|Home | About | Journals | Submit | Contact Us | Français|
How often have you heard somebody say ‘I saw a wonderful systematic review the other day...’ compared to the number of times you have heard a discussion that started ‘I remember this fascinating case... ’? In fact, have you ever heard a group of doctors, in the bar after a long day's work, having an animated discussion about a meta-analysis? While many doctors are happy to admit that the concepts of evidence-based medicine (EBM) are sound, and even that EBM has improved medical practice, it is rarely a cause for much passion or excitement. And have you ever wondered why media scare stories exert such a potent influence on behaviour, ranging from childhood vaccinations to the latest cranky diet?
Reading ‘Made to Stick: why some ideas take hold and others come unstuck’ by Chip and Dan Heath,1 I began to understand why EBM is destined rarely to grab hearts or headlines and why anecdotal evidence and personal experience may continue to triumph over well-designed randomized trials in terms of their ability to influence both medical practice and patient behaviour.
Although Made to Stick is not aimed at a medical audience, it has important messages for anybody involved with medical education or health promotion. The authors (two brothers, one a Professor of Organizational Behavior at Stanford, the other an education consultant and former researcher at Harvard Business School) set out their theory of what makes ideas memorable, contrasting examples of urban myths—which are highly memorable despite being untrue—with useful but dull statistical presentations about health risks—which may be true and important but often have little lasting impact on the hearer.
The Heath brothers summarize their theory using the mnemonic ‘SUCCESS’, suggesting that messages that take hold are Simple, Unexpected, Concrete, Credible, Emotional Stories. On this basis, one can see immediately why a systematic review will never have the sticking power of a case study. To start with, the message of a systematic review is often subtle and nuanced, and the method of reaching the conclusion is rarely simple. Being based on existing studies, reviews rarely reach unexpected conclusions (although, interestingly, those that do, such as the Cochrane review that showed that albumin was harming patients rather than helping them, receive the most media attention and debate).2 By the time the results of several randomized trials have been distilled into a meta-analysis, the reader has long since forgotten that the data once related to real patients, so reviews fail the test for concreteness as well. About the only thing going for evidence-based guidelines is their credibility; they rarely evoke any emotion (except perhaps boredom) and proponents of EBM fiercely eschew the use of anecdotes and stories.
Compare this to the humble case study and one starts to understand why it retains its power to teach and inform. The message is usually a simple one. Most case studies also contain an element of the unexpected, since doctors do not discuss (and journals do not publish) cases that show routine diagnosis and successful treatment by conventional methods. A single case, while lacking the credibility of a large study, is absolutely concrete—sometimes we even know the patient's name—and well-written cases often evoke strong emotions. In other words, individual cases pass the Heath's ‘sticky’ test and are likely not only to be remembered but also to affect behaviour.
I want to point out that I am not arguing against evidence-based practice, or the usefulness of systematic reviews. I simply want to explain why educators and communicators should not expect them to change behaviour. Perhaps I am behind the times—after all, the major religions have been demonstrating the power of stories and parables to change behaviour for several thousand years—but this book gave me some practical ideas for ways to make training and writing more effective. A word of warning, though: Made to Stick is written in a relentlessly breezy and populist style which will irritate many readers, using terms such as ‘unschlocky’ (which I suspect has never before graced the pages of the Journal of the Royal Society of Medicine!). It is also extraordinarily US-centric, expecting readers to recall the capital of Kansas (it's Topeka, in case you were wondering) and to understand unexplained abbreviations such as BBs (which I deduced were ball bearings) and IRS (the US tax office). But, for me, it was worth battling the American slang and psychobabble for the excellent examples, many of which come from public health, such as memorable ways to describe the saturated fat content of a helping of popcorn and effective campaigns to reduce teenage smoking.
Another concept with relevance to medicine, which is well explained by the brothers Heath, is what they term the ‘availability bias’, which explains why dramatic but rare events (such as shark attacks or tornadoes) may, irrationally, be feared more than common dangers (such as drowning and road accidents). The idea that people believe events are more likely if they are easy to remember, and that people fear dangers that evoke a strong mental image, can explain many apparently irrational behaviours and the response to medical scares.
According to the Heaths: ‘a credible idea makes people believe. An emotional idea makes people care... stories make people act’. Perhaps medical educators can couple EBM with the ancient art of storytelling to craft memorable communications that will benefit doctors, students and patients. That would truly be a SUCCESS story.