On a rainy Friday afternoon at the University of Minnesota Community-University Health Care Center (CUHCC), EmmaLee Pallai welcomes a group of health science students and clinic patients seated around a large table. She invites them to grab a slice of pizza and salad and keep up their friendly banter. The hard work will begin in a minute.
Education manager Pallai’s mission is to build trust between future medical providers and their patients and she’s doing it at this south Minneapolis clinic with an approach not typically found in medical texts. Pallai teaches “narrative health,” a model in which providers become better listeners through the sharing of personal stories — their patients’, certainly — but more compellingly their own.
The thinking is that when providers reveal their own vulnerabilities, be it around mental health struggles, weight issues or just their own uncertainty about treatments, doctor-patient walls as immutable as marble tumble down and patient outcomes improve. This is likely why the approach is gaining national momentum.
“Doctors are taught to rely on the test to tell the story,” said Pallai, who was hired by CUHCC about three years ago to create fresh approaches to patient care for the clinic’s extraordinarily diverse and often underserved populations. CUHCC sees approximately 12,000 patients a year — Somali, Hmong, Latino among them. Almost 90 percent are low-income.
“When we think of the traditional medical model today, it’s so insurance driven,” said Pallai, whose master’s degree is, not coincidentally, in creative writing.
“What is lost is the listening,” she said. “If you have diabetes, you need insulin. If you have any interactions with humans, you need to know how to listen. The narrative approach allows doctors and patients together to create the rapport to get the story. They have the luxury of time,” Pallai said, “and the luxury of the patient taking the time.”
And it isn’t just a feel-good approach. The model shows promise for the bottom line. “The better relationship you have with your patient, the more likely they are to come see you,” Pallai said. “We’re keeping patients out of the emergency room.”
The online health resource VeryWell Health noted several studies showing that patients may experience improvements in symptoms and health when encouraged to express their emotions about their illness. That can be accomplished in just two minutes, if a doctor is willing to listen.
New name, old concept
Narrative health is not new; just the name is. “Storytelling for healing has been around from the dawn of time,” Pallai said, “to help people feel better, or to explain what is going on with them.”
Sara Bolnick, CUHCC’s grant and program manager, also acknowledged the concept’s deep roots. “You can look back at lots of older health care practices in other countries used for centuries that are steeped in partnerships,” Bolnick said.
One example is the Community Health Worker (CHW) model, expanding in Minnesota. Also called care guides and health navigators, CHWs offer patient education and informal counseling and coaching, often drawing out important information through casual conversations.
One community health worker, for example, was asked by a client to help her find a free or low-cost gym to work off stress. In the course of their discussion about that, the health worker learned that the woman’s boyfriend was beating her up. She quickly called in a social worker.
Still, putting the patient in the driver’s seat of his or her wellness plan can be a tough sell for practitioners eager to, and trained to, take charge, diagnose and heal. The industrialization of medicine in the mid 20th century shifted care from such partnerships to a more hierarchical and paternalistic model.
Bolnick acknowledges “the high level of expertise and hard work that goes into that profession. But there are a lot of opportunities to learn from patients as well.”
Methods vary for getting that to happen. Pallai attended a conference where the patient and doctor were each prompted to write their own version of their interactions as the patient faced a brain tumor.
The exercise, she said, revealed “how much they didn’t understand what the other was going through.”
Her approach at CUHCC is more informal — and tasty.
“We do it seated together over a meal,” she said, noting that the act of dining together monthly “gives us a chance to start with something neutral. Storytelling over a meal is kind of natural to me. It helps break down barriers.”
Bolnick agreed. “The power of providers being vulnerable and opening up can elicit that same reaction from patients,” she said. “It’s giving a little to get a little.”
Yet, everybody feels intimidated at first, including the future practitioners. Close to 200 students across the U’s professional schools rotate through CUHCC each year, hailing from social work, medicine, nursing, pharmacy, psychiatry, law, communication and behavioral health programs.
Pallai was mentored and inspired by CUHCC’s former mental health director, Dennis Maurer, who championed talking to patients instead of talking down to them. Maurer died in 2017, “but with his encouragement, and his relationships with patients,” she began to build the program.
“Some are so onboard from the beginning,” Pallai said of the students. Others need coaxing to let down their guard and show vulnerability. Patients have their own concerns when asked to tell their health care stories.
“At first, they are afraid of their spelling. They want help writing. As people start coming regularly and getting positive enforcement, they begin to do it on their own.”
A safe space to share
On this afternoon, Pallai has chosen as her prompt a short story titled “Hair Matters,” by Regina A. Arnold. Arnold writes poignantly about losing her hair during chemotherapy.
At an earlier session, Pallai had the group read a poem about a man with Type 2 diabetes.
“These are conversation starters,” she said. Readings are followed by a structured exercise, with everyone in the room writing about an interface with the health care system. In one 90-minute session, a woman without health insurance shared her agonizing 11-year journey to an accurate diagnosis, bandied about from system to system until she finally found a doctor who listened to her.
Sharing stories is optional, but many do.
Marta, who asked that only her first name be used, is a second year U resident in pediatrics and internal medicine. Long a believer in “the power of stories as a way to connect on a more human level,” she was drawn to CUHCC.
She read aloud her story about seeking help a few years ago from a psychiatrist for depression and anxiety. He put her on a medication that caused weight gain, then brushed aside her concerns.
“I felt really small and weak,” she said. “I thought, maybe I don’t have the willpower, but I was kind of shocked that a psychiatrist wouldn’t understand the connection between the medication and weight gain. I can only imagine how my patients would feel, with a lot less empowerment than I had, given my position in medicine.”
After she read, she remembers a patient in the room thanking her, then sharing her own health story. Another patient was inspired to offer up that he was grateful for days when he feels good.
“There’s always a little bit of awkwardness, especially when we come from such different backgrounds,” Marta said. “The assumption is that we have so little in common. Then you go into this vulnerable space with them. Patients want to know that their doctors are human, especially with something as powerful as mental health.”
The pendulum does seem to be swinging back. Columbia University inaugurated the first Master of Science in Narrative Medicine in 2009, noting in its mission statement that “the care of the sick unfolds in stories.” Other universities are offering coursework in the field.
Closer to home, Minneapolis-based Mixed Blood Theatre Co., in collaboration with the HealthPartners Institute, will offer two evening sessions in February using the narrative medicine model “to reduce biases and other barriers” in the Cedar-Riverside neighborhood, said Mixed Blood Chief Engagement Officer Keri Clifton.
Pallai looks forward to more opportunities to teach. One future doctor expressed surprise and delight after participating in a narrative health session.
“When I heard [the patient’s] story,” the student said, “I got all the information I needed to fill out my medical chart.”