Friday, August 17, 2012

Writing persuasive public health narratives - Part 2 of 2

This is the second of two posts updating a short essay on public health leadership that I wrote last summer. Part 1 is available here.


Strong public health narratives can foster a culture of “macro” medicine, much as executives in business organizations successfully have used stories to shape corporate culture. According to John Marshall and Matthew Adamic, persuasive stories “applaud … a certain type of behavior” and include a “call to action” that is consistent with the leader’s vision. Leaders should avoid falling into the trap of providing excessive detail and making it more difficult for listeners to apply the narrative to their particular situations. In the case of prostate cancer, a leader might tell the story of an otherwise healthy 60 year-old man who suffers permanent urinary incontinence and erectile dysfunction following surgery for an asymptomatic and likely slow-growing tumor. Patients and physicians could identify with the person in this story, fill in the gaps about how these complications must have worsened his quality of life and relationships, and be motivated to have informed discussions about the potential downsides of such testing in the future.

In “The Four Truths of the Storyteller,” entertainment executive Peter Guber asserted that the most effective leadership stories are authentic or “true” to the teller, the audience, the moment, and the mission. It’s no surprise, then, that AHRQ (the “teller”) was unable to convince its own superiors in the Department of Health and Human Services to allow the scientists to unequivocally recommend against screening for prostate cancer. Sensitive to stirring up calls of health care “rationing,” and viewing health reform as a mechanism for providing new benefits, rather than taking them away, the agency was an ineffective spokesperson for the story that screening can be harmful. The target audience of clinicians and policymakers was also unprepared to receive this message, especially at that particular “moment”: the day before a midterm election that rearranged the balance of power in Congress.

In fact, some of my colleagues believed that no narrative about prostate cancer screening could have possibly overcome the public perceptions and political obstacles that were arrayed against it. I don’t agree. As Guber argued, everything that the storyteller does must be faithful to his ultimate mission:

When truth to the mission conflicts with truth to the audience, truth to the mission should win out. The leader who knows his listeners is able to gain their trust and spend that currency wisely in pursuit of the mission. But this doesn’t mean telling people exactly what they want to hear. That’s pandering, and, as Hollywood has learned, a formula for a mediocre story. Indeed, sometimes you need to do just the opposite.

Since leaving AHRQ, I have tried to write and speak more effectively about prostate cancer screening, and to refine and extend stories that explain why less testing is in the best interest of the public’s health. Although I no longer have direct influence on the guideline-making process, I felt that I was able to positively affect how that the final guideline was received by the public, by leading the prevailing narrative away from “bureaucrats ration lifesaving test to save money” to the more scientifically accurate “prostate cancer testing leads to more harm than good.”

This is not a small task by any means. As Douglas Ready observed in the context of training the next generation of business leaders, "storytelling, strange as it may sound, is hard work and very labor-intensive for those who choose to try it." The same is true of developing the next generation of leaders in public health. It is not enough just to understand what the science shows, especially if the body of evidence supports a conclusion that contradicts current beliefs. The best way for a leader to persuade people to accept a counterintuitive health message is to craft a compelling narrative.

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