Using narrative learning and story telling in Emergency Medicine. St Emlyn’s

Some years ago I attended the first SMACC conference. It was special in many ways but it was an epiphany for me in my medical education journey. It opened my eyes to the possibilities of presenting data in styles that were both useful and engaging. For me it was the moment when I realised that the traditional conference presentation was dead, or at least mortally wounded. I learned that the power in presentations is really about engaging with an audience and helping them learn. It’s not just about teaching or of us on the stage doing the teaching. It made us all ask what’s the point of being a great teacher if nobody learns (Ed – I think there is a non-sequiter there but go on). Stories abounded at SMACC. Topics that sounded less than interesting were illuminated and contextualised through the use of story telling. I remember sitting in one of the sessions with a talk with the rather dull (sorry) topic of Morbid Obesity in Trauma¹. At the time I was not that interested in that particular topic, but five minutes in I was hooked. This topic was suddenly real to me, it was a topic that could be my patient, my department, my experience, and potentially my nightmare. This happened because this talk started with a story, a story that was real, that linked all of the facts, concerns, experiences, professionalism and challenges of our practice. The talk was by Michelle Johnston² (more of her later), and it was the first time that I really saw the power of narrative in education. it changed the way I teach and the way I think about eductation. This was no powerpoint fest, and although there were facts as we went along, it was the story, which took a significant chunk of the allotted time that made the difference. Michelle taught, and I learned. This week I am in Glasgow, Scotland at the rather unique and combined RCEM and EuSEM conference/congress³. These great organisations have come together to deliver a real festival of learning and social events that are combining to a greater sum of their already fabulous parts. My task this week, apart from chairing, sharing, editing, podcasting and blogging is to deliver a talk on the use of narrative learning in Emergency Medicine. This talk looks at how we use narratives and stories in medical eduation and asks the question as to how we can blend this powerful educational tool into modern day educational techniques. It will be no surprise to those reading here that my view is that technology will not lead to the end of stories, but rather if we use it well it can enhance the use of narratives to embed and develop learning into the future.

Tell me a story

Stories matter to humans⁴. Stories and storytellers predate the written word, computers and even (for our millenial readers) the internet. Before we could write and before we could record our world stories were the currency of knowledge and meaning. What about medicine though? In our increasingly scientific and advanced world where we debate and discuss the minutiae of new diagnostic tests or imaging modalities do stories and narratives still have a place? Of course they do, and I would argue that they are increasingly important in our understanding of how new technologies advance into a society and a humanity that is struggling to keep up. In medicine we’ve always used stories to teach and learn. When we talk about cases we start with a recollection of the history and examination, the ‘story’ of the patient is central to everything that we do. All presentations of patients start with the usual pattern. “Mrs Smith is a 48 year old lady who presents with a 2 hour history of chest pain

The frames of meaning within which learning occurs are constructions which grow out of our impulse to emplot or thematise our lives⁵.

Narrative theory in education suggests that it by turning our experiences and learning into stories that we can create them into coherent narratives that help us understand and subsequently retain that learning. let’s take a couple of examples here.

• Option 1. High sensitivity troponin may be artificially low in patients who present to the ED with chest pain if they are taking Biotin. This only occurs with some analysers and you need to know which one it is.
• Option 2. I remember seeing a 35 year old policeman who came to the ED with a 1 hour history of chest pain. He was a really nice guy, always a risk factor for badness in my opinion. I think his name was Greg. Anyway, he came to the ED with chest pain and a pretty normal looking ECG. His pain had gone and he only had smoking as a risk factor so he went onto the low risk chest pain pathway and had serial troponins that were fine. I remember discharging Greg and reassuring him that everything was fine. It wasn’t. A week later he came back with a big anterior STEMI. I was gutted, distraught and to be honest a bit ashamed that I’d missed it. He did OK, we got him to PCI, but never got back into policing and his life was changed forever really. There was an enquiry of course and it turned out that he was taking Biotin supplements. Apparently they can artificially lower troponins on some assays. That’s why I now always take a note to ask about supplements when I see a chest pain patient.

Both these learning snippets are based on the recent blog by Richard Body⁶ on exactly this question of Biotin interference with troponin tests, but which one are you most likely to remember? They both contain the same information and one might argue that the first has brevity and focus. It’s efficient and perfect for our time challenged world. Forget that, the second is far more powerful. Although it has the same information the story that surrounds the learning point and which puts the learning into a context that is recognisable and valid to the reader has far more power and relevance and thus is much more likely to be remembered. True, the second one takes more time to read and arguably the learning message is somewhat obscured by the surrounding facts, but learning theorists believe that encasing the learning points in a story is a much more powerful way of making the learning stick. Stories are fundamentally part of our human nature, we are storytelling animals. Jonathan Gottschall’s highly recommend  book ‘The Storytelling Animal’ is great and really insightful into how stories are fundamental to our existance and our way of making meaning if our world. As an example try watching the following video and then stop and then write down what you think is happening. When Heider and Simmel⁷ did this experiment back in the 1940s only 3 of 120 people who watched it described it as what it is. It’s just a few shapes wandering about the screen, so those three people were right, but what about the rest? The remaining 117 created a story of the images, a challenge, a romance, a struggle a, well whatever they thought they saw. So many different stories peculiar to the individuals who watch. The point here is that as humans we cannot prevent ourselves from trying to make sense of what we experience. It is fundamental to us as humans to create narratives around events, with us either using the stories that are given to us, or by inventing and creating our own. Stop and think about all the stories that exist in your day, when you day dream, you sleep, you imagine, you mentally rehearse, you try and makes sense of what just happened and more. All of these acts are your brain creating a narrative that links and explains the connections and relationships between facts, experiences and emotions. You are a storytelling and storycreating machine. and that’s something that we might be able to exploit as educators.

Narratives as constructionism in education

For the theorists amongst us it might be worth reminding ourselves of a theory of education that underpins a lot of what we do here on the blog and in the world of social media. As clinicians we rarely if ever learn entirely new knowledge. Having spent years gaining a basis of our practice first in the basic sciences of anatomy, physiology, biochemistry, pharmacology and others we move onto the clinical experience where we embed ourselves in the custom and practice of the medicine the day and its accompanying texts. We build new knowledge on the bedrock of our clinical sciences and then subsequently on our experiences of clinical medicine and experience. We pretty much always construct new knowledge on the basis of previous knowledge. This is the theory of constructionism in education and for most if not all clinicians this approach works. An additional interpretation of construcitivism is that of social-constructivism⁸. In that theory we construct new knowledge not just on the basis of what we previously knew, but also through blending that with the knowledge of others through discussion and debate. How do we do this? I would argue that we do this through stories, cases and narratives. Think about a really interesting case that you saw recently and how you communicated that to colleagues and how you embedded that new knowledge in to your brain. I will pretty much guarantee that you did it through describing the story. You used that story to link and embed the new learning and you told the story to allow others to learn with you, to debate and argue and then form their own new knowledge. If you believe that socio-constructivism is a reasonable model of understanding how clinicians (and especially experienced clinicians) learn then you can clearly see the power of stories in that process.

Where do narratives help us learn?

Stories are a way for us to make sense of an issue and especially to allow connections to be made between different aspects of a problem. In the case about Biotin earlier regarding the troponin false negatives, it allows our knowledge and understanding of risk stratification, policy, new tests and then new information to be contextualised and palced within the realm of real world clinical practice. Narratives help us provide the context and more around the facts that we are learning. Graham Easton’s paper on the use of narratives in medical education lectures gives us a nice typology of areas where narratives might help us learn⁵. He identifies the following areas where stories can help us learn about different aspects of medical practice.

• Meaning-making (engagement, understanding, relevant, context)
• Professional identity
• Memory
• Empathy/compassion
• Reflection on practice

Easton used Labov’s model⁹ of personal narratives to understand how we process and understand knowledge whic fits with a construcitivist model supported by narrative. I quite like this as it divides how narrative has the two functions. A referential function orientates and grounds a story in its contextual world by referencing events in sequential order and than an evaluative function that describes the storyteller’s purpose in telling the story. Stories thus have context and meaning (well the good ones anyway).

There are some interesting examples out there in the literature of how we can use narratives to change the behaviour of clinicians, although I think it’s a relatively under-researched area considering the importance of stories in the human experience. Meisel et al have the best example I’ve found in emergency medicine where they randomised emergency physicians at a conference to receive information about safe opioid prescribing as a traditional guideline vs. a story vignette. They found a significant improvement in engagement with the learning materials if they used a narrative approach as opposed to a more technical one¹⁰.  It seems that even emergency physicians are subject to the power of storytelling.

Patient narratives

When we talk of narratives in medicine it is all too easy to forget that the narratives we share as clinicians are constructs and adaptations, with supplementation of our specialist knowledge, of the patient’s story. The transformation of a patient story into one of ‘clinician speak’ is helpful in many ways. It helps us be brief and provides focus and categorisation of facts, but there are dangers in this. Let’s take a simple exam using our favourite problems of chest pain for example. Think about this case… A 45 year old man comes to the ED with chest pain. He has pain to the left side of the chest which occasionally seems to be felt in the left shoulder. It is there all the time, but it does seem to get worse if he takes a really deep breath, but it also seems to worsen if he walks, but he’s not sure if that’s because he is breathless. Question: Is this pleuritic or cardiac sounding chest pain? I’ve used this example, or something similar, many times in the past and I get three answers. Most people think it’s pleuritic or cardiac (mostly pleuritic as it happens), and a minority of people can’t make up there mind. Of course the answer is that is indeed neither one nor the other. The pain is as described, but the temptation to categorise is often overwhelming as we try and place symptoms into boxes that may then get into the notes and force diagnostic strategies that may be entirely inappropriate. When I was a junior doctor I was berated for investigating a patient using both cardiac and pleuritic chain pathways, my indecision being an apparent sign of diagnostic weakness. Last week I did the same, thankfully now I’m the boss there was no one to argue this time 😉 That’s a really simple unifaceted problem. What about the more complex question of patient experience? If we stop and listen to patients tell their stories without interruption and with a good listening ear we can begin to understand the wider patient experience and thus the real impact of our clinical care. Patient narratives are all around them, we hear them every day, but often only for the segment of time that we spend with patients and their families. Their lived experience is of course much wider than this and much more difficult for us to access. For this we need to spend time listening to our patients beyond their presenting complaint and management plan, and spend more time listening to the wider impact of disease on their health and wellbeing. This will take time and effort, and I’ll be honest that in a busy ED you might not have time to always deliver this human aspect of healthcare, but when you can, you should. Understanding patient narratives can make you more empathic, more reflective and argualble a better clinician^11,12. One caveat about patient stories in education is that we must respect the fact that it is the patient’s story. If you use identifiable features that are not in the public domain then they should know and approve¹³. If in doubt be creative, change details and facts in order to anonymise (as discussed below).

WHO GETS TO TELL OUR STORIES?: HEALTH NARRATIVES AND PRIVILEGE https://t.co/R1YIA2p6IX

— NYU LitMed Database (@NYULitMed) June 29, 2018

Narratives and the hidden curriculum

There is so much more to the practice of medicine than that contained in textbooks, lectures and workshops. The wider practice of emergency medicine encompasses the hifdden curriculum of practice, the areas of learning that explore not just what needs to be done but how do we make it happen, and how do we make it happen here. The power of the hidden curriculum is evident to anyone who has moved between nspecialities, departments or health economies. We also need to recognise our existence within the practice of medicine. Clinical decisions, experiences, uncertainties and more are all a function of the event and also our reation to them. As we’ve talked about in Natalie’s post on the rules of St Emlyn E+R=O¹⁴ in that events happen, but it is our response to them that determines the totality of the outcome. This is as true for personal, organisational and clinical issues. We can support learners (and ourselves) in understanding the hidden curriculum through anecdote and narrative as these describe the interface between what we know needs to be done and how we can achieve it in practice. Narratives around professionalism are arguably double edged swords, in the tribal jungle of healthcare (so eloquently described by Vic Brazil¹⁵) we tell stories of our tribes battles against the forces of evil within healthcare in our quest to do what’s best for the patient at the expense of others who are clearly only acting in their own personal interests. Such stories are rife in medicine, the stupid orthopaedic surgeon, the lazy ophthalmologist, the rude radiologist and the doctors who know nothing and refer everything (the emergency physicians). There is little consistent truth in these narratives but they appeal to our sense of self and the tribes we work in. Sure, there is no doubt that we will occasionally meet a rude radiologist or an idiotic orthopod, and some feel that such encounters make great stories, but they have no more validity than a derogatory sentence starting with ‘The thing about black people is……..’ and we would absolutely not tolerate that. It’s not all bad though. Positive narratives, stories and cases can and do promote professional behaviours and the more obscure areas of our learning. In this regard it’s important that we celebrate success and positive outcomes when we create the narrative of our working environments and lives. I’ve spoken many times before about the power of positive event reporting and the impact of including positive outcome cases in M&M reviews such that they are not just M&M, but that they are also A&A (Awesome and Amazing). The question here is whether your organisational culture is defined by stories of caution, concern and disaster or is it defined by the narrative of success, innovation and development. A good organisation will have this in balance, with a preponderance of positive narratives to tell.

Think about how you frame your learning narratives in practice. Simple stuff such as how you start a story.

You don’t want to do that because……., well this guy ended up dying/getting sued/in pain.

vs.

OK, we’ve developed a way to improve on that practice, let me tell you about a case…….survived/did really well/no pain.

How we frame and develop our stories not only informs through the technical message but also allows us to develop a culture of learning and hopefully positivity and support. This may seem relatively benign but it matters. Learners want to get better. Signposting them to positive narratives of development should lead to a positive learning culture.

Stories in a digital world?

The world of narrative has changed enormously in the last ten years. The rise of digital media, the internet and in particular social media means that the way that we create and consume stories has changed beyond recognition. We’ve talked before about the need for or education and learning to engage with the audience. The current mode of consumption through social media is often in the form of short narratives associated with significant use of visual imagery. Classical narrators might argue that there is something a little sad about this as books are designed to allow the reader to create their own world, but that is the reality of the modern world. As storytellers we must compete, or perhaps emulate the media of the day in order to capture the consumers of the day. For those of us working in digitially based education (like much of #FOAMed) then this means that we must use the digital tools and platforms that are available to us. We might go for this rather simple, but genuinely true comment from Jeff Bullas

‘Create a quality product, deliver an experience that delights (or at least emotes). Be worth talking about and the people will talk and if you don’t they won’t’¹⁶

In other words create a product that engages and entices your audience to do more. We can do this through pretty much any of the common social media platforms. Listen to your favourite podcasts and you’ll find some great examples. Stories are just as important in the digital education world as they ever were. It’s just that we need to adapt the way that we use them to take advantage of the media we are using. As Marshall McLuhan famously said ‘The Media is the Massage’ read more about Medutainment and the impact of media on the final message in our series here^17–19.

Becoming a narrative teacher.

To some extent we are all narrative teachers. The very constrution of the medical consultation, presentation and record is a narrative of the patient’s experience and our reaction to it. I would argue that the narrative is the most important element that underpins how we organise and construct our understanding of any given case. If you agree with me (and you should) then perhaps we can enhance our narrative abilities to enhance the glue between the facts, we can be better story tellers. How you do that will be a personal journey but these are things that I and others have found helpful. 1. Read. Read and read some more, and not just textbooks. Read about the experience of patients, read fiction and pretty much any form of literature. It all helps. If you want an example in the #FOAMed world then read or listen to anything by Michelle Johnston²⁰. She epitomises the link between literature and emergency care. I’ve learned a huge amount from her and would love to emulate her abilities. She reads widely and it shows. Her ability to weave a story and to link the facts with the experience of patients and clinicians is a real skill and something that we should al aspire to. Now at this point many of you will be saying that you simply don’t have time to read, life is so busy and there are so many competing interests and the tiredness of our jobs that it is hard to find time to sit down and read a book. Many of you will reserve your reading to holidays and mini-breaks when the distractions of daily life have diminished, I totally get that, but there are solutions. If you commute on public transport there is time (so many people in London read on the Tube), but if you can’t then I would really advocate audiobooks. Jeremy Faust is an EM doc in New York and co-author of Foamcast (which is amazing). Three years ago he offered me a suggestion when we were out for dinner in New York. He just mentioned that he was an avid listener of audiobooks and suggested I try it. I’ve not looked back. I average at least a book a month this way and mix fiction with fact. Try it, you may find this a way to consume literature within the constraints of our busy lives. If  you’d like a recommendation of how narrative can help us understand medicine and medical education I would heartily recommend ‘Also Human’ by Caroline Elton It’s a bit specific to the UK training environment but it’s also a great example of how patient/trainee stories can be used to make learning happen. 2. Start with a story. Virtually every educational event can start with a story. Use a narrative to set the scene, to make the subject relevant and to contextualise the learning. At the beginning of this blog post I used the story of my experiences at SMACC to try and hook you into the topic. I did that with purpose. It was designed to make you think that understanding narratives and stories can make you a better teacher. Did it work? Well if you got this far then the answer is probably yes. If it didn;t work then I guess you may have ducked out after the first paragraph. Just be careful that your story does not prevent you from clearly articulating what the talk is about and why they are here. A great anecdote or joke is great, but it has to have relevance. 3. Consider split stories. A split story is where you start with half a story in a presentation and then conclude it at the end. This can be a powerful learning tool but has some risks. You want to avoid the shaggy dog story²¹ problem as stories must have meaning and purpose to the learning goals. Whilst splits can keep learner’s attention they should link to the topic and help summarise the key points. 4. If you don’t have a story. Er, make one up. Seriously within the realms of our combined experience it’s always possible to imagine a situation and then to use supporting materials from other sources (Xrays, ECGs etc.) to make up the case. We do this all the time in teaching so as to protect patient confidentiality and to focus the case on the learning outcomes. I might even argue that all stories have an element of creation in them, we never precisely remember what happened, our brains fill in the gaps and even modify our role within them. The reality of any story only ever resides in your mind and may be rather different to those around you. As Dan Kahnman explains in this fascinating video, experience is rather different from memory²². Don’t be afraid of this, embrace it so long as it helps deliver the learning. 5. Create your story book. I used to be a bit sceptical about anecdotal teaching. If poorly constructed it can feel a bit anti-EBM, just a series of anecdotes and we know that the plural of anecdote is not data. The point is that when you do have important learning points, ones that you use on a regular basis then encompassing them within an anecdote (real or imagined) is really powerful and will help your learners remember the points. For example, I use the anecdote about when I missed a significant fracture²³ to talk about the reasons why we miss things and the need to own our mistakes. It’s one of the first blogs we put out and it’s useful there and also when teaching on the shop floor. I’m sure you have your own anecdotes and stories, but have you curated and organised them? Remember that you should have at least as many positive stories as negative ones. My advice is that when telling the positive stories tell them about someone else (someone else did this amazing thing even if it was really you), when negative then feel free to own them (even if it wasn’t you). Humilty in story telling will take you far.

The storytelling animal: Jonathan Gottschall at TEDxFurmanU

This presentation encapsulates much of what I’ve tried to get across in this presentation and better explains some of the examples and concepts. I would recommend you find time to watch a real expert on the storytelling animal.   My final thoughts are for you reflect on how you can use stories in your personal learning journey and in the journey of those who learn alongside you. I really hope you use some of the techniques here and that this blog post helps you listen in and understand the importance of how we construct and link information through the use of stories in healthcare. vb S @EMManchester

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