Abstract

Despite medicine’s technological advances and multibillion-dollar revenue streams, healthcare would not function without stories. Yet, too often in clinical spaces and in the podcasts, social media posts, and news reports that amplify medicine’s achievements, certain stories are told while others are neglected. To create a space for sharing stories from all corners of healthcare, three Houston medical schools joined with undergraduate programs and others to lead a storytelling event. Off Script: Stories from the Heart of Medicine is a twice-yearly storytelling event that helps build healthier communities through creative writing and public performance of diverse stories. Physicians who participate in Off Script report improvements in patient care and self-care behaviors. Students and others report positive effects on their professional development. Through Off Script, narrative approaches to medicine are shared with the community, which may improve patient-physician communication and affect health outcomes.

Keywords: storytelling, interprofessionalism, community building, narrative medicine, self-care

Visit your local barbershop, linger in the grocery store’s produce section, or stand in line at the deli, and you’re bound to hear snippets of stories. They are shared freely among friends, told and retold in office spaces, and broadcast over the airwaves. In daily life, stories hold us together. Similarly, modern medicine could not function without the exchange of stories about patients and new discoveries. In the emergency department, anxious patients commiserate over their indefinite wait times while freshly caffeinated physicians whizz past in elevators debating the latest medical triumph. However, too often in healthcare spaces—and in the podcasts, social media posts, and newspaper articles that amplify them—certain stories are told while others are neglected. Inspired by the diversity of nonclinical stories shared on the Moth Radio Hour, two of Houston’s leading medical schools, McGovern Medical School and Baylor College of Medicine, came together to launch a storytelling event of their own (Nash et al. 2023). The goal was to create a space for sharing stories from all corners of healthcare. In 2016, they held the first performance of this new initiative, which they branded “Off Script: Stories from the Heart of Medicine.” Four years later, the newly built University of Houston Tilman J. Fertitta Family College of Medicine joined the partnership. The college’s focus on community engagement and public health was a natural fit for Off Script.

Twice annually, storytellers from across the Texas Medical Center (TMC) community (the world’s largest medical complex, featuring a network of 5 medical schools, 13 hospitals, 8 undergraduate and graduate institutions, and numerous other organizations) and the greater Houston community gather on the Off Script stage to share stories about uncertainty, joy, healing, dying, and much more. To be clear, Off Script is no open-mic gabfest. Months before the curtain rises, the organizers^[1] select a timely theme and craft several writing prompts. Flyers with the call for stories populate countless inboxes. Soon our submission portal fills with stories, which we carefully review and discuss as a group. Those whose drafts are chosen must then participate in a dynamic writing workshop and dress rehearsal. More often than not, as a story passes through these phases, it undergoes several transformations. The workshop and dress rehearsal give space for stories to breathe, shed superfluous layers, and evolve into evocative and memorable narratives. These phases of the Off Script process serve as catalysts for the co-construction of stories through interprofessional exchange and the development of a diverse writing community. In this essay, I will highlight these two elements, as they are central to Off Script’s success.

The Stories of Off Script

From the start, the primary goal of Off Script has been to celebrate the diversity of stories that emerge in healthcare contexts. The organizers wanted to open a welcoming space within the medical community for interprofessional exchange and community building. While a great deal of media attention is focused on physicians, they aren’t the only ones with compelling stories to tell. Bedside nurses have unique insights into patients’ daily struggles. Graduate, undergraduate, and medical students cope with personal illnesses and their own insecurities as they search for their place in healthcare institutions. Patients have stories to tell as well. Sharing these stories with colleagues in the TMC and with the general public builds stronger connections among Houstonians.

Off Script’s own origin story began with a meeting of the now-defunct Narrative Medicine Program at the Center for Medical Ethics and Health Policy at Baylor College of Medicine in December 2015. In its heyday, the program drew members from across the TMC and included multiple residents, a postdoctoral fellow in medical humanities, a cardiologist, pediatricians, palliative care physicians, and a research assistant. Planning for Off Script began in earnest in January 2016. Members of the program initially conceived it as a way to boost morale, promote self-care, and normalize the practice of sharing stories as an essential part of the humanistic practice of medicine. From the beginning, the organizers expressed concern about how these stories might affect both the audience and the storyteller. We deliberated about whether to begin each event with a disclaimer that would alert the audience that distressing topics might be discussed. We also considered whether a mental health professional might need to be on hand to offer services to those who became overwhelmed. Ultimately, we decided not to pursue either path. We felt the disclaimer would impose a particular meaning on the stories being shared, while having a mental health worker on hand might give the impression that the event was designed to be trauma-inducing or therapeutic—neither of which is true.

To ensure that we serve as many members of the TMC and Houston communities as possible, Off Script has always been open to everyone. The only requirement for participation as a storyteller is to produce a compelling story sketch that touches on the event’s theme and can be read for an audience in seven minutes. Stories may be creative works of fiction, nonfiction, or a mix of both. As a result of casting such a wide net, the Off Script stage has welcomed music majors, residents, literary scholars, patients, art and music therapists, administrators, high school teachers, visual artists, and many others from diverse backgrounds. The stories we’ve received and workshopped over the years have primarily originated from members of local institutions of higher learning. In particular, our partnerships with undergraduate medical humanities programs at Rice University and the University of Houston have expanded our pool of storytellers through their advertising and storyteller recruitment efforts and financial support.

Unique and Uniquely Houstonian

As one of the nation’s largest cities, and the home of the world’s most extensive medical center, Houston is a treasure trove of stories. Many of our students, faculty, and staff come from diverse backgrounds and have unique life experiences to share. We draw on that diversity in choosing the Off Script themes. From time to time, we also try to choose themes that resonate with particular events affecting Houstonians. Sometimes Off Script can serve as an opportunity to share perspectives on troubling events that have affected the entire community, which helps to bring us all closer together. For example, an event focused on Hurricane Harvey and another about how the pandemic affected Houstonians were, for the Off Script audiences, occasions for collective catharsis.

After Hurricane Harvey devastated Houston and the Texas Gulf Coast region in the summer of 2017, we decided to dedicate an Off Script to stories about the flood. Our theme for that iteration, “After the Flood,” drew submissions from students, faculty, and staff. For one student storyteller, the massive rainfall that accompanied Harvey became a metaphor for the emotional impact of witnessing a relative’s final illness and the failure of the medical team to help weather the storm. Another storyteller, a physician, survived both Hurricanes Katrina and Harvey and compared the two in terms of their impact on the storyteller’s family. A third storyteller, another physician, described the receding floodwaters as an opportunity to process grief at the loss of a close relative. Not all stories were focused on personal tragedy. One author found comfort in their children’s enthusiasm for a “hurri-cation,” while another made light of their personal situation to cope with the stress of living in flood-damaged housing.

One storyteller, an administrative assistant, recalled a tragicomic scene with cats who inhabited the bottom floors of the storyteller’s apartment building, which had been partially demolished by contractors after the storm. Her story described the “nighttime rambling” of the neighbors’ cats as they nonchalantly staked their claims on occupied land and the storyteller’s initial impulse to repel the invaders with a water pistol, which eventually turned into a resolution to let the cats “work it out for themselves.” These moments of levity amidst the collective grief and frustration of a city still working its way out of a natural disaster provided a much-needed balm.

As the pandemic unfolded in early spring of 2020, we had already planned an event with the theme of “Hope.” Just when stories of hope would have been most welcome, we were prohibited from holding in-person events, so these stories were shelved until the fall of that troublesome year. As the routines of daily life began to settle over the summer, we resolved to resurrect Off Script as an opportunity for the community to come together. Sadly, as the fall of 2020 approached, we still weren’t ready to see each other in person. Instead, we communed over the cold blue screens of Zoom, trying to breathe life into a medium that sprung up overnight as a way to connect us. Expanding to a virtual format did open up a few new opportunities. Instead of encouraging the crowd to stick around after the live performance to chat with the storytellers and munch on appetizers, we allotted time for Q and A. Storytellers were invited to opt out if they didn’t want to answer questions—no one did. The audiences at these virtual events posed questions about craft and how the writers found time to hone it. In addition, opening up the event to a virtual audience meant that we could host folks from outside the Houston area and expand to a national audience of short story fans. Before that option became viable (and, to be fair, necessary), we were lucky to have 40 attendees. Over Zoom, we regularly attracted 50 to 60 folks. We set a new Off Script attendance record with 120 virtual attendees for a 2021 performance. Although we’ve since returned to in-person events, we occasionally offer a virtual option. Those virtual events likely were so popular because we managed to capture some element of our collective experience of living through challenging times.

In 2021, our fall call for the theme of “Homebound” asked storytellers to consider not only the comforts and pleasures of home, but also, in the context of widespread lockdowns, the ways in which being homebound isolates and confines. We anticipated that the theme would inspire stories about pet shenanigans, roommate feuds, cooking hijinks, or videoconferencing gone wrong. In fact, one medical student wrote a work of fiction about two college-age twin sisters who became stuck in the same household as the city went into lockdown. She explored how the fiercely competitive siblings revived old jealousies, which they then channeled into a collaborative baking project. The author deftly used the metaphor of a marble cake to explore the potential for melding different personalities and perspectives. Another submission from a music therapist related her newfound hobby of watching traffic from her apartment in the city. She described the flow of traffic as a fleeting glimpse of community, something she noted might be the only thing that could save humanity from the ravages of the pandemic.

As a community that strives to be inclusive, Off Script is open to perspectives from all community members. Stories shared on the Off Script stage likely resonate with audience members and participants alike because they tap into universal themes of strength, guilt, resilience, frustration, death, dying, healing, and hope (Table 1). The story sketches described above are only a small portion of the many wonderful stories that have been shared over the last eight years.

Contextualizing Off Script

Storytelling in medicine has experienced a surge in popularity since Off Script began in 2016. Stanford University’s Talk Rx and the Annals of Internal Medicine’s Story Slam are live events that feature stories from healthcare practitioners. Podcasts like What Brings You In Today, The Nocturnists, and The Short Coat provide digital spaces for clinicians and students to share their stories. Yet, the connection between writing stories that originate within medicine and learning to tell better stories within clinical spaces remains underdeveloped. On one such medical storytelling podcast, Explore the Space, Emily Silverman, founder of The Nocturnists, noted that the format they use is not necessarily conducive to clinical spaces (Silverman 2018). However, other projects have demonstrated that stories can be co-constructed from within clinical spaces so that both patients and healthcare professionals can benefit. The My Life, My Story (MLMS) project, conceived in Wisconsin, popularized in Boston, and now featured in over 60 VA hospitals across the nation, is one way in which storytelling is gaining traction within the clinical encounter. MLMS involves training students, clinicians, staff, and volunteers to elicit patients’ stories about their lives outside of the medical context in order to learn more about them as people. Through a detailed interview process, healthcare learners and professionals gather important information about the patient’s needs, goals, and values. These details are then transformed into a narrative, which is then placed in the patient’s chart for all who have access to read. After five years of implementation at a single site, nurses, physicians, and staff continue to report that reading these stories was a good use of clinical time, helped them provide better care, and had an impact on both the patient and the provider (Roberts et al. 2020). Another study involving trainees in the interviewing and writing roles suggested that MLMS is “helpful for building skills for showing empathy, building relationships, and really listening” (Nathan et al. 2022).

Feedback Builds Community

Like the programs profiled above, our storytelling approach is rooted in some common narrative medicine practices but branches off in new directions. Rita Charon, one of the founders of narrative medicine, describes narrative medicine as “clinical medicine fortified by the knowledge of what to do with stories” (Charon, 2006). Narrative medicine practitioners develop what she and others call “narrative competence,” that is, the ability to recognize, absorb, interpret, and be moved by stories of illness and suffering. Close reading and interpretation of complex texts prepares clinicians and learners for the intricacies of patients’ stories—their twists, turns, valleys, and peaks. By practicing these skills in narrative medicine workshops (and during preparations for Off Script as well), clinicians and learners learn to balance emotional involvement and detachment. During narrative medicine workshops, participants receive feedback from fellow small group members on their writing and listen as others comment on texts that they have read together. Off Script workshops differ in that the participants have all read the same texts beforehand and provide feedback following a particular guideline (described below). In choosing which feedback to incorporate, storytellers learn to discern the key narrative elements in compelling stories and how to help patients co-construct their own stories of illness. Feedback from colleagues opens up new creative avenues, just as encouraging patients to describe how their symptoms affect their lives moves the story of their treatment in particular directions.  My colleagues and I view Off Script as training for practicing narrative medicine in clinical encounters, with an added emphasis on attending to the craft of writing. Below, I provide more details on what this added attention entails.

Once the organizers select stories for Off Script, the storytellers receive written feedback from us regarding their use of dialogue, scene setting, characterization, and more. Prior to the writing workshop, the organizers assign storytellers to read two other participants’ work and provide written comments. During the workshop, they provide each other with both praise and constructive criticism that is polite but direct. My colleagues and I describe the mechanics of the workshop in more detail elsewhere (Nash, et al. 2023). Here, I survey some of the insights and lessons learned from the writing workshop and the dress rehearsal based on seven semistructured interviews I conducted virtually as part of a program evaluation (Table 2). Participants were asked the same general questions with tailored follow-up questions depending on how they responded.

Former patients, medical students, and graduate students shared how participating in the workshop and rehearsal developed skills that were both professionally and personally valuable. I learned that while some storytellers have previously published poems, short stories, or scholarly articles, most of the participants did not have previous creative writing experience. Some reported that they were active diarists but had not previously considered sharing their writing publicly. Many were new to the experience of workshopping their stories. When asked about the experience in general and how the workshop and rehearsal affected their writing, participants noted that the rehearsal helped prepare them to share their work with an audience and to consider the adjustments needed to move from the written to the spoken word. In particular, one participant found that “getting laughs at the right moments” made it easier to “write the truth about other projects.” One medical student noted that the act of writing helped refine their thoughts and understand their feelings. Participants also praised the willingness and enthusiasm of their colleagues to give and receive feedback. Some found it “group therapy-ish” in that participants were willing to share insights into their personal lives that extended beyond the stories they submitted for feedback.

When asked about their experience giving and receiving feedback, participants were pleased with the feedback that they received from their colleagues in the workshop and rehearsal. Some noted that they felt no pressure to accept the changes that the group suggested, which made them more comfortable sharing their writing. In this way, the two workshops differ significantly from academic writing, since in that context these writers might have felt pressured to make the requested changes in order to receive a passing grade or to get an article accepted. Participants appreciated receiving “lots of little, tiny ideas and tweaks” from their fellow writers. One medical student noted that they hoped “sharing those really personal things helps other people work through their traumas,” a sentiment echoed by others. Medical students also agreed that writing helps serve as “another tool to sort of deal with the struggles of medical school.” Graduate students saw how some “points of connection” resonated with others and considered why that was true for some passages within their stories, but not others. Other participants felt that reading the stories aloud helped them transform the work into something more conversational. Medical and graduate students were more likely than other participants I interviewed to comment extensively on the feedback portion of the workshops.

When giving feedback to others, some storytellers struggled to find ways to comment on others’ deeply personal stories. One approach was to try to bracket the commentator’s relationship with the author and think only about the narrator’s voice or to offer comments about pace and sentence complexity instead of plausibility or emotional tone. Some participants approached giving feedback by first asking themselves how they might have written the piece to make it clearer or by considering what the writer is taking for granted and then posing the relevant questions to the writer. Before returning to these interviews, in the next section I provide an example of how giving feedback contributed to the final version of a participant’s story.

“Duking Out the Hazards”: An Example of the Impact of Feedback

Written while he was a resident about his first day at a new clinic, Sarat Munjuluri’s short story, “Duking Out the Hazards,” is a clever tongue-in-cheek retelling of a bike commute gone terribly awry. It’s a personal narrative that provides readers with an intimate glimpse into the daily routine of physicians in training. Those who assume that their well-coifed doctor in the freshly pressed white coat always arrives to work looking like they just stepped out of a salon may be surprised to learn that they sometimes have to deal with inclement weather and packs of ferocious dogs.

Munjuluri sets up the story by making it clear that, though he is wearing the appropriate gear for a chilly February morning bike ride, he is constitutionally averse to cold weather. However, bolstered by the community of “grizzled commuters” determined, like him, to enjoy the brisk weather and save a few bucks, he ventures forth. Along the way, he encounters (and flees from) the aforementioned canines, dodges traffic, and arrives disheveled and malodorous. In the original version, he is chastised by a nurse and slinks off to change. The story then launches into a discussion of various challenges patients face with accessing care, which shifts the tone of the story from a relatable episode of bad luck to a more formal white paper on health policy. Munjuluri’s workshop colleagues noticed this dramatic shift in tone and brought it to his attention. They also commented on the complexity of some of the story’s sentences and encouraged him to simplify them to make the story easier to follow. In keeping with the overall self-deprecating tone of the story, Munjuluri inserted a humorous nod to a “21st-century multicultural update” to the Dukes of Hazzard, which he displayed via an improvised leap over a small divot. Most importantly, reading the story aloud to the group helped Munjuluri find the lesson in the story and avoid the digression to abstract health policy concerns. Instead, he described how explaining his disheveled appearance and unpleasant experience opened the door to communication with his patients about their own transportation nightmares. While previous versions contained disjointed tales from different patients, Munjuluri introduced a single new character (a composite patient) at the end who laughed at his story, then grimaced from an impacted molar that couldn’t be removed because of a missed appointment that hadn’t been rescheduled. In so doing, Munjuluri was able to shift the reader’s concern from the resident to his patient.

The polished version of Munjuluri’s story and a video of his performance comprise a separate chapter of this book. Other chapters contain stories and performances by two more Off Script alumni, Sophia Peng and Ony Iheanacho.

Evaluating Off Script’s Impact on the Community

Data on the effects of writing workshops on healthcare professionals are limited. Many of the studies have focused on reflective, not creative, writing. Nonetheless, the evidence from these studies shows that participation in writing workshops and other activities involving reflective writing has an effect on reducing burnout, increasing empathy, and improving communication skills (Roberts et al. 2020; DasGupta and Charon 2004; Winkel et al. 2016; Pennebaker 2000; Lemay et al. 2017). In this section, I provide more information from the surveys and interviews I conducted that contribute valuable insights into how audience members and storytellers responded to Off Script. Audience members provided feedback on the diversity of the stories they heard, their professional storytelling practices, and whether hearing these stories changed their view of medicine. Storytellers provided feedback regarding the potential connection between storytelling and patient care, professional development, self-care practices, and community building.

We have collected data from two informal and anonymous surveys of attendees administered in December 2017 and March 2018 regarding their impressions of the events as described above.^[2] Twenty-eight audience members responded to the December 2017 survey, while thirty-two attendees responded to the March 2018 survey. We modified our survey after December 2017 and added a number of new questions. These new questions asked audience members to comment on their use of storytelling and whether their views of medicine changed as a result of their attendance at Off Script.

As part of our December 2017 survey, 86% of respondents agreed that the presentations represented diverse perspectives of clinical encounters. Others were more equivocal, noting that the perspectives were either somewhat or not really diverse. The negative responses noted that the performances were largely personal (not clinical) or could have reflected more diversity. In our March 2018 survey, 97% of respondents answered “yes” to the question “Do you feel that this evening’s presentations represented diverse perspectives?” The only “no” respondent noted that the stories were “a bit heavy on clinical medicine.”

As part of our revised survey in March 2018, we asked, “How often do you use storytelling in your professional life?”  Responses ran the gamut from “all the time” (3), “pretty often” (3) or “often” (2) to “not much” (4), “occasionally” (8), “rarely” (2), and “never” (4). Those who used storytelling in their professional life included trial lawyers, students, and healthcare professionals. One healthcare professional noted that they use storytelling “anytime we do an H and P [history and physical] on a patient.”

We also asked audience members as part of the same survey, “Did tonight’s performances change your view of medicine and healthcare? If so, how?” 41% answered “yes” while 31% answered “no.” Nine participants did not respond to the question. 53% of respondents provided additional free text responses. Most of the additional positive responses indicated that the audience gained new perspectives or insights into the experiences of patients and providers (Table 1). The negative responses reflected no change in views but emphasized the importance of illness narratives or the “difficulties” related to clinical practice. A limitation of this question is that we did not ask respondents to report their previous views of clinical medicine. Some respondents may have held a more reductionistic view of medicine while others may have already had a more humanistic view. Alternatively, their participation may not have changed their views at all because, perhaps, they did not find the experience sufficiently engaging or transformative.

Although it is not clear whether simply hearing diverse stories is sufficient for audience members to try on these perspectives or keep faith with their current views, exposure to diverse stories may be intrinsically valuable (Brody and Clark 2014). It is also likely that those who currently tell stories as part of their practice may naturally be drawn to these performances as audience members. Further research might focus on whether audience members who use stories in clinical practice intend to use stories more often after attending Off Script or whether audience members who don’t currently tell stories intend to incorporate reading or writing stories into their professional lives.

We also interviewed several Off Script storytellers. In addition to their comments on the workshop and rehearsal reported above, we asked about whether their participation in Off Script contributed to their interest in narrative medicine, the impact of Off Script on their professional development, and their use of storytelling in medicine. While these findings are not generalizable due to the small sample size and the nature of the evaluation, they serve as reflections on these participants’ experiences. This study has been approved by the Institutional Review Board at Baylor College of Medicine.

Storytelling and Patient Care

Physicians, medical students, and others offered reflections on how storytelling can help shape more caring healthcare professionals. For healthcare professionals and learners, part of this shaping involves deepening attentiveness and practicing patience. Martha Nussbaum defines perception as the ability to see a “complex, concrete reality in a highly lucid and richly responsive way” (1990, 7). Storytellers hone their perceptive abilities by becoming open to receiving the stories they hear every day. This practice aligns with Rita Charon’s call to learn to recognize and absorb patients’ stories (2007).

As described by one of the physician-storytellers I interviewed, the act of writing “helps us to understand the perspective of patients and families and acquaints us with the uncertainties of medical knowledge and clinical decision making.” They also observed that physicians who share stories and participate in the construction of stories with others become “more patient” when presented with a patient’s story in the clinic.

Considering time as an integral component of the illness experience, one medical student observed that Off Script has improved their ability to think about hospitalization as a single  event within a timeline. Instead of considering disease as an atemporal or ahistorical phenomenon, storytellers may learn to recognize time as an organizing element for patients’ stories that can help explain the disease process and illness experience more clearly. This realization led the student to “try harder to communicate the [patient] information in a story format or in a timeline, in a time-based format.”

Outside of the medical context, literary scholars who have participated in Off Script have noted that through stories “we grow as human beings, and to bring them into the setting of medical practice seems…a really natural and important thing to do.” They claim that stories in this sense are inextricable from patient care and can be introduced into the patient-healthcare provider relationship as a way to “inspire any individual to…find a way to survive.” The scholar explained that the inspiration to survive as found in stories applies to both patients and healthcare professionals.

 

Storytelling and Professional Development

Storytelling is not traditionally taught as part of the core medical or health professions curriculum. The effects of this lack of attention to stories in healthcare seems clear. As one physician I interviewed noted,

We physicians and scientists are terrible storytellers. And that’s the reason why there is so much distrust in medicine and distrust in science—because we don’t tell the story as well. We don’t tell it as the listener would want to listen to [it]. And even when we write manuscripts, we don’t tell good stories.

The physician went on to cite high rates of vaccine refusal during the early months of the pandemic as an example of telling the wrong story, the one that “misses half the people because it does not fit their narrative.” Instead of conveying facts through colorful pie charts or colorless statistics, physicians and other healthcare professionals must use stories if their goal is to change behavior. Although they may not be trained to tell good stories, they do tell stories as part of their everyday professional lives. Each presentation of a patient’s medical history starts roughly the same way: X-year-old patient was admitted with Y symptoms, worked up for Z disease, and treated with medication or surgery. Turning those plot points into a good story that will stick with the audience (whether it is fellow healthcare professionals, patients, or the general public) requires patience and practice. As Louise Aronson notes, the “best strategy for education and persuasion in the public arena is usually a story that shows rather than tells how the salient facts are relevant in a particular life” (2015, 125). For example, if healthcare professionals want to convince the public to adopt healthier habits, they have to tell good stories. Off Script offers an opportunity to make storytelling part of healthcare practitioners’ professional development, whether they are seasoned professionals or first-year medical students.

 

Storytelling and Self-Care

Storytelling both within and outside the context of narrative medicine is beginning to emerge as an evidence-based practice that can address different forms of burnout among healthcare professionals and learners (Childress et al. 2022; Winkel et al. 2016; Edwards et. al 2021; Malik et al. 2023). Indeed, several Off Script participants noted its potential benefits to providers as a self-care behavior. One physician noted that “if we have to take better care of our patients, we have to take better care of ourselves.” For this study participant, Off Script inspired a new role as leader of departmental writing workshops, which has helped clinical colleagues start “seeing each other as human beings.” As their work environment improved, this physician continued, colleagues experienced a greater sense of joy in the clinic, which translated to their providing better patient care. One graduate student noted that sharing stories can help with the loneliness and isolation that is common to the student experience. Storytelling “lets you know you’re not alone, that there’s help for things or…even just like being able to put your own experiences down on the page and share with somebody else that there’s this community aspect.” In this sense, sharing stories may be valuable for enhancing both individual and community health.

Creative Writing and Narrative Medicine in Communities

As the literature reviewed above notes, there is some evidence for the claim that storytelling can positively impact healthcare professionals. Another question worth considering is how to sustain these benefits over time.. One response would be to build communities of storytellers who routinely share their writing with one another and the general public. During Off Script, storytellers build connections with other writers and with the audience. If all goes well, the audience walks away from the event with more insights into the somewhat insular community of healthcare professionals. Furthermore, Off Script storytellers return to their lives in the community equipped with the skills of close reading and refined writing, as well as the ability to give constructive feedback, which they can redistribute to other community members, increasing the yield of these events.

Since Off Script cuts across disciplinary and institutional boundaries, our storytellers are in a unique position to share these tools widely throughout the community. Clinical practice fortified by this knowledge may contribute to community health by improving communication between patients and providers. Former patients, medical students, and graduate students noted that their understanding of who could practice some of the narrative skills taught in the workshops expanded as a result of participating in Off Script. One former patient previously thought that narrative medicine was simply “doctors doing writing workshops so that they could develop more empathy.” After the workshop, this individual began to see narrative threads among online patient support groups. Physicians were subsequently invited to visit these groups so they could incorporate these detailed illness experiences into their clinical practice.

Some students had previous exposure to narrative medicine from the flagship Narrative Medicine Program at Columbia and wanted to see different varieties of the discipline. One student left the workshop “absolutely fired up about what it is that we’re trying to achieve here and how effective it can be for practitioners, for patients, for providers, for listeners.” Other students saw narratives as critical components of health policy advocacy. They cited examples of incorporating maternal mortality statistics into their poetry to combine the evocative power of metaphor with cold hard facts. In addition, some felt that they were now able to use narrative skills to write into being the world they wanted to see. In general, the graduate and medical students felt “excited to be invited to be in the space of narrative medicine.” There may be hope that these budding storytellers will offer others the same welcome.

There may be other future applications of narrative medicine that extend beyond the local community. One medical student noted the potential for improved storytelling within the clinical space that may be used to build “better electronic and digital representations of real-world clinical processes in the electronic medical record.” Incorporating well-written patient narratives within the data stream of lab values and surgical notes and feeding that information into machine learning software may help improve patient care by linking stories to numbers that can be used to judge the quality of care. While it may seem overly reductive and antithetical to narrative medicine to attempt to tie stories to numbers, narrative medicine functions best when it not only honors patients’ and providers’ stories, but also improves patient care.

Conclusion

Off Script has evolved over its nine-year lifespan. As it continues to gain traction in the Texas Medical Center and broader Houston community, we imagine inviting guest workshop instructors and perhaps even having a one-on-one mentorship component for writers who are interested in publishing their work. This model of assigning a “story coach” has already been adopted by Talk Rx and The Nocturnists. From our interviews, we learned that participants would appreciate an additional writing workshop, perhaps to be led by the storytellers themselves. They would also like a chance to review all of the participants’ stories prior to the workshop and to give more feedback during the workshop. All of these efforts, we hope, will serve to develop the important and distinct contribution of storytelling to community building and patient care.

We continually strive for Off Script to serve as a magnet for diverse voices. To attract stories from communities outside of the TMC, we have formed partnerships with community health organizations and local museums. We’ve invited representatives from various nonprofits that serve Houston’s Third Ward and East End to share our call for submissions with people who are medically underserved. We’ve also held events at the Blaffer Art Museum on the University of Houston campus and The Health Museum. Our search for new venues and voices continues.

Storytellers often ask how they can develop their writing further or seek publication. In the past, we have provided a list of local and national outlets for creative or reflective writing, including Intima, Omentum, Human Ties Digest, Bellevue Literary Review, and others. We may explore creating an online repository of stories, complete with videos of the storytellers’ performances—with their permission, of course. We’ve also considered publishing an anthology of stories. With fourteen Off Script events under our belts, there’s no shortage of stories to choose from. The first step is including stories in this book, which their authors were thrilled to do. We are also offering storytellers honoraria for their work, which has resulted in a slight uptick in submissions. We are firm believers in rewarding storytellers for their work as a way to provide tangible recognition of the value of storytelling.

To evaluate Off Script, we have conducted individual interviews and administered surveys to audience members. We plan to add additional questions to our audience surveys related to the topics, issues, and the intended use of storytelling in their professional and personal lives following their involvement in Off Script. We would also like to export Off Script to community hospitals so that patients may take advantage of the writing workshops we offer. My Life, My Story provides one possible format for the co-construction of patients’ stories. If Off Script is to achieve its long-term goal of building healthier communities through storytelling, then we must ensure that stories from all corners of healthcare are recognized and honored.

References

Aronson, L. 2015. Story as evidence, evidence as story. JAMA 314 (2): 125-6. https://doi.org/10.1001/jama.2015.3930

Brody, H., and M. Clark. 2014. Narrative ethics: a narrative. Hastings Center Report 44 (1 Suppl): S7-11. https://doi.org/10.1002/hast.261

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