated cancellation of a scientific meeting that would have discouraged the use of prostate cancer screening tests. In a blog post, I explained that I could be a stronger advocate for population health by working outside of government. Although I am not certain whether to view my resignation as a personal example of leadership or, as a former colleague implied, simply taking the easy way out, I believe that my previous organization squandered an important leadership opportunity. They did so because they were unable to offer a persuasive narrative to politicians, clinicians, and the public.

Leading by storytelling is not a new concept. In a 1995 review of a book on leadership, Warren Bennis noted that “what distinguishes leaders from, say, psychotherapists or counselors is that they find a voice that allows them to articulate the common dream. … Effective leaders put words to the formless longings and deeply felt needs of others. They create communities out of words." General Electric CEO Jack Welch knew how to regale employees with memorable stories to instruct and inspire them, and have them relate their own experiences to his vision. “In the best case,” reflected Welch admirer Robert Dennehy, “one good story from a top executive can spark the listener’s imagination and trigger a snowball of creativity that eventually permeates the culture of an organization." Moving from “representative anecdotes,” added Janis Forman, leaders “shape the larger strategic story for their organization.”

In “Managing Oneself,” Peter Drucker observed that one’s leadership performance is determined by self-awareness of personality traits such as being a reader (Dwight Eisenhower) or a listener (Lyndon Johnson). Similarly, my leadership model recognizes the difference between being a writer and a speaker. Although I am not shy about public speaking, my capacity to impart messages to groups and organizations is rooted in my ability to move people with compelling writing – whether systematic literature reviews, clinical practice guidelines, or opinionated blog posts about the abuses of politics on the scientific process.

Recently, there has been increasing recognition of the need to develop physician leadership in organizations that protect the public’s health. However, physicians whose experiences consist of caring for patients one by one are often at a loss when it comes to managing the health of populations, which one author has called “macro” (as opposed to “micro”) medicine. Presented with a man whose prostate cancer was detected by a prostate-specific antigen (PSA) blood test and successfully removed, thus “saving his life,” a single clinician is naturally encouraged to do more testing to detect more cancers. Population-level factors such as false positive test frequencies, the burden of treatment side effect, and diagnoses of slow-growing cancers that would have never caused symptoms (much less death) are simply outside this clinician’s field of vision. Expanding that vision is a critical role of public health leaders.