Write Medicine

Story Intelligence: Enabling Learning through the Powers of Story

November 15, 2021 Alexandra Howson PhD Season 2 Episode 18
Write Medicine
Story Intelligence: Enabling Learning through the Powers of Story
Show Notes Transcript Chapter Markers

We tell ourselves stories in order to live, as Joan Didion wrote in The White Album

We talk a lot about the importance of story on this podcast, and about storytelling as a portal to learning. In today's episode, we get to learn from a storytelling master. 

Rick Stone, CEO of StoryWork International, has spent a lifetime crafting stories in many sectors, including healthcare. He is the co-creator of StoryCare, a web-based product to help healthcare organizations improve patient safety and support team-based health professional education. He also created the Living Stories program for Novant Health, which supports patients in telling their life stories in service of improving their health outcomes. 

Rick is the co-author of Story Intelligence: Master Story, Master Life. I think you are in for a treat in this episode. Our conversation touched on:

  • The role of literature and art in cultivating empathy in medical professionals
  • The power of emotional intelligence
  • The narrative structure of the brain and how story is a powerful reagent to rewire the brain and help us learn new perspectives and points of view
  • The difference between case studies and stories 

Story Intelligence
The Healing Art of Storytelling 
Every Patient Tells a Story
Columbia University Narrative Medicine Program
Howard Gardner at Harvard
Mark Nepo
7000 Ways to Listen
Johnny Moses
Ronald Epstein
Paula Underwood
Peter Pappas
Sam Magill

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 Alexandra Howson  12:40

Hello, and welcome to Write Medicine. I'm here today with Rick stone. And we're going to talk about some of the issues he raises in his new book “Story Intelligence”. Welcome, Rick. Could you please introduce yourself for our listeners?


Rick Stone  13:00

Well, it depends upon you want the long story or the short story because there's always a story, right. But I've been for a long time and working with story and exploring its applications, both in personal healing. So, I have an early book that I wrote back in the 90s called the “Healing Art of Storytelling”. And, but I've also been looking at how we can apply it in all kinds of venues. And one of those is healthcare. And so, I've been weaving together many facets of what I've learned about story and bringing them into and applying them in settings like health care. And some of these are ancient lessons. And some of these are more contemporary insights that have come from things like MRI studies, what we're learning about how the brain functions and works. So, I find the weaving together of ancient wisdom with contemporary science feels very compatible with for me, and I think there's a lot to be learned from both.


Alexandra Howson  14:11

I'm really curious on how you do your research when you're weaving together such different traditions and resources.


Rick Stone  14:24

Well, you know, in another lifetime, I was in a doctoral program in psychology and into the consternation and upset of my parents. I dropped out to go study painting in Chicago. So, so I've always straddled both the arts and the sciences and you may hear rumbling of thunder right now. There are storms moving through Atlanta right now serious storms. Yeah, yeah. So can't do anything about that. But and so I've always found great solace and interest in looking at how researchers who define a problem and try to narrow in on, on how things are working, and why they work they serve the way they do. And then, but I've also come at it from a more artistic point of view as well. So, for me story is both an art and a science, by medicine, like medicine. So, there's so much of medicine that is certainly scientifically based and, yet, as a as a practitioner who's sitting with a patient who has a story, and who is bringing their life story to you in that room for those few minutes. And we know that from a lot of the research, the doctors often miss that story. And they miss important elements of the story that could help them in their diagnosis and treatment of the patient. Because they so quickly make a decision about what the diagnosis is. And once they do that, once they have that story in place, very difficult for them to even admit any other kinds of information. And then that story travels with the patient through the years. And then and the next practice, the next practitioner reads the medical record. And then they are influenced by that story in a way that they can't see other data that's presenting right in their face. And so that becomes a very interesting exploration of thinking about the complexities of our relationships with our provider and with ourself. And with our story, which is, carries within it often the clues for diagnosis. I can't remember the author's name, who wrote the he was writing on how doctors miss the diagnoses so quickly. And there's a terrific story in that book in which a woman who had suffered for like 20 years with all kinds of gastric symptoms and problems Finally, a doctor said, put the records the size it, let's start from the beginning, tell me tell me about when this first started when you were a child, and began hearing the story fresh, and said, “you know, I don't think you have x, I think you actually have y”. And that was the beginning of that person's healing and on the road to recovery. And every doctor before that had missed it, because they were deeply prejudiced by the previous stories that have been laid down in their medical record.


Alexandra Howson  17:36

Oh, that's so true. And there's so much good stuff there. And actually, as I was reading your book, "Story Intelligence”, I was thinking about, I was thinking about a couple of things. One was, I think, the same book that you're talking about, and I think it's called “Doctors Things”. How doctors think like, how your room Cooper, Jerome. Yeah, I'll look it up and make sure it's in the show notes. And there's a couple of other books in this same kind of terrain, “The patient's Story” by Lisa, someone who was actually a consultant on ER, or one of those medical series, and I was also thinking about Narrative Medicine because Columbia University has a narrative medicine program. And so, there's some years yeah, there's the kernel of that idea about the importance of the patient story beginning to grow again in in medical education, I think.


Rick Stone  18:31

Yeah, and then and there are counter pressures which you know, that every provider is just being pressured to spend as little time as possible. And within that paradigm, so much is missed. And we don't know we have no way of evaluating the cost of that to the patients to the system. And it looks more efficient, doesn't it? You know, at one level you're on a spreadsheet it looks more efficient, but actually long term it may be less efficient we may be doing great harm actually but through because of that so..


Alexandra Howson  19:06

Let's talk about “Story Intelligence”. Because at the heart of what you do is the application of story as in terms of its power for healing and as a modality for practice and I can really hear that as a star it's pretty amazing.  Describe what you mean by story intelligence. What is it and why is it important?


Rick Stone  19:44

So in my work, I, at some point with my partner Scott Livengood we were beginning to muse about the ways story enter weaves its way into every facet of life and week over a dinner one night on a napkin, we began mapping that out. So what ways are they and we began to hypothesize that there are kind of seven dimensions to it, we call them powers. But there are seven dimensions to which we can almost begin to see how story is the lever are integral to everything. And that our brains are wired for it. So much so that we can't even separate the notion of how we see the world. And in apart from thinking of it as a story, is that we have, and that those were stories actually get wired in neurally. Their neural patterns. There's the notion Donald Hebb came up with a concept probably 50-60 years ago, neurons that fire together wire together, right. And so, we know that as young people, our children are beginning to learn and they're exploring the world, they're laying down new neural pathways, and they're making connections, neural connections are happening. And suddenly, new wiring is happening all the time of ABB remarkable to be able to observe that, and it's still happening for us as adults as well. But at the same time, there's a certain degree to which patterns get sort of locked in. And there's great benefit to that, you know, you don't have to be thinking about in the morning, when you get out of bed, should I, will the floor meet my feet, and will I not go floating up to the ceiling, if I get out of bed, or you can brush your teeth and read a magazine at the same time, you don't need this, because those patterns that you know, you can go on automatic pilot. And there's a benefit of that. So just as in the in the mid 1990s, there was a lot of research that was being done on emotions. And you know Howard Gardner at Harvard came up with this notion of multiple intelligences back in the 80s. And, and a number of other researchers began using the term emotional intelligence, they began to see that there's something much more important to us than just our intellect, and our ability to solve problems intellectually. They saw that emotions were so crucial. And what we've been hypothesizing and beginning to believe is that, actually, with the newer research is being done with MRI machines that we're putting people in those machines. And as they're listening to stories and seeing what's going on neurally and the entrainment that happens between listeners and tellers is that there may be a substratum of intelligence that is even more important than the emotional and the intellectual, which is what we're calling story intelligence. And we're saying that story is so integral to what it means to be a human being, is that we can't separate our concept of humanity from our concept of story. And we can't we can't create a fine line between our neurophysiology and our culture in which is transported through stories. And if we think evolutionarily, is that probably story in our brain development over almost like stairsteps? You know, how is it that we, as humans, Hom sapiens, were able to dominate all the other human races that were around, there were other there are the Neanderthals and the HOMO Denis, Denis vins, and others. And somehow Homo sapiens, I think, develop the capacity to tell stories in a way that these other groups couldn't, which allow them to organize themselves in different ways. Because now I could tell you a story, and you now have a picture that you can carry with you. And, and if you tell that same story to 1000 people now 1000 people have the same story and the same picture in their mind. And now they know how to organize together and come together around a central idea, whether it's protecting the tribe or going out on a hunt, to capture a woolly mammoth, or whatever it was. And so that allowed for a much more integrated society to pause to happen. And if we look at culture, how are cow cultures transported? And how is it transmitted? It's through stories. And it just so happens that when we have a we have a shared story with all these other people that we have something in common, we feel like they're one of us. And likewise, at the same level is that when we feel like that people are foreign to us, and they're living in a different story than they're dangerous, and we have to be careful about them, because who knows what they what they value. And we develop stories often about the other, which can often as we know, be very tragic and pernicious and exploited by politicians and leaders. And so we have lots of examples of that as well.


Alexandra Howson  24:56

Well, let's talk about that just a little bit. Because one of the points you making the book is that you know, stories are fractured. We're not sharing a common story. And there are lots of meta narratives that deny the interconnectedness of everything. And emphasize, you know, our kind of separate us, given where we are historically, politically. And given how fractured healthcare has become, how does story start to work its magic in that kind of fractured setting?


Rick Stone  25:37

Yeah. So the first thing that I think is so crucial for us is to understand that we're living in that story. And so what happens so often is those stories live us. And we're unconscious of that. And we assume that that's the way the world is. And so we make very profound assumptions about ourselves and others and the world and the systems we're working in. And that this is the way. Well, this is the way things are, and this is the way they have to be, they should be. So first of all, that we have an unconsciousness, the fact that we're swimming in stories, just like a fish is not conscious that they're in water. That's the, that's the that's it, they're surrounded by water. That's all they know. And in some ways, we're swimming in stories. And we don't realize that and so there are some powerful stories about what the American healthcare system is, we'll focus on the American healthcare system and, and how it should be. And, and there's so much. There's so many stories that are myths, there's a mythology about American health care, which those of us who have worked in and around American healthcare, know are often way off base. And there are political forces that we'd like to keep those myths alive because they benefit from a fractured system, for example. So, I believe that we all can become the author of our stories. If we become conscious of them in it's so interesting, the word author and authority have a common root. So, he or she, who tells the story becomes the authority. Right? And so, who's telling the stories about American healthcare? And how are those stories being told? And what are their motivations for maintaining that story, you know, versus a different story.  And so there are competing stories and stories can be used as weapons against other groups and other people. And, and then we don't have often an agreement about even what the cause is there, there is often a common story, but we're seeing it through very different lenses. Okay, so if you're a nurse, you see that the story of healthcare through a very particular lens, if you're a physician, you see it from a different lens, if you're administrator, you see it through a different lens. And, and so and so what happens often is that people come to work together with the assumption that we're all within, we're all working on the same story, but we're not. And so those stories, bringing those stories to light and having conversation about what is the story that we're living here in this hospital, this is like a hospital. You know, why is it we're having so much harm is happening here, for example. And that, often, we don't look at that story. And or it's a complicated story, as we know, it has many layers of you know, Steve Powell, who's our colleague, you know, I don't know where this came from. But I learned it from Steve was that you know that hospitals are filled with experts. And everyone has gone through extensive years of training to develop their expertise in their little narrow area. Right? Yeah, they're there. They're very soft, but we don't have expert teams. We don't know anything about teamwork. You know, so we make an assumption, because we are if we have a staff of experts that they also and is sort of in some way four of us Moses can become know how to work well as a team. And that often is a faulty assumption is that the you know, the story here is that we're all working, you know, you are separate the ways are a little silo compartments. And that and then the patient suffers because of that. 


Alexandra Howson  29:45

Yeah, that's definitely a critique of healthcare, not only in the US, but also in the UK and other European health systems to some extent, and certainly something that we hear a lot of in the kind of education context a lot about siloed learning happens starts with undergraduate, the medical curriculum, a little less so in the nursing curriculum now than perhaps even a decade ago. But, that siloed learning continues right across the learning trajectory. When you talk about, you know, one story, different perspectives, but also competing stories happening at the same time in the same institutional or organizational context. And one of the remedies to that fracturing fragmentation is the power of listening. And you talk about this in your book. So, can you tell us a little bit more about how listening to stories, has a connecting power, and I was really struck by this, because I don't know if you're familiar with the work of Mark Nippo, a poet. He has a wonderful book, 7000 ways to listen, which is just phenomenal. Phenomenally rich in terms of layers of listening, and you talked about us on unconsciously swimming in stories, he kind of offers a way to, you know, dive in and explore, through different ways of listening to those stories, so, I, I'd love to hear from you. 


Rick Stone  31:37

So, we know very little about what it means to listen deeply to each other, I think. And we have very little training in that. And very little focus on that in our education. We take it for granted. You know, you don't see any courses in the curriculum on how to listen deeply, you won't, I never had a course in it. You know, and I don't think you'll find that course in any nursing or medical school. Because we say we really assume because we have two years that we can listen, well, we might be able to hear, but we may not be able to listen. So, you know, there's been a deep understanding and native cultures that listening is something that has to be nurtured, and engendered.  So I knew a wonderful storyteller Johnny Moses, years ago, and Johnny comes from the northwest of the United States. And in his tribe, he had sort of roots in a variety of tribes. But in one of his traditions, he would be telling a story, and then he would often just pause in the middle of the story, and would not continue, he would sort of look down to the ground and would not continue, listen, telling the story until the audience said, How Macao, which we're listening. And then he would resume the story. And so, from time to time, he would pause. And, and if you think of this as a device, especially with children, you know, who are antsy and moving around, and, you know, how do we begin to bring them into the story and be sure that they're really focused? And so, we have no comparable devices, I think, in our conversation, to even know whether the other person is hearing it or not. They're nodding, you know, maybe we don't know, but we don't know what's going on. Do they? Are they listening to me? And how do we know that they're listening? And so, I talk in the book, Paul Costello actually was kind enough to let me replicate a piece that he had done on listening. Can't remember which the end of which chapter that's in? I think it's on the chapter to unite. You may not have gotten to that yet. But Paul's done a lot of work about how do we bring groups together who have been living in competing stories and warring? Maybe now with great, great harm to each other because, and doing violence to each other. So, he started bringing students from Northern Ireland from Belfast, Catholic, and Protestant students. And this was at the height of when there was really a lot of conflict. And there was not a lot of listening room space for hearing each other's story that and because people had grievances, they were filled with grievances, and the grievances went back for dozens or hundreds of years sometimes. And so, it's very hard for them to even be in the same room together. He tells that 1928 there was an event in Belfast, in which I think the IRA attacks British soldiers and the Protestants attack the Irish and by the end of the day, 100 homes were destroyed. 100 people died 1000 people were injured. It was a disastrous event. So that story is still told in the pubs today, like it happened yesterday. So. 100% people love this metaphor there pickling. And that juice, you know, as a young person, if you went with your parents to the pub, and you're hearing that story every night, but through the lens of whether you're a Protestant about the terrible things the Irish or the IRA had done, they cut the Catholic student or if you're going in the Catholic pub, hearing about the Protestants, and so your brain gets pickled in that juice. And, I wonder, also in health care how much our brains get pickled in our own juices of our own points of view about the way things are, could be or should be. So, we have not created spaciousness for listening. And there is really a wonderful metaphor of one, a friend of mine, who is a therapist has worked with couples for many years. And she calls it crossing the bridge to the other is that the notion is that each of us lives in a foreign land, we assume that we're in the same land, we're all we assume we're living in the same story, but we're not. We're each living in our own particular story. And if we're curious enough to be able to listen. And so, it's a very disciplined approach. So, if you and I were a couple, and we were having a conversation, and I first say, I would have to request permission to come across the bridge to your world. And if you say, yes, come on over, but you come over with respect. I want to be sure that you're coming in with respect, then, for me to really hear what you're saying it to affirm it to say it makes sense not to react to it. Because you know, you may say something, I go, well, I disagree with that. Now suddenly, you know, but I'm in your world. And so, I think for us to listen, well, we have to realize that the other who is apart from us who's across from us, lives in a different world. And we have to be curious enough to know what's going on in their world, whether it's a patient, or whether it's another professional we work with, and to and to be willing to take the time and the space to say that's curious and interesting. Can you tell me more? I didn't know you saw it that way? I didn't know you felt that way. Oh, I didn't know that you understood it that way. Oh, I've been seeing it entirely differently. Tell me more about how you see this. So that requires a level of humility I think that often is missing among professionals. That and it also requires a level of commitment to each other and commitment to the relationship. So that's a different kind of contract, we often find in our relationships and healthcare among professionals. We don't have that kind of shared contract. And, you know, thinking like things like team steps, for example, which is right, here's a kind of a system which requires a mutual contract, among all that are working there. And that's not an easy thing, as we've seen, to initiate and to perpetuate, it degrades pretty quickly. I have weddings that shocked me, through the last few years, I'll occasionally run into someone who's working in healthcare, and I'll just say, oh, by the way, do you guys use Team STEPPS? And they look at me perplexed. They haven't even heard of it. Oh, yeah, we had one training in that, you know, so once again, it's as though that, oh I go and take the class and get the lesson in that. And then, you know, lightning hits. And I understand we all have suddenly thought  that there's a calamitous moment where we all kind of connect, it requires something much deeper than that. So, if we're going to create safe healthcare, we have to create safety in our relationships with our fellow professionals. 


Alexandra Howson  39:32

And I was just gonna say, when you're talking about story, you're talking about relationship connection and communication. That's right.


Rick Stone  39:39

Yeah. And so that requires we have to create space and time for that. And if we're also busy, that we don't have the space and time to even talk together, then how could we ever know what's going on with the other person, what's going on in their world, the weather across the bridge, and so often what happens is coming back to the patient is that we tend to be so mechanical and the way we interact with patients, it's scripted often and you know, having been a patient a few times in the hospital for some surgeries, it when people come in with that script, I bristle. And occasionally someone comes in who's authentic? And when they say, how are you doing today? What's going on? You know, I feel like, they really want to know what's going on. And then they're pausing and they're listening deeply. And so that is something that isn't easily trained, it has to be grown or cultivated, I think it's not just a, you know, okay, this is a skill that an instructional designer can do 123, and we do these practices, and now I got it. That's cultivating something deeper. And I think story is very well suited the power of stories, were well suited to engendering that. So, we as human beings, you know, the question is, how do we become so empathic? How do we develop empathy for other brothers? And, I think it's only annoying the other story, that we develop that capacity, and there's been so much work that's been do in literature, and people reading people's stories, that it changes how they feel about people who before they read that story, they may have had a negative attitude toward. So, this is the role I think of literature in medical training is that we want to develop and cultivate within medical professionals have deep empathy for human beings. There's probably no better way to do that through the power than through the power of literature and art.


Alexandra Howson  41:58

Because well, everyone should be checked off.


Rick Stone  42:01

Well, that's right.  What if we all read Chekov as part of our medical training, you know, so that you wouldn't be able to go in and listen to a patient in the same way ever again, you know, you suddenly, have a much more complex being there who's standing before you.


Alexandra Howson  42:22

 I think that's really interesting. One of the things that I was thinking about, as you were talking about communication and listening to patients is, you know, there has been a lot of work in the last couple of decades, I'm thinking of Ronald Epstein's work on patient provider interaction and communication, there's been a lot of work particularly around patient provider relationships that are not race concordant, in terms of the disconnection in the communication, and a lot of work around how can we make those communicative relationships better, but of course, and Ronald Epstein's  work focuses on empathy as well. But what one of the things that happens is in that work is that empathy is seen as a skill that can be learned that people can be trained to do but what I'm hearing from you is that's a little transactional, that's a little mechanistic, we have to go even deeper.


Rick Stone  43:38

Yeah, so that, you know, if we look at this metaphorically, we think of it's okay, we're all gonna go to empathy class, we're gonna learn the three skills of empathy or whatever they are, you know, it's been broken down into nice pieces, right? That's different than the metaphor of growing empathy, cultivating one's empathy. And that is not something that's done in a one-hour class or a three-hour class or in a classroom. That is something that's done, that I think only can be accomplished over a period of time. And once again, through the arts, through story, through literature, and that's developing an internal capacity to be with the other to be in their space to really, as we say, metaphorically walk in their shoes, you know, to be in their shoes and you know, I think that for doctors, that's hard, and that's difficult for patients I knew a physician in Orlando A number of years ago, and he had to go through some procedure that was very painful and difficult, a procedure that he used to administer to patients for years. And not until that happened, it changed him profoundly, he never understood. He realized he had been somewhat callous all those years. For him, it was just a mechanistic, a mechanistic procedure. And he treated the pain is sort of don't worry about it, you know, we'll take this or whatever. And it changed him profoundly to have gone through that. And there's lots of examples in the literature of dog doctors who themselves have gone through difficult things, and then suddenly, it's changed how they see medicine and the treatment of patients and they don't walk into that patient's room, the same person anymore.


Alexandra Howson 45:49

Right? Formation there. Yeah.


Rick Stone  45:51

So, you know, we don't all have to have a heart transplant to be able to become more heartful in our work. But we have to be open to the soul of art, to be able to discover that the soul of the person sitting across from us, I think,


Alexandra Howson  46:14

I love that expression, that sort of art. Can you talk a little bit then about? How does Story Work in the context of learning in teams in a healthcare setting?


Rick Stone  46:33

Yeah. Well, you I think, in our pre notes, we talked about this product story care that I has developed. And so to understand that, we need to go back in time, to a teacher of mine, Paula Underwood, who is Native American, came from the Oneida tradition. And in her tradition, they didn't even have a word for teach. So that's a very interesting, fascinating thing. The closest in kind of transliteration would be an enabler of learning. So, they understood that people who were teachers, they were more of guides, or they were enablers that they enabled learning. And they understood that there was this powerful reagent, think of it in terms of that was called story. And that worked on our brains in a certain particular kind of way, that allowed us to make new connections, and to learn new perspectives and points of view. And so, what story does, when we hear a story, we find with the MRI studies that are being done, we find that it's actually engaging all the sensory aspects of the brain. They're all getting activated, as well as the language of centers for comprehension and understanding. And so, what happens is, there's the potential for new neural connections, new possible perspectives, insights that can arrive when we're hearing a story that doesn’t occur if we're just hearing a concept in language. So, someone's giving us a lecture on a particular topic. And they're presenting slides with lots of data, for example. It doesn't actuate all that other neural activity. So, what you get is a rich enactment of a story that is both visual and auditory and is sensed and felt, right. And so, the Native Americans understood that was something powerful. And so, they would start at a very young age and start telling children's stories. And they would never tell them what they meant, because they understood that that short circuited the learning process. So, if I take here's the story, and it says, you know, in our Western tradition of fables, and we tell the story and say, therefore, children, don't ever go into those dark woods again, you know, by yourself. There won't be any learning, there won't be the connection, they won't be the grappling the engagement. And so, they developed a process of reflection, that's as it sounds, when you hear it, it sounds very Socratic. So, you wonder where Socrates and Plato where did they come? Where did that come from? I don't think they invented it themselves. I think they were just passing on what had become a very common understanding about how we learn is they would tell the story and say, what might we learn from this and then they would shut up and they would let you know a five-year-old hearing this or he would say, oh, well, I think it means, you know, they would see one point of view. And the older boys affirm it, they go, oh, that's interesting. Tell me more about that. Oh, you see it that way, oh, and then maybe at age 10, they hear the story again. And now, they have a whole different pattern of brain, their brain is a whole different brain. It's metamorphosed. And there's this wonderful research and work being done on children's brains. And we just think that adults are just sort of kind of extensions of children, but children, I don't think so. It talks about childhood being a time for exploration, and we're making just huge, massive connections. And then adults, we become more exploiters of what we already know. And we often lose that childlike ability to explore and see afresh. And, you know, we often are poets talk about that, you know, an artist's talk about that is keeping fresh eyes so that we cannot get tied in with one point of view. So, with Story Care, what we were starting to look at, we were saying, how could we engage teams to learn quicker and have deeper insight into their own their own practice, and how they could improve their practice. Now, we could have said, here are the five lessons you need to learn how to improve teamwork and communication. And we could send them to a class and here are the five things you need to know about teamwork and communication. Or we can have them listen to a story. And in the story, the patient is harmed. And in the story, they were harmed because there was a breakdown of teamwork and communication. And so, what do we do? We took that ancient question, what might you learn from the story? And we said, what might we learn from this story, and then the team gets to debrief it. So, you know, we call this like very low fidelity simulation, there was no mannequin there was just the story. But the team then gets to reflect on the impact of the breakdown communication for the team about in the story they're listening to. And inevitably, it leads to themselves. And they go, oh, you know, this sounds very much like something that happened here last week, or that was last month, when we had that event, where we almost lost a patient or maybe was a tragedy, and we lost the patient. So, and the other component of that is emotion. Stories carry an emotional thread with them. And they engage us. There's something at stake here in this event with you know, it's not just I once heard the description of a case study, someone came up to me, after I was giving a talk at a healthcare conference, and they said, you know, what is the difference between a story and a case study. I said,  well, a case study is an act of reverse alchemy, taking gold and turning it into lead.


Alexandra Howson 53:09

I love that.


Rick Stone  53:10

Yeah, I just I that stuck with me, obviously. And, and so you know, we'll often use case studies in our training, you know, that we have a patient 53 years old as these cognitive comorbidities and you know, so it's been very sanitized, okay. And we can have a nice intellectual conversation about it. But if we suddenly hear a story where a patient is 53 years old is brought into the emergency room and then you know, they're hemorrhaging and one of the stories that we developed in it story care, I knew a newer cert neurosurgeon. And we were working on some other projects and I met him for breakfast one day, and I said, How are you doing? And he said, I've had a terrible week, I suppose what happened it's tells me the story, which we ended up developing with his permission when it gets a call to in the morning, and patient has been brought into the ER and with a cerebral hemorrhage and in the head of the ER calls him and says, I think that we got you know, we've called airbag to airbag this person to Boston, but suddenly their vitals are really doing some weird things here. And I think we got the diagnosis wrong. Can you be here and he's able to call up the film and see it he says, yeah, that you got it wrong. I'm coming right now. He drove like a bat outta hell and he got there in 15 minutes, you know, and it comes running into the ER, you know, and they have any wants to, they want to drill a hole into the person's brain to relieve the brain. And they have a kit there. I can't remember the name of the kit. And there's two kinds of two big brands that make the kits and one of the kits does not come with a little piece of plastic. That's a kind of a spout kind of thing. 


Oh, Okay, it doesn't come with that. So, he says, I need one. But you know, get one, give me one of these things. And they says, give me give me this give me the shears, the shears weren't charged. I think he threw them against the wall. He's a very fiery guy. .


Rick Stone  55:15

Yeah, he was flipped out, and someone comes running with another. It wasn't charged either. So now they're having scissors to you know, and they're looking for this little valve. Okay, does anybody have one? No, you can't find it. They're looking everywhere and all the cabinets and says, well, I think so. And so up in the operating area on the third floor operating as they call it there. And they're in the middle of an emergency c section. And they're running short. They have no other people. And everybody is scrubbed up in there. And the nurse answers the phone says I know where they are, but I can't get  in because I'm in. And here he is in the flight, the flight crew, and their people are saying what are we going to do here? What's, what's the story. And everybody's in tears, the nurses are standing around, they're helpless, and he is helpless to do anything. And this is like a 10-cent piece of plastic because of that. So, you know that you listen to that story, and then debrief it. And boy, it hits you right in the stomach. And then you start asking the question, are we prepared to have, you know, all the things that you know, things like a pair of shears being charged or you know, are we prepared for the exceptional event that could come in here to save a life. And so that engages people differently than if I did a case study about, you know, a 35-year-old woman who has a cerebral hemorrhage is brought into the hospital, they were able to, that that all that's all the richness of that detail of what had happened there, with the breakdown of the system would have been lost.


Alexandra Howson  56:53

I hear that.


Rick Stone  56:54

So that's what story can capture for us. And that's what it can elicit in us. And it can force us to be in the story. So, when we hear that story, we inevitably identify with a character or characters in the story, we become that character, we become the doctor, we become the nurse who can't find the piece of plastic. And, and we enter into the story in a raw kind of visceral way. And that's where real learning can happen. I think. And, and so, so much of medicine has nothing to do with the tech, not the techniques of how you would, you know, drill a hole in the person's head to relieve the pressure, it has to do with the relationships and all the other stuff that comes with that? And how do you replicate that in an environment? I'm working with some people who do a lot of work in virtual reality now. And we're having some interesting conversations, could we never put people in a situation where we could reproduce the richness of those kinds of situations, so people could really deal with them, you know, in a real way, in VR, you know, with a real patient in VR and having to deal with the breakdowns of all that. And could we change people that way? So anyway, that's what story does for us. That's how it works on us. And that's how it engages us as an audience. And when you pair reflection, the process of reflection with that, something powerful happens. And the native peoples understood that Plato understood that. And, I think we've just more and more understanding that creating space for reflection on practice becomes crucial. You can practice, practice, practice, practice, practice. But if you don't take time occasionally to step back and say, what am I learning here? What's missing here? What do I understand now about this? Now that I've been doing this for a while? Where are the edges that I need to develop more? Without those kinds of questions, and I think that we, I think we lose a lot. Rick, do


Alexandra Howson  59:21

Rick, I'm conscious of our time, do you have time for a few more? Or maybe two more questions? Do you think that like listening, reflection is something that it takes time to develop and it has to be grown, particularly among professionals? You know, reflection is one of these things that you know, it's all over the education literature, right. Sure. And certainly, you know, people in the healthcare education field will be familiar with, excuse me the importance of reflection but certainly in professional education and continuing medical education, although we talk about it a lot, it's really challenging to build reflection into education programs and activities. And then the other side of that is what is it we're talking about when we talk about reflection, because for a story, reflection is critical. You need that time you need that space, as you said, to understand the story and your place in it. So can you talk a little bit about what you mean by reflection, what it looks like, and how we can start to think about building that into adult learning? 


Rick Stone  1:00:40

Hmm, yeah, so we talked about it in a very broad sense, and we assume that everybody can do it. You know, so I think like listening, as you said, I think it is something that requires development. And requires space and time. So we rarely create space and time in the healthcare field for reflection. It's not valued. We don't value reflection, we give it lip service, but we don't value if we valued it, then we would make it a priority and give it space and time. So, I think that's the first thing is that we don't value it. And if we did, then we would have people after Sentinel events, or, you know, or where there is an emergency c section, you would have people taking time out to say, let's go into a room and let's have a conversation about what just happened. What did we look at? What might we learn here from what just occurred? What could we have done better? Where did things break down here? And can we look at it with clarity and without blame? So that there are other taxonomies of reflection, you know, Peter Pappas is developed one, you mentioned that in my discussion in I found that very useful. And it's actually really thinking about it from a story perspective. And so Pappas has a you know, hierarchy or taxonomy of reflection, and he talks about, the first step is remembering what do we do? And we may have different stories about that, especially as a team, you say okay, what happened here? And depending upon where you were in the room, and what your role was? Okay, so how do we begin? And let's not make the other story wrong? Oh, you have that story? Oh, okay. I didn't see that. I couldn't have seen that because where I was standing, I wouldn't have been able to see that. Or I didn't have that as a lens. Then he has understanding what's important about that? What is important about that, and once again, each of us may have different ways of finding things of import, I may see a differently. The third level is applying it. Where can I use this again? So where might we apply this? And then analyzing? Are there any patterns here? Is this like other things that have been going on here? Is this been going on here for a while? Where else has this going on? And then? And then she talks about evaluating? or how well did I do? How well did we do we okay, well, we didn't do so well? Could we? How could we do better? And then creating? What should I do next? But what can we do next? And I find that to be a wonderful structure for conversation. And, but once again, if we create spaces for that conversation, and these six simple questions. If we can say if we ask these six simple questions, and we listen, coming back to listening, respectfully to the way each of us sees it, without trying to negate your way of seeing it, but to be curious, oh, you see it that way? Oh, well tell me more about that. Oh, that might inform my thinking in a different way. There's a wonderful teacher, Nancy Klein has been one of my other teachers in my life. And she talks about how we think better. And so, she talks about the power of thinking and how do we create better meetings, and she talks about have going around. And so if I know that we're going to go around and hear each person and I know I'm going to have a chance; I don't have to be sitting there trying to formulate what I'm going to say I can listen to what you're going to say. Right? And by the time it comes to me, the thing that I initially thought I was gonna say is suddenly my thinking has been informed by the deep thinking of the five people who preceded me. And so, then you say I go, oh, I see it differently now. Now. Yeah. So, if we can create that kind of space and healthcare, and I'm not sure what it would take to get there, because, you know, one of the big insights I add was that healthcare is not a learned there is no such thing as a healthcare learning organization. Healthcare is not interested in learning; we assume all the learning happened before people arrive to come work there. And so, we have not created there is no recognition that healthcare is learning that healthcare organizations need to be learning organizations. And I have yet to see one that I would say even comes close. So that requires a whole cultural shift in healthcare, is that we have to become invested in learning and create. And if we're going to do that, then we have to be invested in giving people time to reflect and time to listen to each other. And that doesn't look very effective and efficient on a spreadsheet? 


Alexandra Howson  1:06:13

No, I can see that. I think the other part of that is, in order to hold that time in space, you need a facilitator. And so, I'm curious, when you are using these tools to encourage health professionals to reflect, to listen to other people's stories. Is this a facilitated process?


Rick Stone  1:06:46

Yeah, I think it has to be at least initially, you know, to a team that's done it a lot probably can get pretty good at it and won't need another person in the room to keep people focused and on task. Because people's patterns of behavior will overtake the process and kind of degrade it very quickly. So yeah, I think it needs to be facilitated, especially in the beginning so that people, a team, can begin to learn it. You think about Team STEPPS and how in the early days when I started being pushed out. And you know, it was it was trained and facilitated, the facilitator would be there in the operating room being sure that that, you know, everything was going and at some point, everybody has ingested it. And it's become part of the culture. It's the way we do things around here. And everybody's sort of tacitly knows the rules of how we do it together. And if someone is sort of stepping out of that bound, people can say, hey, Jack, you know, remember, we don't do that. Second, we do that third. Oh, thanks. You know, so the team can become self-correcting. So, if we really were invested in doing this, yeah, we'd have to have, we'd have to create the space and have teams of facilitators, somebody who could come in and just who's who knows the knows the, the story that we're going to try to work on? 


Alexandra Howson  1:08:19

Yeah. I think we're kind of over our time. Two questions, just to finish up. What are you working on now? And where can listeners find you?


Rick Stone  1:08:29

Sure. I'm working on this broad idea that Story Intelligence is an essential part of culture, and is essential for our survival as a human race. And so, I have a big vision, about education, about business in the corporate world, and about spreading this idea so that we're all wising up to the fact that we live and breathe stories, and that we can become the authors of our stories. So, I'm sort of on this track now to figure out how do we do that in a big way. And so, I'm thinking about a TV show, actually, right now. If you think about Neil DeGrasse Tyson, who does his wonderful show on the universe? Well, what if there was this fabulous story of a show on the power of story in our lives, loving and so I'm exploring that and right now with some people. And if people want to reach me, they can go to storyintelligence.com that's the name of the book. And there's obviously plenty of places to contact there. But there's also lots of resources we're kind of doing I've got my own little talk show that I've been doing called explorations and I'm interviewing people who are just remarkable experts on the power of story. So, in each one of those interviews I'm working you know, one right now a guy named Sam Magill, who is a coach of coaches. He's a supervisor of coaches, and he talks about the poetics of coaching in the now. And so, I'm actually editing that right now to be posted up there so they can find me at storyintelligence.com.


Alexandra Howson  1:10:15

Wonderful. Thank you so much for taking time to talk with us today. Rick Stone. Thank you. 

Rick Stone 1:10:29

You're welcome. Glad to be here, Alex.

There's always a story
The story of Story Intelligence
What it means to listen deeply
Growing empathy
Engaging healthcare teams to have deeper insight to their own practice
Taxonomies of reflection
Six simple questions
Wrap up