Policy experts need to lead by storytelling

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.

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.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.

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