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The stories we hear and the stories we tell

2014; Wiley; Volume: 11; Issue: 2 Linguagem: Inglês

10.1111/tct.12238

1743-498X

Jill Thislethwaite,

Cinema History and Criticism

The Clinical TeacherVolume 11, Issue 2 p. 77-79 EditorialFree Access The stories we hear and the stories we tell Jill Thislethwaite, Jill Thislethwaite Co-Editor in ChiefSearch for more papers by this author Jill Thislethwaite, Jill Thislethwaite Co-Editor in ChiefSearch for more papers by this author First published: 14 March 2014 https://doi.org/10.1111/tct.12238Citations: 1AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat A major part of being a practising health professional involves eliciting, listening to and responding to stories. In medical jargon, this task is frequently referred to as 'taking a history'. This phrase invokes the professional-centric approach to patient care: the clinician is in the active and powerful role of the diagnostician; the patient is a passive answerer of the questions posed. Such paternalism is being superseded, however, by the patient-centred approach in health care that involves, among other things, consideration of the patient's agenda, their psychosocial circumstances and emotional status, and a shared decision-making approach to management.1 Similarly in education, the student-centred approach has been heralded as a means of involving learners more actively in their curricula.2 A cartoon used commonly in faculty development to illustrate the difference between teaching and learning involves two children and Spot the dog. The little boy states that he has taught Spot to whistle; his friend replies that she cannot hear Spot whistle, to which the retort is – I said I taught him to whistle, I didn't say he had learned to whistle. We are all familiar with similar scenarios as health professionals and educators. Just because we prescribe a drug X for Mr Smith doesn't mean that Mr Smith will take it. Students and patients are no longer conceptualised as passive recipients of teaching or health care. Students are encouraged to seek out learning opportunities, set their own learning outcomes and develop their own learning plans. Tutors are now frequently referred to as facilitators of learning, rather than as teachers, as problem-based learning (PBL) and more recently the flipped classroom have become widespread educational processes.3 Of course these approaches are not new, but they are not always adopted. Patient-centred and student-centred approaches have similar associated tensions. Clinicians and clinical teachers have not always developed the necessary communication skills for such active processes. They may not have the time to engage in such a way. Consultations and feedback as a dialogue rather than mainly one-way conversations require patience and a professional who is not always rushing away to the next meeting or emergency. When we have to involve patients and students in a three-way interaction the task becomes even more complex. Active learning involves stories; students thrive on the stories that they hear – the clinical anecdotes of their teachers and the histories of the patients. With early patient contact, before they have learned to retell the histories in the medical way, students begin to explore what it means to be well, to be ill, to recover and sometimes to die. Soon they shape the narratives into the classical format: presenting complaint, history of presenting complaint, past (medical) history, social history and the long list of questions of the systems review. As teachers we encourage this formula as a path to clinical reasoning, but when we talk of 'our' patients we remember the idiosyncrasies, the emotions, the lessons we learn and the unpredictability of our profession. It is these richer narratives that hopefully motivate the students and encourage their patient-centredness. How May Clinical Teachers Best Use Stories To Promote Learning? Problems and cases are of course the backbone of PBL and case-based learning (CBL). These 'stories' are often amalgams of real-life incidents reworked to stimulate discussion and the achievement of defined learning outcomes. Biomedical scientists and clinicians may be asked to collaborate and contribute 'material' to keep problems up to date. Clinical and community life may also be portrayed through the use of stories from literature, theatre, film (see Gallagher and colleagues4 for an example of this) and TV. Such 'cases' involve health professionals, their clientele and their environments. They may form the content of medical humanities courses, which aim to develop empathy and compassion in future clinicians by helping them 'to understand the nature of suffering…and the experience of illness in parallel with the traditional instruction on the pathophysiology of disease'.5 Tutors may need to help filter the ideal from the reality, and the artistic license from the authentic. Nurses and doctors are commonplace in the media, but it is rare to see other health professionals having more than minor supporting roles – something to think about if using such media for interprofessional activities. Books of illness journeys, including insights gained when health professionals become patients, are commonplace, and may trigger discussions about health beliefs, work–life balance and values. Such stories may acquire greater immediacy through the use of graphics, including cartoons that convey communication and non-verbal reactions that jump off the page. For example, Graphic Medicine is a website that 'explores the interaction between the medium of comics and the discourse of healthcare' (http://www.graphicmedicine.org). Dr Ian Williams, the founder of Graphic Medicine, explained to the BBC that he is '…interested in the narrative of medicine – the way doctors and patients think of illnesses in terms of stories, and what it says about how we have thought about illness through history'.6 Early patient contact within curricula involves patients coming to the classroom, being interviewed in clinical settings or being visited in their own homes. Students are advised to explore the patients' illness scripts, and their stories of the impact of health-related conditions on their lives and those of their families. Learners realise that, unlike many novels and TV shows, stories are not linear, facts are forgotten, timelines distorted and what is important to the professional is not always as vital to the client, and vice versa. Later, more senior students understand that what is written in the patient record is only an approximation of the patient's narrative. Clinical teachers also need to remind students that patients should never be labelled as 'poor historians': we all have different interpretations of events and ways of describing episodes of care. Patient experiences should illuminate all parts of the curriculum. In this edition of the journal, Soar and colleagues describe how they collect and use such experiences, specifically related to autistic spectrum conditions, for the development of e–learning;7 however, the innovation is relevant in many other areas of clinical education. Telling Our Own Stories As teachers, our stories are interwoven with those of our patients and clients. We can narrate our own paths to qualification, explain the career choices we have made and discuss how we have learned from our experiences. Health professionals' stories of their own illnesses are powerful, and frequently demonstrate that by taking on the role of the patient we come to a better understanding of the community we work within. As educators we also invite students and junior colleagues to tell their stories. The interchange of experiences from clinical attachments enables us all to consider episodes of learning at second hand, acknowledging that it is impossible for everyone to have the same placements and the same patient interactions. Students may need coaxing to discuss their personal reactions to events, and their emotions in relation to such traumatic events as viewing their first dead body, being involved in their first death, seeing major injuries, and witnessing the unprofessional behaviours of their seniors and colleagues. As an alternative to oral story telling, Hayes and colleagues describe a devised theatre special study module in which students develop performances based on their narratives and using their own words on the theme of 'healing'.8 Finding time to debrief learners is a challenge. We all have difficulties in making space for the observation of clinical performance and work-based assessment, let alone encouraging reflection. I will finish with two questions that challenge all clinical teachers. Who is responsible for ensuring that fledging health professionals are able to tell their stories in a supportive and non-judgmental environment? And, similarly, whom do we talk to if we have challenging teaching sessions or unresponsive learners? References 1Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-centred medicine transforming the clinical method. Thousand Oaks: Sage Publications; 1995. Google Scholar 2Brandes D, Ginnis P. A Guide to Student Centred Learning. Oxford: Blackwell; 1986. Google Scholar 3 Teaching and Educational Development Institute (TEDI), University of Queensland. About flipped classrooms. Available at http://www.uq.edu.au/tediteach/flipped-classroom/what-is-fc.html. Accessed on 27 February 2014. Google Scholar 4Gallagher P, Wilson N, Jaine R. The efficient use of movies in a crowded curriculum. Clin Teach 2014; 11: 88– 94. Wiley Online LibraryCASGoogle Scholar 5Wetzel P, Hinchey J, Verghese A. The teaching of medical humanities. Clin Teach 2005; 2: 91– 96. Wiley Online LibraryGoogle Scholar 6McGrath P, Watson K. What's up, Doc? How comic strips are improving bedside manner. Available at http://www.bbc.co.uk/news/health-25112785. Accessed on 1 December 2013. Google Scholar 7Soar S, Ryan S, Salisbury H. Using patients' experiences in e–learning design. Clin Teach 2014; 11: 80– 83. Wiley Online LibraryCASPubMedGoogle Scholar 8Hayes P, Cantillon P, Hafler M. Discovering emotional honesty through devised theatre. Clin Teach 2014; 11: 84– 87. Wiley Online LibraryCASPubMedGoogle Scholar Citing Literature Volume11, Issue2April 2014Pages 77-79 ReferencesRelatedInformation