Expanding Narrative Medicine through the Collaborative Construction and Compelling Performance of Stories

Abstract

This essay proposes an expansion of the concept of narrative competence, beyond close reading, to include two more skills: the collaborative construction and compelling performance of stories. To show how this enhanced form of narrative competence can be attained, the essay describes Off Script, a cocurricular medical storytelling program with three phases: 1) creative writing workshop, 2) dress rehearsal, and 3) public performance of stories. In these phases, Off Script combines literary studies, creative writing, reflective practice, collegial feedback, and drama. With increased narrative competence, Off Script participants are likely better equipped to engage in more impactful health advocacy and partner with patients more effectively.

In healthcare, stories are everywhere—from anxious whispers in waiting rooms to snappy presentations on rounds to weary complaints after a long day’s work. Media culture in the United States also abounds with medical tales: illness memoirs, physician-led podcasts, hospital-based dramas, and a news cycle spiked with scandals and breakthroughs. In such a swirl of stories, it is easy to forget that much of medicine revolves around a crucial exchange—often halting, broken—between one who is ill and another who promises help (Brody 1994).

Sadly, in clinical settings in the US, patients’ stories are routinely discouraged and dismissed. Yet, patients remain eager for their doctors’ attention. They know that careful listening contributes to a healing relationship (Jagosh et al. 2011). However, for doctors, distractions are rampant. For example, the more actively physicians engage with the electronic medical record (EMR), the less likely patients are to participate (Street et al. 2018). Even when doctors try to listen, they tend to resist patients’ elaborations, interrupting them early and often (Rhoades et al. 2001). Stories are cut short.

Despite such corrosive forces, a hunger for sharing stories of illness and caregiving persists among clinicians, researchers, trainees, and the non-medical community. We have seen this first-hand. In 2016, two of Houston’s medical schools (Baylor College of Medicine and McGovern Medical School) came together to launch a co-curricular program called Off Script: Stories from the Heart of Medicine. In 2020, a new partner joined the act: the University of Houston Tilman J. Fertitta Family College of Medicine.

We chose the phrase off script for its layers of meaning. Medicine has many scripts. From filling EMR boxes to taking a history to presenting a patient, clinical contexts often come with strict expectations regarding what information should be conveyed, by whom, and how. Sometimes, however, it is valuable to disrupt and expand those scripts (Poirier and Brauner 1988). In that spirit, Off Script is open to community members of any background. Twice annually, we assemble a diverse cast of participants to share stories in their own voices. They tell of disability, comfort, grief, healing, addiction, and much more. Furthermore, the phrase off script reminds us that there are always larger stories that could be told—narratives of patients, their loved ones, and caregivers that are not easily squeezed into traditional clinical formats. Finally, like theatrical scripts, Off Script’s stories are written to be performed for an audience.

From the start, our primary goal as organizers was to highlight the central role of stories in healthcare. We sought to spark greater interest in narrative medicine among clinicians and trainees at all levels. But it soon became clear that Off Script would also be a space for interprofessional exchange and community engagement, which tend to make stories more thoughtful and responsive to diverse experiences. In Off Script, a participant’s story begins as a creative text, is refined through collegial feedback, and culminates in a public performance. Through these steps, we wish to add to narrative medicine’s traditional focus on close reading two equally important skills: the collaborative construction and compelling performance of stories. We argue that because these skills are crucial to good clinical care and health advocacy, they should be seen as essential to narrative competence. By helping participants develop all three of these skills, Off Script offers them enhanced training in narrative competence. In this way, Off Script contributes to both the practice and theory of narrative medicine. Our hope is that other educators may learn from the Off Script model and adapt it to fit their own institutions.

Going Off Script: A new approach to medical storytelling

In 2016, when Off Script began, we joined a family of similar offerings nationwide. Just before the inaugural Off Script, The Nocturnists held their first live storytelling event for internal medicine residents in California’s Bay Area (Silverman 2017). The same group has gone on to host similar performances in New York City and to create a podcast. Also in 2016, in Philadelphia, Annals Story Slam began giving physicians regular chances to narrate their experiences of doctoring. The following year, with Talk Rx, Stanford University’s School of Medicine followed suit, staging a variety of stories by trainees in medicine and other health professions.

In this mic-tapping milieu, several things set Off Script apart. First, Off Script is not only a storytelling event; more like a train than a single car, Off Script is comprised of interlinked phases: the choice of a timely theme, circulation of a call for stories, review of submissions to select participants, a dynamic writing workshop, dress rehearsal, and performance. Often, as a story passes through the latter stages, it undergoes a metamorphosis. For that reason, Off Script can be understood as an iterative process of collaborative narrative development.

Second, one need not be a healthcare professional to participate in Off Script. We partner with undergraduate medical humanities programs at Rice University and the University of Houston. As a result, almost every iteration of Off Script includes stories from students who major in music, architecture, journalism, or other fields. Recently, we also joined forces with Inprint, a literary arts non-profit supporting readers and writers in various genres. A natural ally, Inprint helps solicit stories for Off Script and invites thousands of people to attend the performance. Finally, we share our call for submissions with dozens of health-oriented community organizations. Through such outreach, we consistently generate a diverse cast of participants, including artists, motorcyclists, teachers, poet-gardeners, lay caregivers, former patients, and others. For healthcare professionals and trainees, Off Script is a site of community engagement—one of learning from (not merely speaking to) non-clinicians.

Third, Off Script is an interprofessional experience, beginning with the three of us, the organizers. We each work in academic medicine, but we do so in different capacities: a clinical ethicist, a physician, and an educator in medical humanities. We conduct scholarly research, but we also publish fiction, poetry, and creative nonfiction. With these diverse skills, we each lead writing workshops for Off Script participants. In each workshop, medical students and physicians gather around a conference table (or virtually) with professionals and trainees from other fields, such as nursing, dentistry, and art therapy. The setting is egalitarian, where a 19-year-old social work student might question a metaphor deployed by a retired oncologist. In this way, the workshop becomes a venue for interprofessional exchange. Participants speak from contrasting perspectives of training, practice, and life phases, offering one another constructive comments on their stories. Similarly, the performance draws a diverse audience, serving as a bridge between medicine’s more insular scripts and the social issues that can illuminate medical education and practice.

Below, we begin by contrasting traditional training in narrative medicine with Off Script’s more expansive approach, which encompasses a writing workshop, storytelling rehearsal, and dramatic performance.

Traditional training in narrative medicine

In recent decades, various scholars have expressed frustration with the trend toward overspecialization, bureaucratization, and dehumanization in US medicine (Fox 1985; Rothman 2003). Narrative medicine is a force that seeks to counter those trends. Rita Charon has defined narrative medicine as “medicine practiced with the narrative competence to recognize, absorb, interpret, and be moved by the stories of illness” (Charon 2006, vii). Narrative competence can be gained, Charon argues, by reading and writing either on one’s own or with others in workshops.

The traditional narrative medicine workshop aims to instill in participants the skill of close reading, which involves a careful examination of various aspects of a text, such as its genre, use of imagery, and portrayal of time (Charon 2016). Workshop participants learn to scrutinize literary texts, discuss them rigorously, write reflectively about them, and explore one another’s responses to their writing. This approach stems from the premise that, when paying careful attention to a creative text or another work of art, participants mimic the kinds of close observation that patient encounters demand of clinicians (Spiegel and Spencer 2016). More specifically, the narrative medicine workshop prepares participants to register details of patients’ experiences, sit with discomfort, tolerate ambiguity, explore multiple interpretations, and empathize with unfamiliar perspectives (Spiegel and Spencer 2016). Typically, the workshop’s facilitator does not pre-assign reading or writing. Instead, the group reads and responds to texts together, with the goal of improving participants’ capacities to relate to one another. Through it all, participants strive to gain greater narrative competence for a single, overarching reason: to improve their care for patients (Charon, Hermann, and Devlin 2016).

An overview of Off Script: Workshop, rehearsal, and performance

Like traditional training in narrative medicine, Off Script values the skills of close reading, reflective writing, and interpersonal understanding; however, we believe that training in narrative medicine should not stop there. By also engaging participants in creative writing, collegial feedback, and performance, Off Script provides richer training in narrative medicine. Before arguing for that claim, we offer an overview of Off Script’s three phases. In this section, we wish to show that various approaches to representation (e.g., creative writing and oration) need not be kept separate. In Off Script, several approaches are entangled, which might nurture participants’ reflections on storytelling processes and diverse narrative forms.

Creative writing workshop

The Off Script workshop format was designed by one of us (M.E.), a physician and graduate of the Iowa Writers’ Workshop. To catalyze each Off Script, we issue a public call for stories that respond to a particular theme (Table 1). Writers are referred to HIPAA guidelines, and submissions are vetted accordingly. Not every submission is accepted. Our selection depends on several criteria: how well a story suits the theme, the quality of writing (e.g., clarity and creative style), the text’s potential for further development, and a final slate of stories that will be varied in plot and tone. We also strive to ensure the representation of the Texas Medical Center and broader Houston communities by including students, clinicians, patients, and others.

Table 1.

Sample Off Script prompt

Theme	Family
Prompt	Without support from family or friends, navigating the unfamiliar can be nearly impossible. Yet, at the same time, familiar bonds can be strained or weakened by our desire to protect loved ones. Tell a story about the meaning of “family”—how family was disrupted, strained or bonded, repaired or redesigned. Your story may be true of imaginary.

After we select storytellers, we provide initial feedback and request a first revision, which is the draft to be shared in the workshop. We always point out that making changes is voluntary, but to date, no one has declined to revise. To accommodate each storyteller’s schedule, we offer two 90-minute workshops approximately two weeks before the performance. Each storyteller participates in one workshop.

In contrast with the traditional narrative medicine workshop, Off Script storytellers are expected to read and write outside the classroom. First, prior to the workshop, each storyteller is asked to read—and make notes on—two stories by fellow participants. To aid them in doing so, we give them guidelines (Table 2). As a result, each storyteller writes brief letters to two of their peers, offering them generous praise and supportive advice. Furthermore, to inspire creativity and increase awareness of key narrative elements, the workshop facilitator assigns participants another short reading: a published literary piece that is exemplary in some way (e.g., unique structure or voice). In our experience, these pre-assigned tasks keep the workshop running efficiently, with a focus on craft and constructive feedback. Examples of craft considerations are character development, suspenseful scene construction, realistic dialogue, and diction’s contributions to narrative perspective. For example, if a story is told from a patient’s point of view, the author should probably minimize their use of medical terminology.

Table 2.

Off Script workshop guidelines^a

Before Class	Prior to workshop, you are expected to read the two manuscripts that were assigned to you. If you have time, our recommendation is that you read each manuscript twice as follows:
First Read	You are reading to learn what the story is about, identify large themes, determine the story’s overarching structure, identify characters, and familiarize yourself with the language or prose style. You can annotate the texts but try not to spend too much time on minutiae. This is a cursory read.
Second Read	Take a break from the text. When you return, focus on details. Annotate the text if you haven’t done so already. Pay attention to awkward sentences or grammatical errors. Write a short 1-2 paragraph letter to the author summarizing your thoughts and suggestions. If you have trouble organizing your thoughts, consider using the In-Class conversation guide to structure your letter.
In Class	Each writer will be given an opportunity to read their story. After reading, the writer is not permitted to speak until the group’s discussion of the story has ended. We’ll ask each assigned reader to offer what you thought the story was about (plot, social issue, moral question, etc.), what elements of the work excited you most (character, images, etc.) and, finally, one important suggestion for revision. Keep your remarks brief. After both readers have commented, we will open discussion for additional comments before allowing the author to ask questions.
Additional Rules of Etiquette	As participants, express your comments and criticisms respectfully. Frame your questions in the context of the text; that is, try to reference “the writing” or “the narrator.” The story might be nonfiction and deeply personal. Please do not pressure the author to reveal more than they wish to share. Be generous with your praise. Remember: it takes an immense amount of bravery to share a piece of writing. The writer can ask questions at the end, but only for clarification. Avoid defending or explaining your artistic choices.

^aAdapted from the Ethan Canin Workshop, Iowa Writers’ Workshop, Fall 2014.

During the workshop, each participant is encouraged to read their story in less than seven minutes—an expectation they know in advance, which, down the road, allows the group of six or seven to perform in under an hour. Accordingly, stories range from 900 to 1,200 words in length. After each reading, the other workshop participants discuss the piece for ten minutes or so, giving special attention to the close reading elements of form, frame, time, plot, and desire (Charon 2005). The facilitator often follows the “In Class” guidelines to stimulate conversation (Table 2). Each storyteller is encouraged to listen attentively and refrain from speaking as their piece is considered by the group. As participants discuss a story, the storyteller undergoes the challenges of monitoring their own responses, refraining from hasty reactions, and pondering proposed changes. When the discussion ends, the storyteller is permitted to do no more than ask clarifying questions. This, participants find, is one of the most challenging aspects of the workshop experience: quiet, careful listening. Informally, many storytellers report that they fight the urge to interject with rebuttals or clarifications. Yet, for clinicians and trainees, it is a valuable exercise—an experience comparable to that of a patient who has been consigned to a passive role as their condition is discussed at the bedside. Through this format, each Off Script participant occupies the dual role of storyteller and respondent. As a reader, writer, and commentator, each person is gaining experience in the collaborative construction of stories.

Before the workshop ends, we reserve time to discuss the published literary piece that participants were asked to read in advance. Because not all storytellers will have a high level of health literacy, we find it helpful to assign stories that do not foreground medical events or experiences. This strategy directs attention away from topics like medical professionalism, diagnosis, and treatment. Instead, the group’s focus stays squarely on aspects of craft, such as what retrospective narration adds to Haruki Murakami’s “The Wind Cave.” Through such discussions, storytellers often glean additional ideas for improving their own writing.

In one sense, to represent is to depict or portray one thing (e.g., an idea or experience) in another form, such as dance, painting, or story. As an action, Charon points out, representation involves a creative fashioning of what has been experienced into something new (Charon 2016). The result is a novel product, not an exact copy.

Medical education has tended to treat various approaches to representation as distinct (Howley, Gaufberg, and King 2020). For example, the Fundamental Role of the Arts and Humanities in Medical Education (FRAHME), published by the Association of American Medical Colleges (AAMC), discusses narrative medicine, theatre and drama, reflective writing, literature, and creative writing in separate sections. No portion of the report considers the potential for the integration of these approaches (Howley, Gaufberg, and King 2020). Similarly, a scoping review of the literature (1991–2019) on how the arts and humanities are used in medical education found that creative writing and poetry represented the smallest portion of pedagogical approaches (8 percent) compared to theatre and drama (9 percent), narrative medicine (11 percent), reflective writing (15 percent), literature (26 percent), and others (Moniz et al. 2021a).

The scoping review did not consider or identify learning strategies that combine multiple approaches, as Off Script does. In Off Script, we strive to help storytellers gain greater awareness of their capacities for representation in various forms. We do so by interweaving literary study with creative writing, reflective writing (e.g., participants’ letters to each other), and techniques from theatre and drama, as discussed below. On this particular point, we share Nellie Hermann’s (2016) view of narrative medicine. Hermann contends that it is possible to overcome pedagogical partitioning. She argues that all storytelling—oral or written, fiction or nonfiction—involves craft. That is, every story expresses choices—made consciously or not—about form, perspective, style, language, imagery, and much more (Hermann 2016). For Hermann (2016), craft is central to narrative medicine’s work of representing, whether clinicians write about their own experiences or those of others. We agree. To reflect more deeply on their experiences and to represent others’ voices more compellingly, Off Script storytellers often employ creative techniques (e.g., literary allusions and nonlinear depictions of time).

Here, it is worth noting that the research team behind the scoping review also recently proposed a new model to advance a theory of practice for arts and humanities in medical education. This “prism model” highlights four functions of the arts and humanities—mastering skills, perspective taking, personal insight, and social advocacy—that are “most powerful in combination, as a method to refract the spectrum of pedagogical possibilities” (Moniz et al. 2021b, 212). As we discuss later, some Off Script stories fulfill all four functions endorsed by the prism model.

Charon (2005) writes that the attentive posture of an oral historian or interviewer enables a storyteller to hear themselves speak. Telling, she argues, cannot go on without a listener, whether real or imagined (Charon 2005). By convening a sundry group of storytellers to respond to one another, Off Script encourages participants to internalize a teller-listener dynamic. We believe telling, listening, and responding can be refined. During the workshop, participants prod each other to search for more precise language, evoke vivid scenes, and paint characters with new layers. When a detail is not clear or events do not flow smoothly, we say so. The storyteller is expected to work harder to reveal the conflict or generate suspense. By stretching their writing in such directions, workshop participants often find expression for what had previously resisted articulation.

Anthropologist Clifford Geertz has described such writing as “thick description”—an essential tenet of ethnography and a writing practice that seeks an accurate representation of human behavior (Geertz 1973, 3–30). Thick description requires exquisite attention. When each storyteller, prior to the workshop, writes letters to peers about their stories, they have begun to practice close reading and representation of another’s work. That is, before workshop participants ever meet, they have already adopted the posture of attentive listeners to each other’s stories. This is consistent with Charon’s view that representation, rooted in witnessing, follows from close reading and careful attention (Charon 2005).

Successfully deploying point of view in creative writing is an example of an act of representation. During the workshop, we specifically discuss who is doing the telling and from what perspective in time and space. Consider this excerpt from a medical student’s story:

Not every relationship has that moment of singular clarity where its hopeful outlook becomes a fated reality. But somehow mine did. I’ll never forget it. It was nighttime. The 47-degree cool wind gently brushed our faces as we looked onto the shimmering surface of the lake. Just cold enough that even bundled up in layers, we had to huddle together for warmth. The campfire crackled in the center. We’re roasting marshmallows. But I’m not paying any attention. I’m rambling, jumping from topic to topic. I am fully myself. There’s no pressure to perform. She keeps up, responding in stride. She wants to stretch her legs out so she stands up. I look up at her and all of a sudden I’m on the outside looking in. Wow. We could actually work out. I could picture our life together. This was it. Something I never knew I was searching for my entire life. That feeling of deep connection which the breadth of human language could not fully encapsulate. In Chinese, we would call this Yuan Fen.

This was a lovely work of fiction about a Chinese American son’s growing adoration for a young woman, despite his father’s disapproval of the relationship. In the workshop, the writer was complimented on his use of vivid imagery, humor, and snappy dialogue throughout the piece. However, regarding the scene depicted above, fellow storytellers expressed their desire for a more robust representation of the young woman. Could we hear her speak, or could she do more than stretch her legs? The storyteller agreed and revised accordingly.

Here is an excerpt from another story, written by a university professor, that benefitted from post-workshop revisions:

It was midnight and my husband had gone to bed. I had been sitting for way too long as I graded papers and had forgotten to take my heart medication the night before. I got up from my chair and took the pills I needed. But as I climbed the stairs towards our bedroom, I became faint and finally collapsed. My body was splayed across the top several steps of the staircase, with my head on the landing. All I could move were my head and my arm. I called out to my husband, but our bedroom door was closed and he didn’t awake. I noticed that my phone was in my hand, but I didn’t think to call him with it. Instead, I threw it at the bedroom door, only to watch it bounce right down the hall.

In this non-fiction piece, the author had already offered a marvelous account of her relationship with her mother, who had died peacefully after breaking a hip. Embedded within this story was the author’s own encounter with the disordered body—the sequela of a pulmonary embolism. That encounter reached its climax in the scene above. During the workshop, fellow storytellers responded to a previous draft by asking for clarity as to where the author’s body was in the domestic space, which body parts were unmovable, how difficult it might have been to lift the phone with the one working hand, and then, whether the inability to move was a result of true paralysis or overwhelming fatigue. The author pondered these questions, weighed their relative importance, and produced a richer, more precise rendering, as seen in the excerpt above.

Both of these storytellers were delighted with the feedback and received it warmly. But above all, it was the diversity of their workshop groups that allowed for textured conversation. In Off Script, representation also means representative points of view. That is, we are interested in clinicians’ and non-clinicians’ experiences of health-related phenomena. The workshop’s assemblage of clinicians, pre-health professional students, trainees, and other community members is a central feature of Off Script. So far, through 13 iterations, Off Script has had 65 storytellers, ten of whom contributed on two or more occasions (Table 3). As participants are aided in the development of their stories, they are encouraged to consider and respect others’ perspectives. Ideally, the workshop becomes a space for egalitarian collaboration, where each storyteller is a full participant and is striving for better listening and representation (in narrative form) through the group’s own diversity of representation. That diversity is crucial, as noted earlier, for ensuring that Off Script is a place for mutual learning through interprofessional exchange.

Table 3.

Off Script participants by career, role, or stage of training

Participants	Count
Faculty
Hospitalist	2
Pediatric Palliative Care	3
Internal Medicine	2
Physical Medicine and Rehabilitation	1
Pediatric Neurologist	1
Humanities	2
Obstetrics and Gynecology	1
Pediatric Infectious Disease	1
Neonatologist	1
Pediatric Ophthalmologist	1
Total	15
Postdoctoral Fellows
Humanities	1
Clinical	1
Total	2
Residents
PGY1	1
PGY2	3
PGY3	2
Total	7
Medical Students
1st Year	2
2nd Year	3
3rd Year	6
4th Year	4
Total	15
Dental Students	1
Other Graduate Students	2
Undergraduate Students	14
Administrators	3
Nurses	1
Art Therapists	1
Music Therapists	1
Others Community Members	3
Total Participants	65

Yet, such empathic witnessing of stories does not end with the workshop. It extends to the dress rehearsal, during which facilitators and fellow storytellers offer each participant additional comments.

Dress rehearsal

Off Script’s focus is not simply on developing well-written and engaging stories but also on the performance of those stories in front of an audience. Honing one’s ability to deliver an emotionally resonant performance of a text requires a different focus and set of skills. As the storytellers are revising their drafts, we encourage them to read the words aloud, preferably to someone else—such as a close confidant, attentive pet, or most proximate high school drama teacher. Not only does practicing help ease the nervous tension that normally accompanies public speaking, but it also helps the storyteller develop an ear for language and the differences between the written and spoken word.

A few days before the performance, we reconvene for a dress rehearsal. Off Script organizers and peers comment on each storyteller’s penultimate draft and their performance of the text. We listen for the emotional current of the piece and look for places where a change in pace or tone of voice might produce the desired impact on listeners. We might also suggest gestures to accompany particular aspects of the piece. For example, one storyteller enhanced his delivery by miming the action of furiously pedaling his bicycle, and nervously glancing behind him, as he told of being chased by a pack of angry dogs. Suddenly, the audience could absorb the scene as the storyteller wanted—as one both horrific and hilarious. One need only imagine the same events being told in monotone with hands hanging flaccidly by the storyteller’s sides to see the difference that a bit of gesticulation can make. Such stage directions—alongside pointers regarding emphasis, eye contact, body language, and more—all work together to help storytellers develop stage presence, which is a “performance sensibility that ensures the delivery of a good story” (Hammer et al. 2011, 19).

Healthcare encounters can be understood as performances in which physicians, students, other caregivers, and even patients all enact different roles (Case and Brauner 2010). Of course, the dramatic events that transpire in hospitals and clinics are real; yet, as we note above, there are certain scripts those encounters routinely incorporate (Frank 2007). Our purpose in helping storytellers focus on their performance is to develop their voice as healthcare professionals or community members who have experienced illness or cared for those who are ill. By learning to perform engaging and memorable stories, healthcare professionals, in particular, can improve their ability to communicate with patients and colleagues. Participants learn not only how to share their own stories but also to consider the emotional impacts their stories might have on others. Performing a story in front of an audience cultivates empathetic imagination, “a cognitive skill set that helps one to imagine the experiences and responses of another person” (Case and Brauner 2010, 159). By conveying their stories to others with emotional resonance, they might learn “not to turn away from the struggles presented, but rather to accept and acknowledge them at a deeply empathic level” (Shapiro, Kasman, and Shafer 2006, 236). In light of these points, it seems likely that, for healthcare professionals and trainees, the practice of vulnerable self-revelation in front of an audience of strangers could help prepare them to be more emotionally engaged with patients.

Performance

As performance day draws near, storytellers work feverishly to finalize the pieces they will share with the live or virtual audience. Meanwhile, the Off Script organizers labor behind the scenes to ensure the performance runs smoothly. We develop slides with pictures and colorful biographies to introduce the storytellers, advertise widely, and make decisions about the order of performance. These decisions are often based on the overall tone of their individual stories. For example, to keep the audience engaged (and not overly disturbed), we try to juxtapose stories of suffering with light-hearted personal narratives. While most of the accepted pieces tend to be serious in tone and subject matter, there are often enough heart-warming stories to offer a respite through a shift in mood and perspective.

Before the COVID-19 pandemic, our storytelling events were held in various auditoriums on the Texas Medical Center (TMC) campus. Audiences were comprised primarily of faculty, staff, and trainees from TMC member institutions but also included family, friends, and interested community members. During the pandemic, we have moved our performances online, which has opened the experience to a wider audience. We have also introduced a Q&A session as part of the program, which allows audience members to learn more about the writers’ craft and their inspiration for the stories, such as why a palliative care physician chose to write about the death of a particular patient. To produce the event, the three Off Script organizers take turns serving in the roles of emcee, stage manager, and Q&A moderator. Each role is vital for ensuring that attendees leave the auditorium (or virtual event) with a deeper appreciation for medical storytelling. To date, Off Script performances have reached an audience of approximately 800 people.

Expanding the concept of narrative competence

So far, we have described and illustrated the phases of Off Script, contrasting them with traditional training in narrative medicine. In this section, we argue that Off Script makes unique contributions to the theory and practice of narrative medicine. Specifically, Off Script trains participants in two skills that, alongside close reading, should be recognized as components of narrative competence: the collaborative construction and compelling performance of stories. These skills are vital to narrative competence because of their centrality to good clinical care and meaningful health advocacy.

Collaborative construction of stories

People seek medical care, Howard Brody (1994) has argued, because their stories are broken. Brody was among the first scholars to illuminate the significant role clinicians play in helping to repair patients’ disrupted stories. Underlying all else that happens during medical care, a “major part of all good doctor-patient encounters” is what Brody (1994, 85) calls “the joint construction of narrative.” Through their interactions, doctor and patient ultimately seek both an explanation for the patient’s experience and a therapeutic plan that are mutually acceptable. This task, Brody (1994, 85) acknowledges, is “complex” and “consists of many elements,” not the least of which is the patient’s full involvement in the “give-and-take” of conversation. The patient brings particular beliefs, concerns, values, questions, goals, and much more. The physician must offer their careful attention, professional skills, specialized knowledge, and compassion. Both persons should contribute, Brody contends, to the authorship of the new story that emerges from their relationship. The patient must see themselves in the physician’s explanation before they can embrace it and engage with treatment. For doctors, failing to partner with patients in coauthoring stories is to bypass a crucial route for understanding, comforting, and empowering patients as participants in care.

Brody’s emphasis on the dialogical construction of the patient’s story seems to have influenced narrative medicine. For medical learners at all levels, the goal of training in narrative medicine is “to achieve a state of attentive and empathic affiliation with a patient” (Charon, Hermann, and Devlin 2016, 347). This state requires a clinician “to seek the necessary perspectives beyond their own,” wondering about the mysterious, asking questions about the unclear, until, finally, they arrive with the patient at a story that both regard as an adequate representation (Charon, Hermann, and Devlin 2016, 347). Such “narrative reciprocity … implies that the care situation is an interaction between equal participants who collaboratively construct meaning rather than one where the expert practitioner dictates meaning to a patient” (Weiss and Swede 2019, 4).

Building on these ideas, Off Script contributes to narrative competence by training participants in the joint construction of stories. As noted earlier, it is typical for an Off Script story to be revised at least three times: pre-workshop, post-workshop, and between dress rehearsal and performance. Through written and spoken feedback from their peers and us, each storyteller is nudged repeatedly to revisit the tension between what they wish to communicate and others’ interpretations of their story. From start to finish, Off Script is a collegial process, with each participant learning to respond to others’ suggestions for revisions. Doing so requires vulnerability and humility. Through their story, they expose their previously hidden thoughts and feelings to others’ scrutiny. Furthermore, each time they return to what they have written, another storyteller models empathic witnessing by carefully reflecting on the choices they make as the author. By considering potential alterations, they allow their voice to commingle with the workshop’s other voices.

However, even more valuable than the work of crafting their own narratives is, we suspect, learning to respond helpfully to others’ stories. This is where participation in Off Script connects most clearly with patient care. Of course, physicians, trainees, and their fellow health professionals are already adept at responding to one kind of narrative: the clinical case. More than 30 years ago, Kathryn Montgomery observed that this specific form of the patient’s story had emerged as the basic unit of knowledge and discourse in medical education and practice (Hunter 1991). Physicians translate each patient’s experience of illness into the concise language of the clinical case, which typically includes markers of the patient’s identity, current symptoms, recent medical interventions, the patient’s other health conditions, and so on. The clinical case is chronicled in the patient’s chart, to be expanded there and shared, perhaps, in rounds, conferences, and other settings. Ironically, for the sake of medical understanding and treatment, Montgomery writes, the patient’s experiences and accounts of illness are “distorted,” “flattened,” and “almost obliterated” when rendered a clinical case (Hunter 1991, 13).

Like most of us in the health humanities, Montgomery is troubled by this flattening of patients’ stories. She goes on to propose that “good decisions about patient care beyond the diagnosis call for a richer narrative than the traditional medical case” (Hunter 1991, 149). Evidence for this claim has emerged from clinical settings as varied as genetics counseling, fetal cardiology, surgical training for medical students, and primary care (Charon, Hermann, and Devlin 2016). What doctors need, Montgomery concludes, is “a literary sense of the lives in which illness and medical care take place” (Hunter 1991, 149).

To develop a literary sense of a patient’s life, doctors must pay careful attention to them, inviting and listening for information that exceeds the framework of the clinical case. To do so, various conversational approaches could prove useful. One influential and time-tested method is the BATHE Technique, which guides clinicians in “obtaining psychosocial data while supporting patients and building a therapeutic relationship” (Stuart and Lieberman 2019, xiii). Designed for primary care doctors, BATHE is an effective tool for developing rapport and exploring the patient’s perspective within the time constraints of a typical office visit.

BATHE is a five-step acronym that helps physicians “understand patients’ problems in the context of their total life situations” (Stuart and Lieberman 2019, 3). The first four letters stand for aspects of the patient’s experience (Background, Affect, Trouble, and Handling), which the doctor should probe separately through open-ended questions (Table 4). The acronym’s final letter reminds the doctor to express empathy for the patient’s trouble and how they are handling it. Ideally, BATHE occurs after the patient expresses their chief concern and alongside the history of present illness (HPI), but the timing is flexible. For the doctor, the goal is to uncover and respond supportively to the story the patient is telling themselves about the way things are. Together, they forge a shared understanding of the patient’s experience, which guides the development of a mutually acceptable treatment plan. BATHE can also help physicians identify patients who should be referred for counseling or other care.

Table 4.

Analogy between clinical interview and Off Script workshop discussion

The BATHE Technique: Clinician’s Questions for Patients	Off Script Workshop: Questions Participants Could Ask about a Peer’s Story
B – Background
What is going on in your life?	What motivated or inspired the story? What is happening in the story? How does a main character’s background inform the story’s action?
A – Affect
How does that make you feel?	What emotion, tone, or attitude is expressed by the story’s narrative perspective? What are the dominant moods associated with the story’s action? How does the storyteller want the audience to feel about, or in response to, this story?
T – Trouble
What about it troubles you most?	What is this story’s central conflict? What is a main character’s most significant problem or struggle? How, if at all, should the storyteller make the conflict clearer?
H – Handling
How are you handling that?	Does this story have a resolution? How does a main character address their most significant problem or struggle? Are the story’s resolution(s) and the storyteller’s goals for the work aligned?
E – Empathy
That must be very difficult.	Show support for the storyteller’s efforts. Express admiration for something the story does successfully. Affirm the value of one of the story’s main themes, struggles, or goals.

When Off Script participants respond to a peer’s story, they do something similar to the doctor’s work of eliciting and addressing what is happening in a patient’s life. Notice, for example, the analogy between BATHE and the range of questions workshop participants might pose about a peer’s story (Table 4). Each part of BATHE is mirrored by an aspect of the story that participants illuminate through discussion and often helps the author improve. They talk about the story’s background, moods, conflicts, and potential resolutions, inviting the storyteller to consider new possibilities. Furthermore, because most Off Script stories are personal narratives, a storyteller’s experience of peer encouragement and admiration for their work can be significant beyond feeling supported in their literary efforts.

Apart from BATHE, there are other behaviors and communication strategies doctors could adopt to cultivate meaningful interactions with patients. For example, Donna Zulman and colleagues (2020) synthesized evidence from a systematic literature review, observations of primary care encounters, and qualitative interviews with physicians to identify five practices that foster physician presence and engagement with patients. One such practice is to “connect with the patient’s story,” which involves considering “the personal circumstances that influence a patient’s health” and focusing on the positive by “acknowledging a patient’s efforts and celebrating successes” (Zulman et al. 2020, 77). Whether clinicians prefer BATHE or another approach, there is clear evidence that exploring the patient’s story, affirming their perspective, and encouraging their efforts contribute to positive health outcomes (Zulman et al. 2020).

By teaching Off Script participants to respond effectively to peers’ narratives, we prepare them to engage with patients in the collaborative construction of stories. After seeing the transformation of their own stories, participants often express gratitude to peers and facilitators. Apart from anecdotes, we do not yet have evidence for the long-term effects of participation in Off Script. However, in a recent study, Christy Remein and colleagues (2022) identify the impacts of an interprofessional narrative writing session at an academic health sciences center. Most participants reported growth in communication, self-reflection, active listening, and perspective-taking, while slightly fewer than half also experienced greater empathy for others (Remein et al. 2022). In light of these findings, it is reasonable to suppose that Off Script sharpens participants’ communication skills in similar ways. Clinicians, trainees, and other health professionals are likely to come away from Off Script better equipped to partner with patients in the joint construction of their illness and treatment stories.

Compelling performance of stories

Physicians and other healthcare professionals communicate with colleagues and the lay public through various channels, such as news interviews, legislative hearings, and social media. To converse effectively and deliver compelling performances, they must master several skills. First, they must know their audience. Rhetors in the ancient world called this decorum, which is the assignment of the appropriate level of style to distinct rhetorical purposes. Discerning how audiences will respond to particular rhetorical devices enables the speaker to make their message resonate. Orators from Cicero to Bill Clinton have thrived because they understood their audiences and spoke directly to their needs. They knew what to say, how to say it, and what not to utter. When the audience is composed of other healthcare professionals (HCPs), brevity and clarity are essential. HCPs are accustomed to receiving information in a highly formulaic presentation that emphasizes plot over character, whether it is delivered aloud or through texts, emails, or notes in the EMR. Language that is overly flowery or conveyed with excessive emotion is likely to be poorly received. This observation brings us to the second skill: diction. Choosing one’s words carefully is essential. The wrong word at the wrong time can be devastating. For example, saying “I understand” in response to someone who is grieving can strain credibility and undermine trust (Patel 2018). Finally, compelling performances are built on confident stage presence and intentional delivery. The right body language is essential for rapport and compassionate communication. HCPs who deliver their assessments from doorways or who tower over patients—instead of sitting thoughtfully, like the doctor in Fildes’s painting (Kao 2022)—project imperiousness and condescension. Attention to proximity and gestures can help build bonds. In different places, each of these skills comes into play in different ways.

In inpatient settings, attending physicians and trainees tell each other stories almost daily during handoff and rounds. While the script for information exchange varies slightly between specialties, the opportunity remains to tell moving stories that provide insights into both the patient and their disease. Conveying accurate health information is important, but there are also techniques that may make presenting a patient more memorable, such as mentioning a hobby, a career, or an achievement. Initiatives are underway in numerous hospitals to post personal information about patients unrelated to their medical care in their rooms and as part of the medical record. When blended with medical information, these glimpses into patients’ personal lives might remind HCPs that they are treating complex people, not disembodied diseases.

Effective storytelling is also vital to efficient and compassionate communication during family meetings to discuss goals of care. Patients and their loved ones often ask physicians and other HCPs some version of this question: “What would you do if you were me or if it were your loved one?” Many clinicians are reluctant to respond for fear of either saying the wrong thing or implying that what they would decide should be determinative for the listener. However, a compelling story about how the doctor struggled through a similar challenge can be very effective when told to acknowledge the current difficulty.

As we help storytellers refine and perform their work, we try to demonstrate the value of good storytelling for improving health-related communication, whether among HCPs, between clinicians and patients, or in health advocacy. One Off Script participant, V. Karri, published a story from the perspective of a patient who had recently been incarcerated (Karri 2019). Writing with narrative humility (DasGupta 2008), Karri draws on her clinical experiences as a medical student to craft for the patient an imagined, internal monologue describing his frustrations with weight gain, stigma, finding meaningful employment, and providing for his family. Karri’s story transports audience members beyond statistics to the heart of another’s predicament, making them aware of health disparities and the need for social change. Stories such as hers can draw readers into the moral universe of disenfranchised and marginalized populations. When performing on the Off Script stage, Karri adopted a quiet, almost wistful persona that channeled the narrator’s anxiety and unease while visiting the clinic for the first time since returning home from prison. Her performance was compelling because she was able to draw on a range of emotions and moods: confidence, defensiveness, jocularity, hopefulness, fear, and the joy of feeling heard. In these ways, Karri’s story fulfills each function of the prism model discussed earlier: mastering skills, perspective-taking, personal insight, and social advocacy.

Like Louise Aronson, we regard the performance side of storytelling as a necessary tool for “public medical communication” that physicians should learn to practice (Aronson 2020, 126). In this moment of anti-science bias and “fake news,” physicians and other HCPs must be able to tell compelling stories to educate, correct misconceptions, and promote changes in health systems that will benefit patients, caregivers, and communities.

Off Script’s co-curricular contributions to health humanities education

At each level of health professions education and in every type of training program, the humanities’ role in curricula varies widely. As a co-curricular experience, Off Script is designed to supplement the health humanities requirements of our institutional partners by offering students training in narrative competence.

Tzipi Weiss and Marci Swede (2019) have argued that teaching narrative competence to undergraduates is a useful way to prepare them for the practice of relationship-centered care (RCC) as health professionals. According to the RCC model, the effectiveness of care depends in part on the quality of a doctor’s relationships in each of four dimensions: self, patients, colleagues, and society. These dimensions, Weiss and Swede observe, mirror narrative medicine’s four basic narrative situations. While undergraduates might be years from starting their careers, Weiss and Swede (2019) contend that it is not too early to help them develop habits of reflection, self-awareness, cooperation, and empathy, which are central to RCC. Such habits are reinforced, we have argued, by Off Script’s interpersonal approach to teaching narrative competence. So, for undergraduates with little other exposure to narrative medicine, a program like Off Script could cultivate their readiness to practice RCC.

The same is true, we believe, for medical students, residents, and other trainees in the health professions. Ideally, these phases of education would include robust humanities experiences, but at many institutions, they do not. Because Off Script combines literary studies, creative writing, reflection, interprofessional exchange, and performance, a program like ours would serve as a rich resource for learners at humanities-poor institutions.

Furthermore, to counter the danger of a training program becoming a “bubble” that isolates learners from patients and other communities (Gaw 2015), an Off Script-like program could puncture the bubble, providing a place for social engagement. As noted earlier, Off Script performances attract large and diverse audiences, including many from outside healthcare. For clinicians and medical trainees, an Off Script performance can be a practical venue for reflecting on the physician-society dimension of relationship-centered care. For performers, this setting also offers the chance to tell a story that runs counter to US culture’s dominant narratives (also called “malignant narratives”), which are the oppressive, overarching stories that perpetuate health inequities (e.g., the narrative of race as a biological trait) (AMA and AAMC 2021, 5). As storytellers anticipate performing for a diverse audience, we hope they will craft a health equity-based narrative, which is one that attends to “inequitable systems, hierarchies, social structure, power relations, and institutional practices to reveal the sources of inequalities and the mechanisms that sustain them” (AMA and AAMC 2021, 24). Storytellers who choose to do so would, like V. Karri, engage directly in health advocacy through this forum for public medical communication.

Finally, it is worth noting that an Off Script-like program could take many forms, adding a new dimension to learners’ education in the health humanities. For example, an undergraduate instructor in nursing, social work, or health humanities could oversee an Off Script program that includes both their students and participants in a transitional housing program. Similarly, an Off Script program could pair medical students in a health humanities elective with, say, members of an artists’ collective. Or geriatric fellows and their attendings could partner with residents of an assisted living facility. How plentiful the possible permutations.

Conclusion

After reviewing various approaches to teaching writing in healthcare education, Lisa Kerr ultimately advocates for instruction in literary creative writing. Such training has the capacity to encompass the more self-oriented goals of reflective writing, she contends, while also preparing learners to care for others. “In health care,” Kerr (2010, 300) writes, “focusing attention beyond the self is crucial to projects that seek to teach narrative competence, especially if the goal is to promote not only self-expression and self-awareness but also the ability to observe, listen, and empathize.”

Off Script adopts the methods of literary creative writing and situates them in an other-directed process. We train participants in narrative competence not only by teaching close reading but also by imparting skills in the collaborative construction and compelling performance of stories. Such training, we have argued, is likely to prepare participants to partner with patients more effectively and to engage in more impactful health advocacy.

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