STORYTELLING AS A TEACHING STRATEGY FOR MEDICAL EDUCATION

A dual function of medical educators is to guide medical students through the mass of medical facts as well as help them hone their communication skills
with the patient. I have presented some teaching strategies which are not
new, but I feel bear repeating. I have tried to convey the informational material
in a practical, informative, and entertaining manner, using stories from my
own personal experiences to illustrate the points of discussion. Storytelling engages the students and thereby enhances their learning experience. In my teaching role at the University of California Medical Center San Francisco (UCSF), I have worked with Dr. Paul Turek, Chair of Urologic Medical
Education at UCSF. I agree with him that stories provide an essential counter-balance to the highly technically oriented field of modern medicine
and help physicians develop healthier and more human doctor-patient
relationships. I have presented some of my teaching strategies which utilize storytelling in the medical student curriculum.

BASIC TEACHING STRATEGIES

One basic rule I emphasize to the students: There is no such thing as a dumb question. The students must feel free to question any presented material. They are confronted with a plethora of multiple, often conflicting, ideas and must constantly analyze this information and decide on its relative validity.

Maintaining the students’ attention is paramount to the teaching process. Prior to class time, I learn the names of the students via a set of class pictures. If I observe a student with seeming lack of attention, I try to refocus him/her to the discussion at hand. Direct eye to eye contact encourages an active dialogue with the student. For that reason, a totally dark room, such as with the use of a projector, should be avoided if possible.

I try to convey the informational material in a practical, informative, and entertaining manner, using stories to illustrate the points of discussion.

FIRST PATIENT ENCOUNTER

During the first such encounter, the medical students often feel more intimidated than the patients. Often the patients have been informed of the fact that this is a learning situation for the medical students and are generally desirous of helping in this potentially traumatic circumstance.

Case: During my third year of Medical School, (after two years of having been inundated with lectures and textbooks), we students were informed that that the time had arrived for us to see our first “real” patient in the General Medical Clinic. Needless to say, I was eager, but a bit apprehensive, at the prospect of this new awesome responsibility.

I entered the General Medical Clinic. A rather brusque nurse literally shoved me into an examination room. Not knowing what or whom I would encounter greatly increased my anxiety level. But my fears were quickly dissipated by my “patient” ….yes, my very own patient: a delightful 85 year old woman.

In a most professional manner (at least, I tried very hard to give the impression of professionalism) I asked what was bothering her. She replied: “Oh Doctor”... (She called me Doctor…I was both excited and delighted!) “My urine has the most terrible odor!” I replied (in the most competent voice that, a 3rd year medical student can muster) “I’d like to check a specimen if possible.” She looked up and said: “Of course, Doctor, I’ve brought you a sample.” She then reached into her purse and removed a small vial which she handed to me. I unscrewed the top and took a whiff (trying to do such in a suave fashion…though how does anyone smell urine in a suave fashion?). “My,” said I, “This urine smells sweet.” “Oh yes, Doctor,” said she with a slightly embarrassed smile. “I added a few drops of perfume so it wouldn’t offend you.”

COMMUNICATING WITH THE PATIENT

I emphasize to the students the importance of establishing a good communication at the start of their relationship with the patient. If successful, this process will give the patient increased confidence in the judgment and ability of their physician.

CASE: A 72 year old woman comes to you as a new patient with the complaint of vague abdominal pains. She appears rather frightened, expressing concern that she thinks she has cancer. She uses what might be considered rather “earthy” words to describe her symptoms. How can you best alleviate her anxiety? What steps can you take to make her more comfortable?

Put her at ease and be sensitive to her feelings of insecurity. Since, to her, you are likely the ultimate authority, you must try to establish a comfortable basis for communication. A warm handshake with direct eye to eye contact combined with appropriate introductions is a good start.

Address her appropriately: Do not assume that calling her by her first name, especially on this, her first visit, will create a friendlier relationship. Indeed, this might be insulting to her, particularly since she is likely your senior. Ask her how she would prefer to be addressed. If you choose to address her by her first name, it is only fair to offer her the option of calling you by your first name. Very likely, however, she will opt to address you as “doctor."

(During patient rounds, I stress that the patient should be addressed by their name, rather than by their disease. I always introduce the patients to the students or residents and make a point of involving the patients in the discussion. I stress that that patients generally feel extremely vulnerable and are very sensitive to any words or actions spoken in their immediate vicinity. I caution the students to avoid any “side remarks” since the patients will inevitably assume that such comments are about them.)

Treat her with respect: Be sensitive to her feelings. Never correct her grammar or give the impression that you feel that she is lacking in education.

Avoid medical jargon: Be certain that both you and she understand what each of you is saying. Never assume that she has grasped your explanation. She may give a nod of comprehension to avoid appearing “uneducated,” yet not know what you said. Try to use the same words that she used to refer to a particular part of the anatomy or a symptom. Listen carefully for she may tell you the diagnosis (in her own words). Drawing pictures or diagrams are often helpful. Good communication cannot be overemphasized!

Avoid the perception of time constraints: In these days of HMOs there is often pressure to limit the time spent with your patient; however, your patient must never be made to feel that she does not have your full attention. If you converse with her while you are in a sitting position, she will likely perceive that there is no time pressure. (Even if you spent exactly that same amount of time with her when you were in the standing position, she would probably perceive that she was being rushed). During these sessions, you should be interrupted only for emergencies.

Address all of her questions: Before she leaves the office, your last query should be: “Do you have any other questions which you would like to ask me?” (One very distressing, and unsettling, situation for patients is to leave the office, feeling that the doctor did not address all of their concerns.)

INVOLVE THE PATIENT IN HIS/HER THERAPY

I like to use the metaphor of a business enterprise as it relates to the patient-physician relationship. The enterprise can be set up with the physician as the boss who gives the orders to the patient. While some patients may favor this approach, it has the potential of putting the patient in an adversarial position. I prefer the concept of “partnership. “ In a joint venture, both you and your patient have a more active incentive to have this enterprise succeed. By understanding the possible diagnostic and therapeutic steps which will be taken, your patient is in a better position to anticipate the course of the disease process. There is definitely a strong therapeutic benefit of self involvement, not to mention the improved compliance with the therapeutic plan.

CASE: A 58 year old man presents with symptoms of shortness of breath, exacerbated during pollen seasons. He has been told by his physician to take anti-histamine medication daily during these times, but he has experienced marked difficulty with urinating since starting the medication and has unilaterally decided to discontinue it. He is irritated by his physician’s dictatorial approach in the prescribing of medications and feels that he has had no input as to when and how much of the medication he should take. What do you think is the best way to resolve this problem?

Unless the physician and the patient are in mutual agreement with the treatment plan, there is a strong chance that treatment--and results--will be sub-optimal. You can help this process by involving the patient in his own treatment decisions. Potential adverse side effects must be discussed with your patient. Antihistamines are notorious for causing problems with voiding, because of interference with bladder muscle tone. The principal problem here was unsatisfactory patient communication.