More than words

A consultant’s ‘Letter from ICU’ during COVID – a promise of care for the most vulnerable – goes viral.

Mr Bates vs The Post Office, a TV drama about a national scandal that has been rumbling on for years, catapults the sub-postmasters’ fight for justice to the top of the political agenda

Army veteran ‘Captain Tom’ walks 100 lengths of his garden each day in lockdown to mark his 100th birthday and raise funds for health charities, and becomes a national hero.

All three captured the public imagination unexpectedly, although their message was not new. What unites them is the power of story: one person’s struggle coming to represent the human condition and forging a strong emotional bond with us.

There is a growing recognition that storytelling, that age-old social glue and sense-maker, can help organisations where people are finding it hard to connect with each other or with clients.

So, are there things healthcare can learn from storytelling? Three doctors involved in both fields share some thoughts.

John Powell, who trained in psychiatry and public health medicine, is professor of digital healthcare at Oxford University. He is also a medical adviser to TV and film, and an occasional writer of fiction and comedy himself. 

Incongruously, given his area of research is digital healthcare, he specialises in advising on historical dramas, from ITV’s Downton Abbey to the film Ammonite. It is a creative outlet for him but it is instructive, too.

He was the adviser for Lady Sybil’s eclampsia in Downton, for example, helping scriptwriters to shape the dialogue between her GP and her obstetrician, then working on set to ensure her treatment and her death played out convincingly.

The eclampsia storyline was never intended as an awareness campaign: the medical adviser’s role is about charting a course between medical veracity and dramatic imperatives, not pushing a public health message.

But Downton’s global reach and viewers’ emotional connection with a hugely sympathetic character probably had as great an effect as any campaign the NHS or pre-eclampsia charity could achieve. 

‘I love the creativity of forging something from experience and imagination that can convey an important message in an entertaining way,’ says Prof Powell. ‘I like the idea of an audience having a shared, simultaneous connection with the narrative, which can then spur further reflection and discussion. It also has a much greater reach than any academic paper.’

Christopher Peters, a surgeon at Imperial College Healthcare NHS Trust, has worked as a medical adviser on many a health-related plot in several TV series. This includes the highly acclaimed EastEnders storyline about Stacey Branning’s postpartum psychosis, part of a BBC programming season exploring mental-health issues.

Yet, the example he gives of that powerful connection that sets us firmly in a character’s shoes is ITV’s Mr Bates, which transformed a dry legal case into a story about real people.

‘I’ve been reading about the Post Office scandal for years but it hadn’t hit a certain level of public awareness until ITV made a drama about it,’ says Mr Peters. ‘It’s the difference between reading something which is abstract, and not relatable to you, and seeing a really good actor translating it into your own lived experience.’

Intensive care consultant Matt Morgan wrote ‘A letter from ICU’ in March 2020, at a time of national crisis when people were searching for connection, empathy and meaning.

His message to those most at risk of the virus was sparse. There are times when intensive care ‘offers no fix’,  for all its ‘fancy machines, powerful drugs, and talented staff’, he wrote in the BMJ. But, he said, ‘We will be honest, we will hold your hand, we will be there. We have not forgotten about you’.

It was an unplanned response to another long, late, devastating shift – but it spoke to millions as if penned at their bedside. 

 ‘The truth is those letters were written for my own family: I’ve got relatives who are vulnerable, frail, elderly,’ says Dr Morgan. ‘I was sitting on the sofa, family in bed, and I just wrote it on my phone, almost like a note. Then, 48 hours later, there was Sky News, ITV, BBC News, outside the house. Very bizarre.’

Dr Morgan’s love of narrative was sparked at medical school in Cardiff. ‘A neurologist, Tom Hughes, started our lectures with a simple question: “What do all patients want?” And the answer he gave was: “Somebody to make sense of their story.” 

‘In ICU, for example, often there isn’t a cure: about one-in-five people admitted to ICU will die in hospital. “Why?” is often the question they ask.

‘Sometimes, the best you can do is to make sense of the story for the people who love them.’

Dr Morgan, who is the author of two popular science books, often writes to patients in ICU, in simple, acronym-free language, whether or not they will ever read their notes.

‘During COVID I wrote for one patient: “I met with you today. I told you how unwell you were. You told me about your work.” And that person subsequently died. The family, who were overseas, asked for a copy of the medical notes and could see somebody had been with their loved one shortly before they died. 

‘I’m pretty passionate about trying to get medical professionals to think about narrative in their own writing, rather than just using bullet points for everything. If we’re to have empathy, we need deeper connections with patients’ experiences. And narrative can capture the complexity of medicine when lists simply cannot.’

Dr Morgan’s recent role as medical adviser for Nye, Tim Price’s play about Aneurin Bevan, has reminded him that ‘every patient brings a story’, that they are ‘individuals with a past, possible futures, fears and aspirations’. 

‘Every day, I am a medical adviser really: the patient is the boss, not me. I’m there to help them understand, decide and communicate.’

Increasingly, organisations are using storytelling to strengthen team culture and comms.

After space agency NASA experienced the loss of the Challenger space shuttle and its crew in 1986, it emerged staff had not felt able to share their concerns about the shuttle’s safety, or their concerns had been ignored. 

To help rebuild a culture of knowledge sharing, NASA eventually hired not project management consultants but storytellers. It set up forums where people shared personal perspectives, learnt from one another and reconnected.

Medicine too has its Balint groups, its surgical morbidity and mortality meetings, its clinical debriefs. But perhaps there are other things it can learn from storytelling and drama.

Notably, when asked what has struck them most about working behind the scenes in drama and theatre, all three medical advisers mention the efficacy and sheer joy of on-set multi-professional teams where everyone is focused on the same end: producing a show. 

Prof Powell says he has learnt lessons for his own practice in having a ‘shared team goal, clear roles and responsibilities based on professional training and experience, and strong leadership’.

For Mr Peters, who is a cancer surgeon, working on set helps make sense of all that is powerful about a cancer multidisciplinary team.

‘You find a whole team of incredible experts – from actors, directors and camera people to make-up artists and prosthetic experts – all of whom are working together to produce the best-quality end result they can. Exactly like we do in cancer care. This pulling together is massively motivating and satisfying.’

What interests Dr Morgan about theatre and its ‘more radical cross-disciplinary working’ especially is the way it encourages subjective contributions (when the director asks, ‘Have you thought about saying it like this?’) and cultivates empathy through seeing up close other people’s contribution and challenges. 

He is reminded that ‘the most valuable communication skills training we have is often with actors in medical school, who do an amazing job crying, shouting, laughing’.

‘In ICU we have a lot of emergencies. We are teams thrown together, with a kind of director coordinating the resuscitation, advising people on different things, people having different tasks. It is clichéd to say it but theatre is definitely like medicine when it is working well. 

‘Perhaps it is time to bring a little more theatre to the theatre, more art into the art of medicine.’

One of drama’s greatest gifts is the reminder we share a common struggle, and human behaviour is often predictable, that we’ve been here before.

When teaching a module on innovation as part of a healthcare leadership course, Prof Powell draws on his work as medical adviser to the writers of Casualty 1909. This was a hospital drama set in the early days of anaesthetics when health workers were adapting to rapid change.

‘There is nothing new about innovation,’ he says. ‘In health systems we are always dealing with change. We’re struggling now to think, for example: How do we get AI systems adopted into hospitals? 

‘There may be lessons for us from looking back and asking: How were the first anaesthetics introduced? Or how was a new medical profession established in Victorian times? The technology is new, but most of the challenges are not.’

If stories help health professionals reconnect with patients and colleagues, could they help healthcare connect more broadly, perhaps with those it struggles to persuade?

One serious challenge the health system needs to address, Dr Morgan says, is the widespread ‘lack of trust in institutions’, which plays out in reactions such as vaccine hesitancy.

During COVID, he was active on social media, challenging anti-vaxxers, although he is more wary now of engaging with them and helping algorithms highlight conspiracy theories.

Similarly, pushing back against negative portrayals of health professionals is something Mr Peters is very hot on. 

‘One of the things I really try and get across in all the dramas I work on is: doctors really care about their patients and want to do the best by them.’

What is clear is the NHS needs allies from other fields to help present its case, whether that is engaging the public, advocating on patients’ behalf to policymakers, or speaking up for its workforce.

The recent ITV drama Breathtaking made powerful policy points about personal protective equipment and staff wellbeing through a dramatised retelling of COVID’s early days in secondary care. Its author, Rachel Clarke, was a documentary-maker before going into palliative medicine.

And perhaps there are new alliances and new storytellers to be explored, says Prof Powell.

He is interested, for example, in the largely untapped potential of celebrities and influencers – those whose stories or values we find compelling – to persuade especially young people into healthy behaviour.

‘That age group live digital lives and get their information from TikTok or YouTube. We can’t just stand by and observe. Public health needs to engage with this world and begin to understand how it’s used for health messaging.’

He recently undertook a review of published work on social media and health which showed influencers can have significant effects on outcomes such as diet and body image.

One study showed how children were more likely to favour a healthier snack when the unhealthy alternative was promoted by an overweight influencer, suggesting the messenger may be as important as the message. 

Choosing Prof Sir Chris Whitty and Sir Patrick Vallance to front the daily COVID briefings during lockdown, to build public trust and compliance, was one of the Government’s smarter moves.

But perhaps there is another point: medicine needs also to find ways to tell its own story, distancing itself sometimes from the high drama of TV soaps. Being honest about ‘unfixable’ problems was the poignant part of Dr Morgan’s ‘Letter from ICU’ – and a good place to start, he says.

‘I often say there are probably only three important tools we have in ICU that save people’s lives: time, antibiotics and good nursing care. There are a few others, like surgery and steroids, but there is not a massive secret cupboard of cures. It is often the simple things which are the most impactful. We need to be clearer about what medicine can, should and should not do.’

Editor’s note: Dr Tom Hughes, a consultant neurologist in the University Hospital of Wales, said he was pleased to be quoted by Dr Morgan, but he would like to give the original source of the quote. It was he thinks the late Julian Tudor Hart, one of the greats of general practice, who, when asked ‘What is it reasonable for a patient to expect from a consultation?’, said, ‘Some help in making sense of their story’.