“Raise your hand if you know what the acronym IMRAD means.”
This is a gimmick I sometimes try with doctors. In repeated efforts with a few thousand audience members, fewer than 1 percent of hands go up.
I follow it with the question, “Have you ever read a research paper broken into four parts—‘I’ for Introduction, ‘M’ for Methods, ‘R’ for Results, ‘A’ for And, ‘D’ for Discussion?” By the time I reach “R” there are chuckles. Every doctor has read hundreds to thousands of these papers; they just don’t know there’s an official acronym for the narrative structure of what they read.
IMRAD was introduced over 80 years ago as a simple tool to help doctors communicate better. The brain is programmed to receive information according to an ideal structure that the IMRAD matches. Doctors, without this guidance in their heavily informational lives, would find it easier to just spew information like a robot. The IMRAD keeps their communication more human.
“How do we keep medicine human?” has historically been a major challenge. Sir William Osler, widely recognized as the father of modern medicine, developed and implemented the practice of medical residencies, created to keep doctors from becoming too aloof and detached from their patients. He also maintained a legendary sense of humor and was even known as an inveterate prankster. Humor, of course, is hugely human.
Two generations later, John P. McGovern, co-founder of the American Osler Society, dedicated his medical career to this same basic cause of keeping doctors from losing their human side. In the early 1970s, he co-edited an entire symposium volume titled Humanism in Medicine.
Today, there are countless articles providing lists of tips for doctors to maintain compassion in their interactions with patients. But there hasn’t been a single structural tool like the IMRAD that provides a framework for the doctor-patient interaction.
There is a new narrative tool called the ABT Template. I derived it from the teachings of Hollywood screenwriters. The clearest source of the ABT elements is legendary screenwriting instructor Frank Daniel, who in the 1980s began talking about the fundamental importance of the words And, But, Therefore, though not as a template. It’s like an even more condensed version of the IMRAD.
The ABT narrative template is:
_____ AND _____ BUT _____ THEREFORE _____
This single sentence captures the core narrative for everything from arguments to stories. In workshops with doctors, it’s the template for their case studies. Take misdiagnoses: they tell stories story along the lines of: “A woman said she had these symptoms AND was told she had this disease, BUT I noticed this other symptom and THEREFORE realized she actually had this other disease.”
In 2013 I gave a TEDMED Talk about the ABT, which is now the centerpiece of my Story Circles Narrative Training program, involving thousands of doctors and scientists from places ranging from the National Institutes of Health to Genentech. But there’s more to the ABT than just a communication tool.
Narrative is central to humanity. Going back thousands of years, it is the core of everything from storytelling to argumentation. But it’s even more powerful to look at the three forces that create narrative.
The first element—the “and”—is the force of agreement. This is how narrative begins. Even with argumentation, you want to begin with what we can agree upon before you get to the disagreement.
You can see this in the title of the enormously popular textbook for argumentation, They Say, I Say, by Gerald Graff and Cathy Birkenstein (it has sold over two million copies and is used throughout the humanities). The first element is “they say”—that is, what everyone agrees on.
Agreement is then followed by the problem—the “but” element, which is the force of contradiction. This is where the problem is stated.
Once you’ve established the problem, we want to know what you’re going to do about it—the actions to be taken. This is the word “therefore,” the force of consequence.
The ABT words embody the three forces of narrative—agreement, contradiction, consequence. This three-part structure has deep roots in the humanities tracking back to the Hegelian dialectic of thesis, antithesis, synthesis. It's also the form of three-act structure in drama, initially formalized by Gustav Freytag in the 1800s. You can rearrange the forces to challenge people’s brains—that’s a lot of what art consists of. But if all you want to do is communicate simply and clearly, this is the ideal sequence.
Now let’s talk about doctors and patients. In a world of too little time, there’s an impulse to cut to the chase. In 1984, a study revealed the average time a doctor takes in visiting a patient before getting to the “but” (the patient’s problem). The shocking answer was 18 seconds. This basically means the doctor says, “Okay, good morning Mrs. Smith, what’s your problem?”
This is dehumanizing. It’s a failure to establish a human connection before getting down to business. It might seem trivial to look at a vase of flowers beside the bed of the patient and comment on how lovely they look, but the fact is, humanity begins with agreement, not contradiction.
From there, it’s obvious what else is needed—the establishment of the problem; then equally important what we’re going to do about it—the “therefore.” But the tough thing is not bypassing the agreement.
There are of course countless other tips for how to humanize medicine, but they all follow downstream from this simple, basic structuring of the three forces of narrative. And this is where the ABT ends up being such a powerful and simple tool.
It should always be there in the front of your mind. It should be absorbed so deeply that when the urge arises to “cut to the chase,” the human side kicks in, prompting the health care worker to once again invest even just a short amount of time to open the channels of communication.
The basic ABT narrative dynamic needs to be second nature for all medical professionals interacting with patients. John P. McGovern would be proud of you if you always include this one simple consideration. And Sir William Osler would be especially appreciative if your opening statement of agreement included even the tiniest bit of humor—the ultimate mark of humanity!