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.

STORYTELLING AS UTILIZED IN PRIVATE PRACTICE

I also used storytelling during interactions with referring physicians in my private practice.
Examples are included below which include an introductory letter from the referring physician outlining the problems to be resolved followed by my response. As with the medical students, I attempted to present this material in an instructive yet informal style seeking to capture their attention with accompanying stories. I subsequently utilized these stories during my seminars with the students.

BUBBLE BATH URETHRITS: A SOAP OPERA

Dear Sumner:

I have a challenge for you (as she has been for me since I first saw her about one year ago). Gwen is a 45 year old single woman who has already seen 2 other urologists because of persistent irritative symptoms of the lower urinary tract. Although no infection had ever been documented, she had been treated empirically with various antibiotics, without relief of her symptoms. She underwent both radiological studies and cystoscopy and even had a psychiatric consultation, none of which revealed any obvious abnormalities. She pleads for help. Can you work any of your magic on her?

Dear Carol:

I appreciate your confidence in my ability to come up with a magical cure. After much discussion, Gwen decided that her irritative symptoms might be caused by something other than infection. We went over some possibilities, including a reaction to perfumed soaps, vaginal creams or bubble bath products or a vaginal infection. (Local inflammation of the urethral-vaginal area can also result from atrophic urethrovaginitis) Gwen volunteered that her symptoms were minimal during the day. However, every evening, despite relaxing in a nice warm sudsy bubble bath, her symptoms of irritation flared up. All of a sudden, as if she were experiencing an epiphany, she suddenly realized that this pleasurable (albeit transiently pleasurable) activity of the bubble bath was a very likely source of her problem. She agreed, albeit reluctantly, to give up the bubble baths. She called me last week and reported that her irritative symptoms had completely cleared and that she was overjoyed with her new lease on life.

Since I had such a happy ending to that adventure, I thought you might enjoy hearing of another case which involved a physician whose twin sons had received a bottle of bubble bath for Christmas. The young lads really enjoyed their nightly bubble baths. However, after just a few days, one of the boys starting wetting his bed and complained of pain during urination. His twin brother had no such problem. Their father, a physician, immediately became concerned that he was possibly dealing with a very serious underlying condition. He became very distraught, even imagining that his son might end up with a kidney transplant. (This is a good example why physicians should not treat close family members). Fortunately his wife, the mother of the children, appraised the situation, and suggested in a very calm voice (in no way did she wish to embarrass or seem to question the diagnostic acumen of her husband, the physician) that, just perhaps, the bed wetting and the painful urination might be a result of the bubble bath acting as a local irritant. The bubble baths were stopped and the boy’s symptoms cleared completely. However, the physician, the true scientist, wanted to check out the accuracy of the etiology of the symptoms. Accordingly, he added bubble bath to the tub water of his sons once again. Within twelve hours, the symptoms returned. Yes, the bubble bath was then duly discarded and ever since that fateful day, the family has lived in joyous harmony. And, Carol, the time for confession has arrived: Since then, my son has had no further such problems.

Postscript: I subsequently became aware of many such patients who had experienced these adverse effects from bubble bath/liquid detergents and wrote an article for a medical journal titling it “A Soap Opera”. Shortly after publication of the article, I received samples of bubble bath products from companies throughout the world. They requested that I try their product on my patient and attest to its safety and, of course, to its pleasurable qualities. Needless to say, neither my wife nor my son would agree to such.

WHAT GOES IN COMES OUT

Dear Sumner:

Bill Jones will be calling your office for an appointment. He is 75 years of age and is a bit of a hypochondriac. He has been my patient for the past 25 years and claims to be very aware of the way his body “works”. He becomes fixated on particular bodily functions and is currently loosing sleep worrying about his current fixation, that of urinary frequency. Save for mild problems with his prostate (he claims his stream is “not what it used to be”) he is in amazingly good condition. He complains that he has to urinate every hour, day and night. I would be most grateful if you could help Bill (and me!)

Dear John:

I, too, found no gross abnormalities on Bill. His prostate was palpably benign, his urine was free of infection, and his post-void residual was negligible. We had a rather extensive discussion re the machinations of the urinary tract. I had quite a time getting him to accept the simple concept of intake and output: i.e. what goes in must come out. He said he enjoys his cups of coffee with each meal and his eight glasses of water during the day. In addition, in order to help him go back to sleep each time he gets up at night, he drinks a large glass of warm milk. It was very exciting (and most gratifying) to note Bill’s expression on his face when he came to the realization that merely modifying his fluid intake could take care of his problem (It will be interesting to see what his new “fixations” will be!)

John, I’d like to tell you the story of a patient I saw during my Urology Residency. This man was referred from the Medical to the Urology Clinic because of urinating five times during the night. The doctors in the Medical Clinic had run multiple diagnostic studies to rule out any serious medical conditions--much to the distress of the budget people in the Medical Department. During my interview, I learned that he voided at most once during the day. And do you know why? He was a night watchman.

I suggested to the Medical staff that an intake and output chart, including time, be a part of any evaluation for urinary frequency--with the admonition that different measuring cups be used for what goes in and what comes out.

BUT IT’S FUN!

Dear Sumner:

I would appreciate if you would evaluate a 22 year old woman for me. Since her marriage last April, Sue has had one bladder infection after another. Her husband feels like it’s his entire fault (which, indirectly, it probably is!), and is ready to move into another room! I have treated each infection with 7 day courses of antibiotics, but the infections keep recurring. I realize that these infections are related to sexual activity, but my dilemma is coming up with a simple way of “breaking the cycle” of the recurrent infections. Sue (and her husband!) will be eternally grateful for your help!

Dear Mary:

You are absolutely correct that most urinary tract infections in women follow sexual activity. I suggested to Sue that she void right after intercourse, in hopes of “flushing out” the organisms before they can multiply and cause the local tissue reaction with its associated irritative symptoms. We talked about the fact that the normal, non-inflamed urethral-vaginal tissue has a “built-in local defense mechanism.” With many recurrent infections, this tissue becomes inflamed, rendering it more susceptible to the offending organisms. I am optimistic that if Sue remains infection free for a prolonged period, there will be the re-establishment of healthy tissue, making it more difficult for these organisms to colonize. If infections recur, then Sue will add post-coital medications for a few months--e.g. one tablet of nitrofurantoin or trimethoprim sulfa--along with the post-coital voiding.

Mary, “just for fun”, I’d like to share with you a story of how I learned the importance of obtaining an accurate sexual history. During my early years of training, I saw a 16 year old with a problem of recurrent urinary tract infections. Haltingly I inquired...”Do you…you know…ever have sex with anyone?” Her reply was a combination of denial by both verbal and body language. I have since learned to ask the question directly, as illustrated by a recent interchange with one of the coeds at a local University. I asked: “Do these infections occur about 24 to 48 hours after sex?” She looked me straight in the eye and responded: “Dr. Marshall, that’s hard to say since hardly 24 hours, goes by without my having sex.”

KEEP RELIGION IN HER LIFE

Dear Sumner:

I have a delightful 92 year old woman as my patient who has had progressive urinary incontinence over the past 20 or so years. The problem occurs only when she does any physical activities. This is particularly distressing since one of her great pleasures in life had been attending church, but the embarrassment of wet panties has curtailed this activity. She is very reluctant to undergo any surgical procedures and has asked me whether there is some “non-invasive” procedure which will help her. Let me know what you and she decide is best for her. By the way, Myrtle is one of my favorite patients, and I am sure she will soon be one of yours as well.

Dear Kim:

After meeting and talking with Myrtle, I can certainly understand why she is one of your favorites. Not only is she delightful, she is also very bright and seemed to grasp the entire subject of the various approaches to urinary incontinence. For example, she explained to me that “Pee spouts get droopy after a woman has babies,” a very accurate description for urinary stress incontinence. We discussed some options and decided to try a vaginal pesssary to provide added urethral support. I told her that sometimes local inflammation can occur with the use of a pessary, and occasionally it can become displaced or even fall out. I asked what she would do if the pessary popped out when she was walking down the aisle in church. Without a moment’s hesitation she looked at me with a twinkle in her eye and said: “Why, Dr. Marshall, I’d just pick it up off the floor, and hold it up in the air and ask: Did anyone here loose this?”

Postscript: The pessary resulted in marked improvement of her urinary control and it stayed in place both during, as well as after, church services!

TRAINING MY PARENTS

Dear Sumner:

I need your advice on how to handle a particular four year old girl named Beverly, who wets her bed nightly. I realize that this situation of itself is not unusual, but her parents are beside themselves, and are not willing to accept the fact that she will likely “outgrow it.” Her mother has told me on many occasions how bright and well-adjusted she is and how well she gets along with her classmates in pre-school. However, when Beverly walks through the door of my office, she immediately starts crying and clinging to her mother. The family refuses to consider any medication and becomes very angry when I suggest some “counseling”. However, they were most pleased when I suggested that you see her. Are you willing? I hope so since they’ve already made an appointment.

Dear Phil:

I appreciated very much your introductory note on Beverly. Accordingly, when Beverly first walked into my office, clinging to her mother, I asked Beverly to help me examine her doll. Subsequently, she was quite amenable for me do a similar exam on her. After finding nothing awry on either physical or urine examination, I made the bold assumption that Beverly really wanted to stop wetting the bed. I asked her to make a calendar with all the days of the month. If she wakes up dry any morning she will affix a star of her favorite color to that day. If she wets, she will record possible causes; her parents will oversee the process. (Some of the things the kids write down as possible causes for the wetting are quite original: e.g. “the dog peed on my leg “or “my pajamas fell into the toilet.”) To try to get Beverly to play a more active role herself, I asked her to postpone voiding as long as possible, noting the maximum volume of urine she can produce at any one time. Obviously one of her parents will have to help her collect and measure the urine. Whether this actually increases her bladder capacity is not as important as making her aware of the sensation of bladder fullness, and then recognize that the time has come to deposit the urine in a proper receptacle. I further suggested that she stop and start the stream during voiding to try to reinforce her awareness that she can control her voiding pattern. I am well aware that these steps may not result in totally dry beds, but if we can get any dry nights, this will be a positive step.

I then asked the family to make an appointment for 3-4 weeks hence in order for me to go over the record with the child. (Her parents’ eyebrows rose at the thought of paying for another office visit, but quickly relaxed when they are told there will be no charge for that subsequent visit.)

Phil, it is very gratifying when a child appears with a big smile, so pleased that there are some stars on the calendar to show me (besides which, she also gets a chocolate chip cookie along with my encouraging words). The main point is that she must answer to a person other than a parent.

As a reward for sending Beverly to me, I’d like to share with you a couple of experiences I had with some other families involving bed wetters. A 6 year old youngster came to office with his mother. His mother looked lovingly at her son as she told me: “Dear Johnny tries so hard to stay dry and whenever he does, we give him a reward. Why last week alone he got a new tricycle, a special puzzle and a Mickey Mouse watch.” When I talked to Johnny separately, I asked him how he felt about being dry. He acknowledged that, while it did make him happy to wake up dry. He didn’t want to wake up dry every day, at least not right away. His reason: “Doc, I got it made! Do you see the way I got my Mom twisted around my little finger?”

However, not all parents will accept this plan. For example I had one mother who wore a very satisfied look on her face when she brought her son back for a follow-up visit. “Doctor” she said, “you may have all your fancy calendars and chocolate chip cookies, but I discovered a quicker way to stop my son from wetting. I got him an electric blanket and told him that if he wet the bed, he’d electrocute himself. (I personally do not recommend this approach for the treatment of enuresis!)

I DID IT WITH MY BARE HANDS

Dear Sumner:

I have a family from Berkeley that I’d like you to see. They wish to have their son circumcised, but they want to be sure he will not experience any pain during the procedure. They have searched the internet for information about the risks of local anesthesia in a newborn as well as the possible physical and psychological trauma which might result if no anesthetic is used. His father wishes to watch the procedure being done. Will this be OK with you? They will be calling your office for an appointment.

Dear Bob:

There is little argument that the use of some form of local anesthesia in the newborn helps decrease the pain level during circumcision. I addressed this issue with the family as well as the possibility, albeit very rare, of an allergic reaction to the anesthetic. With their own religious backgrounds, they were already well aware of the use of wine to sedate the child (the mainstay for religious circumcisions for centuries!). We also talked about the use of topical anesthetic cream, (to be effective, it should be applied at least one hour before the procedure is started). After much discussion, weighing the pros and cons (including potential risks) of local anesthesia, all parties involved decided that subcutaneous local anesthesia would provide the most effective method off minimizing the discomfort of the circumcision.

Re their desire to be present during the procedure, I pointed out very clearly that I did not want to have to divert any of my attention to either of them, should they become distressed during the procedure. Using a very tiny needle, I injected less than 1cc. of 0.5% lidocaine circumferentially in the area just proximal to the foreskin. The procedure went very smoothly for Josh, his parents and his physician.

Bob, I’d like to share another story of an older boy, just to point out that anesthesia is not always necessary. Mark, age 4, came to me for the release of adhesions of the foreskin to the glans. Given his age and level of concern of his father (although the boy himself was pretty relaxed about the whole thing), I planned on using a local anesthetic to try to minimize the trauma. When the time came to proceed, since Mark was not very enthusiastic about having a needle stuck in his penis, I thought I’d give a quick try to see if I could release the adhesions without the use of an anesthetic. “OK, Mark” said I, “This may hurt for just a few seconds.” A quick maneuver and the adhesions were released. Mark looked down, looked up, and with wide-eyed wonderment exclaimed to his father: “Wow, Dad, Dr. Marshall did it with his bare hands! “

DON’T LOOK

Dear Sumner:

Robert, who is a 44 year old man, will be seeing you in the near future. He recently discovered blood on the sheets after having had intercourse with his wife. She was not having her period at the time. He did not see any blood in his urine, and there was no associated discomfort with either urination or ejaculation. Needless to say, he has since been VERY upset, and is convinced that there is something very seriously wrong. He denies any new sex contacts, although he is now wondering if this is from some pre-marital “exposure”. I tried to reassure him that the underlying condition is most likely not serious, but I think he needs your special touch. I wait hearing your words of wisdom.

Dear Martha:

I can certainly understand Robert’s distress. The presence of blood in the ejaculate is very frightening to a man. He verbalized to me that he was afraid he had either a malignancy or a venereal disease. He was concerned that this might portend the loss of his ability to have erections! Robert became more relaxed when I explained to him that bloody ejaculates (aka hematospermia), fortunately, is almost always benign in nature, usually caused by an inflammatory process of either the prostate or seminal vesicles. The bloody ejaculates are usually of brief duration, although in some cases they may persist for years. I did send a urine specimen for cytology and, as expected, it showed no malignant cells. I told him that if the bloody ejaculates did persist, I would get x-rays and/or ultrasounds of the area and possibly even look up into the urethra and bladder and if anything unusual was found, proceed with biopsies. However, as I explained to Robert, the necessity for doing any of these invasive procedures and the likelihood of discovering any serious underlying problem was very minimal. When he asked what he should do if the bleeding recurred (assuming that no serious underlying problem had been found) I advised him to have sex in the dark.

GETTING STRONGER WITH AGE

Dear Sumner:

I have asked George, a 62 year old man, to call you for an appointment, since I have been unable to provide him with satisfactory solutions for his problem with maintaining erections. He states he is able to gain a fairly firm erection, but as soon as he attempts insertion, the penis becomes flaccid. He has tried Viagra, Muse, penile injections as well as a vacuum pump, all with variable degrees of success. I found no obvious causes for his difficulties. It’s your turn now! Thanks in advance for your help.

Dear Craig:

As I’m sure you’re well aware, almost every male feels that his erections are sub-optimal and will go through all sorts of steps to try to improve his sex life. George is no exception! During our talk, I tried to have him analyze the circumstances when he had difficulties (or no difficulties) achieving and/or maintaining erections e.g. with a partner-- or partners-- as well as during self stimulation (Craig, I had a patient consult me because he was having problems maintaining an erection when with his wife. He had no such problems when with his mistress.) Since George was able to achieve firm erections during vacation without the use of medications or devices (consistent with the lack of any intrinsic disturbance with his erectile “mechanism”) my main approach with him became one of counseling---and reassurance.

Here are some of the principal points of our discussion: I pointed out to him that while a teenager may be able to attain an erection “at will”, this ability lessens with age (and George realizes that he is no longer a teenager) and it is not unusual for any man to experience intermittent difficulty with erectile function. George was able to recognize that when he was feeling guilty or anxious for one reason or another or if he was angry with his wife, he really had problems not only with erections, but with general communication. He said that he would then try to will the erection… trying to “perform” to see if it still “worked.” The encounter usually ended in failure. He was subsequently reluctant to attempt a repeat performance for fear of repeating his failure. Unfortunately the failures turned into self-fulfilling prophecies.

Should George’s problems persist, I suggested he try what is sometimes referred to as “sensate exercises” (variations of the techniques of the sex therapists, Masters and Johnson). Basically this involves stimulating and subsequently bringing his partner to orgasm without his inserting, the purpose being to avoid any pressure on him to “perform“. (Usually, during the time of his partner’s being stimulated, he himself becomes aroused--and erect). Hopefully, this approach will resolve the problem. Since he was concerned about his wife’s reaction to his failure of performance, I suggested that, if the problem persisted, she should accompany him at the next appointment. However, I am optimistic that his recognition that his reactions are not abnormal will itself be therapeutic. I am holding off on the uses of medications or mechanical devices for now.

Craig, I’d like to share a story with you which illustrate the role of one’s own attitude concerning his erectile abilities. This is about a patient who told me that on his 85th birthday he
wrote in his diary: “Last night I had an erection. I was unable to bend it with both hands.” On his 86th birthday he entered in his diary: “Last night I had an erection. I was able to bend it with both hands. I must be getting stronger.”