|Year : 2021 | Volume
| Issue : 2 | Page : 337-344
Storytelling in medical education, clinical care, and clinician well-being
Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota, USA
|Date of Submission||19-Oct-2021|
|Date of Decision||27-Nov-2021|
|Date of Acceptance||16-Dec-2021|
|Date of Web Publication||29-Dec-2021|
MD Cory Ingram
Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota
Source of Support: None, Conflict of Interest: None
We all share our lived experiences with others through stories. Sometimes we may share a story in conversation over a cup of coffee or simply share a photograph with a friend to illustrate an event in our life. During our health care training we can learn concepts through reading textbooks, medical articles, and informational lectures. However, it is often the real-life stories that teach the lessons, so it is best understood, remembered, and applied. This actionable knowledge is created through patients, family members, and/or clinicians sharing their stories. When learners are able to acknowledge, absorb, interpret, and act on the stories of others they are practicing narrative medicine. Storytelling bridges the worlds of patients, families, clinicians, health systems, policy makers, communities, cultures, and traditions to help us find common understanding to create experiences that match our expectations and improve the lived experience of giving and getting patient centered healthcare. This paper reviews the literature on storytelling as a methodology that lends a rich opportunity for meaningful academic productivity in research, community engagement, and quality and safety improvement. I close the paper with a sincere invitation to explore a specially crafted storytelling workshop to train patients to craft their stories of receiving health care to share with intentionality, confidence, and emotional wellness with medical audiences to improve the delivery of patient centered care; to improve the delivery of narrative medicine.
Keywords: Storytelling, narrative medicine, medical education, clinician well-being
|How to cite this article:|
Ingram C. Storytelling in medical education, clinical care, and clinician well-being. Arch Med Health Sci 2021;9:337-44
| Introduction to Storytelling|| |
We all share our lived experiences with others through stories. Sometimes, we may share a story in conversation over a cup of coffee or simply share a photograph with a friend to illustrate an event in our life. Sometimes, we take time to write a letter, e-mail, or text to share an important memory with another person. At times, we may be on the receiving end of a story and we remember the essence of what is being communicated to us.
During our health-care training, we can learn concepts through reading textbooks, medical articles, and informational lectures. However, it is often the real-life stories that teach the lessons, so it is best understood, remembered, and applied. This actionable knowledge is created through patients, family members, and/or clinicians sharing their stories. When learners are able to acknowledge, absorb, interpret, and act on the stories of others they are practicing narrative medicine. For this reason, this paper will explore the power of storytelling.
Storytelling bridges the worlds of patients, families, clinicians, health systems, policymakers, communities, cultures, and traditions to help us find common understanding to create experiences that match our expectations and improve the lived experience of giving and getting patient-centered healthcare. As a methodology, it lends a rich opportunity for meaningful academic productivity in research, community engagement, and quality and safety improvement. Storytelling through digital, first person and even virtual reality are various modalities to convey stories that impact the medical care is delivered and received.
Those of us working in health care likely consider ourselves striving to be holistic patient-centered practitioners. In becoming holistic patient-centered practitioners we must ask ourselves the impact of the stories of our patients' experiences on our professional development coupled with our reflective practices to harvest the essentials of what our patients are teaching us through stories to help sort through our own thoughts, ideas, and reflections and establish perspectives on self and others in the societal context. Storytelling is a fundamental part of clinical practice as it is through the story in which clinicians and patient's communicate and developed meaning and understanding of illness and what it is like to live with the disease. “Everyone has a story to tell. If we want to provide real value to our patients, we will listen to their stories. When we do, we will quickly discover that they care more about being treated with dignity and respect than about mortality rates, healthcare reform, or policy. Patient stories acknowledge the patient's own expertise—his or her life and experience with an illness. Listening to their stories will help us see patients as the unique individuals they are. In the words of one individual, “You don't know me until I tell you my story.”
First-person storytelling improves attitudes, knowledge, and clinical outcomes for patients receiving first-person storytelling interventions. First-person storytelling offers unique intervention opportunities for chronic disease self-management. It has been proposed that the adaptive value of storytelling lies in developing understanding of nonroutine, uncertain, or novel situations which then enables the collective development of previously acquired skills and knowledge while at the same time promoting social cohesion by strengthening meaning within the group identity and clarifying the group relations. First-person storytelling in the form of movies recordings of patients' stories has been found to be powerfully persuasive for health provider audiences.
Storytelling allows science to become comprehensible and meaningful for general audiences., Storytelling in all its' forms can bridge gaps between patients, caregivers, medical providers, medical systems, culture, society, and researchers.
| Storytelling in Health Care Education|| |
We learn best through humor and storytelling because we learned best when we are emotionally engaged with the subject. Digital storytelling in health education has been shown to enhance learning, especially when clinicians and patients co-create their story.
Storytelling is a powerful tool to build community in Graduate Medical Education and may also serve as an effective approach to promoting resiliency in graduate medical education. Digital storytelling is a modality for knowledge translation in healthcare for both caregivers, patient's, policymakers, and healthcare professionals. Storytelling in Medical Education is also a resource for interdisciplinary collaboration.
Medical students find the patients storytelling strongly resonated with them and helped them become emotionally better clinicians through gaining understanding of patient's experiences., Storytelling is an important modality to teach and help prepare medical students for the uncertainty that exists in the clinical environment which can cause significant anxiety and negatively impact the medical student's well-being. Digital storytelling in the Medical Oncology curriculum for medical students has been shown to improve critical thinking, deep learning, communication skills, and teamwork. Storytelling has been found to play a key role in medical education to convey examples and role models of practical wisdom that can be conveyed through stories to teach medical ethics. Medical students consider personal stories of medical errors an effective and engaging means of learning about patient's safety.
Medical Oncology fellows were introduced to storytelling as a didactic to teach healthcare communication skills. They considered this approach to communication skill acquisition to be relevant, valuable, organized, relevant, and acceptable as a form of teaching methodology. This storytelling curriculum lent to training highly technical learners' reflective skills, mindfulness techniques, and empathy.
Additionally, storytelling in Nursing Education is proven to be an effective modality to engage nursing students in the acquisition of subject matter related to caring for patients with mental health illnesses. The nursing students noted that it was more enjoyable to learn through storytelling and that they developed a better understand of the subject of mental health which better prepared them to care for their patients. Through the patient storytelling project in the ICU, nurses identified the following themes in thinking about their work more positively: perspective taking, emphasizing the value of caring, providing positive closure, engendering team belonging, and building a sense of hope.
Virtual reality storytelling has proven to be an effective modality to engage and motivate nursing and midwife students to learn abstract concepts of patient care. Student midwives realize the importance of listening to mother's voices, regardless of nationality or cultural background, through watching video-recorded first-person storytelling accounts of childbirth experiences. Four main themes arose from these storytelling experiences: adeep reverence for women and mothers, respectful attitude as a midwife to support mothers, wish for the safe and secure birth environment, and importance of learning from the mother's voice.
Pharmacy students have participated in a reflective exercise after hearing first-person stories from pharmacy school faculty and students, resulting in a strengthening of the students and schools reflective culture, and fostering stronger relationships, trust, and respect between students and faculty. Pharmacy education has highlighted how patient stories teach us to focus on the patient and less on the technical problems to foster patient-centered care instead of problem-focused care.
| Storytelling in Caring for Ourselves|| |
Four themes have been identified for self-care through storytelling for nurses and other health-care providers: cultivating a self-care culture, healing through storytelling and writing, co-creating layers of connection, and preferring face-to-face contact. Positive benefits include meaning-making, emotional conveyance, and therapeutic connections between storytellers and listeners. Storytelling has been found to be an acceptable, valuable, and easily implemented initiative to enhance physician faculty well-being through an “origin story” storytelling group. Additional themes of benefit are: genuine curiosity, safety for reflection and vulnerability, insight of lived experience, nonlinear life trajectory, creativity empowerment, and enhanced collegiality.
| Storytelling in Clinical Medicine|| |
Storytelling in oral and recorded digital forms has been found to convey positive benefits to patients of various illness categories. Digital storytelling is the opportunity to provide culturally relevant connections in communication in removing barriers to telling stories that lend for disease prevention, awareness, and education. Storytelling has been studied to improve outcomes in thyroid disease, public health, self-management of type II diabetes, decrease dental caries in children, and support family caregivers of allogeneic hematopoietic stem cell transplantation patients.,,,,,, Storytelling has been employed as one methodology in a package of approaches to improve hypertension management in Vietnam.
To serve patient's and family's living with obsessive-compulsive disorder (OCD), stories of their experience with OCD were shared through a theater performance to a live audience followed by post-show discussion. The outcomes of this study demonstrated that storytelling could lead to a reduction in both self-stigma and community-stigma around mental illness. In addition, better relationships can also be formed between patients, family, and clinicians due to an improved understanding of the lived experience of OCD.
Digital storytelling is incorporated in many facets of shared decision-making., Digital storytelling has been found to augment traditional educational approaches to increase living kidney donor transplant rates by helping to overcome time limitations of busy clinicians to provide education, reduce fears, increased self-efficacy about their transplant and to help more patients share about transplant within their social networks. Digital storytelling intervention was created to increase the knowledge and promote the use of HPV vaccination in a population of Korean women.
In an effort to stop violence against women in Turkey, first-person storytelling showed support to a woman's agency and contributed to the collective struggle against violence against women more broadly. The preeclampsia Foundation has employed storytelling as the basis for its effectiveness in advocacy for patient's living with hypertensive illness during pregnancy. First-person storytelling has also been used to understand the experience of women needing an unplanned cesarean section delivery to better prepare obstetrical teams to care for this population of patients. First-person storytelling has also been used to help children with autism and eye gaze disorders.
Digital storytelling has been used with varying rates of success for person's living with dementia in the form of life review, reminiscence, identity, and self-confidence., The TimeSlips storytelling activity shows that people living with dementia continue to express their values and concerns and maintain their identity. These storytelling efforts may impact patients living with dementia in multiple positive ways.,,,,
Storytelling is also used by informal caregivers to recreate a cohesive caregiving story and to incorporate a narrative identity to facilitate a positive transformation for informal caregivers. Storytelling was shown to facilitate growth in meaning-making in the setting of grief and bereavement in caregivers who had lost a loved one on hospice care and those in the ICU.,,
| Ethics in Storytelling|| |
Storytellers want to first do no harm. In the same breath, that does not mean they leave no trace. Storytellers will want to make certain they are ready to share their stories. Patient's stories are powerful tools to help educate healthcare providers, convey clinical lessons to other patients, and provide meaningful information for clinical decision making, however, there are inherent risks for patient's and clinicians sharing their stories.
A patients' readiness assessment is been created for programs considering patient participation in storytelling efforts and medical education. Storytellers may also want to consider the following three issues when contemplating if they are ready to share their stories. These issues are: Having support for choosing the stories they tell about their life, acknowledging that they are making interpretive decisions about how they understand their story, and duty to reflect on the consequences of their story on their life and those around them. The relationship between the audience and the storyteller remains a vulnerable space and the facilitation of that space remains crucial to the delivery of the story and the intended curriculum that it is supporting to assure the safety of the patient storyteller and the audience.,
The dangers of storytelling are often in the narrative form which means that there needs to be a character in a conflict where obstacles need to be overcome and a hero may emerge. Sometimes death is an obstacle that is not able to be overcome. So, the resolution is the mastery of how death is dealt with or experienced. Patient stories often fall into the categories of reminders, lessons, and inspiration. In his book, Frank has proposed three narrative forms: Restitution (a plot based story), chaos (share the messy experience of illness), and quest (share the lessons learned through the journey of illness). There may also exist a coercive nature that stories can be used to achieve goals that may be misaligned with the storytellers intention; such as fundraising for example.
In my field of palliative medicine, we tell stories in very similar ways on very similar topics: End of life care. This can be problematic as our stories start to make sense within our specialty group because of the moral insularity of our stories. Often, we are preaching to the choir. The question we must ask is how does a different choir experience our chorus? Our stories situate principles, rules, and guidelines in a practice location. Stories demonstrate how different actions result in better or worse outcomes. We can become committed to one story as the privileged “truth” and guide to what is happening. The best and perhaps only remedy to the dangers of stories is openness to more stories. An openness to counter narratives.
| Community Engagement|| |
To improve patient engagement stories of the lived experience of patient's and illness encounters with healthcare organizations have been studied and resulted in identifying four major functions of the stories to promote community engagement with the healthcare system and support provider education: Establishing mutual understanding, adding expansion and depth, characterizing abstract concepts, and providing context for patient experience as the most frequently occurring theme.
| Cross-Cultural|| |
Storytelling seems to have no boundaries and is a common communication commodity transcending cultures and continents. Oral storytelling in 53 forager cultures spending 5 continence in 30 for language family's and diverse biomes were studied suggesting that storytelling is a mode of instruction providing cross-cultural evidence of teaching in forager populations. Health-care workers need a solid culturally specific understanding of other cultures and must consider their needs, culture, language barrier. Storytelling can help to bridge this gap between health care providers and systems and their patients., Digital storytelling in the Hong Kong Chinese community has been shown to improve critical thinking, self-esteem, perspective-taking, and curiosity towards the new information while at the same time, the need for cognitive closure decreased. Digital storytelling has also been employed at the intersection of Western and first Nations people's knowledge imbedded within the historical and social context.,
Oral health knowledge improvement was reached through storytelling with American Indian and Alaska Native Communities with dedicated attention to the cultural tensions between the oral history of storytelling in the digital world of moderate-day storytelling. Digital storytelling, as found in a pilot study in Uganda, was a culturally appropriate way to modernize oral storytelling traditions and had broad use in Uganda. Digital storytelling could be used to address ethical and logistical challenges working with vulnerable groups in the country. In-country facilitators perceived digital storytelling as an advantage to address many community priorities.
Storytelling is a valuable modality to highlight what is often ignored in the Western paradigm of medicine, indigenous people's health practices and the alignment of those practices with her healthcare priorities. Storytelling has been found to facilitate an ancient Anishinabe way of knowing called Debwewin. This is a way that connects one's heart knowledge and mind knowledge as studied with first Nations women living with breast cancer. The promotion of culturally respectful cancer education through digital storytelling has been created to decrease the mortality among the Alaskan native people from cancer.,
Storytelling in the Healthy Hawaii Initiative, in addition to other community efforts, helped to encourage the shared value of health among the lawmakers leading to the development of health policy champions that facilitated the implementation of a broad, diverse, multifaceted system change and filled key gaps around building a culture of health in a multi-cultural state. Storytelling has been employed as one methodology in a package of approaches to improve hypertension management in Vietnam.,
Arts-based approaches, including storytelling, to foster healthcare promotion in sub-Saharan Africa have been used predominantly in the HIV/AIDS public health delivery and efforts are being explored to bring in arts-based approaches to healthcare promotion more broadly and draw on the deeper added historical traditions of the indigenous groups in combination with important traditions from Colonial engagement.
| Gaps in Research|| |
Although we easily intuit the benefits of storytelling for storytellers and the audience, there remains a paucity of high-quality research in the areas of training people to tell their stories, safeguarding the emotional wellbeing of storytellers in training, and in story sharing, and the clinical outcomes associated with storytelling initiatives.
| Training First Person Patient and Family Storytellers|| |
Efforts to train patient family storytellers have been undertaken and guidelines have been created to help assist others in creating similar training programs. Challenges have been identified in creating stories for educating patient's and family's to ensure accuracy, credibility, and relevance. Patient and family storyteller can also experience the therapeutic value of telling their stories and attention needs to be paid to their skills of storytelling in the healing process. Shared stories lead to lessons learned. Our workshop to train first-person patient experience storytellers is designed so that storytellers emerge from the workshop with a novel skillset to craft their story and stories with intentionality, confidence, and emotional well-being to share with the medical student or similar audience. Our workshop functions on agreed upon ground rules and a culture of safety with emotional support for participants immediately available through psychology and social work.
| Artistry|| |
We encourage our patient experience storytellers to consider their storytelling a form of their artistry; a gift that keeps on giving. Humans are imaginative creatures. Storytellers need to consider what they say, how they say it, and how it may make the audience feel. They need to think carefully about the relationship they are creating with the audience. Storytelling is very much an art and as such may convey the following therapeutic impact: Remembering, hope, sorrow, rebalancing, self-understanding, growth, and appreciation.
- Remembering: We forget what matters…softening of lows and enrichment of highs. “Art banks our winnings”
- Hope: We lose hope easily and art can keep hope in view
- Sorrow: Art casts a realistic dose of sorrow in normal life
- Rebalancing: Provides clarity to our qualities and possibilities
- Self-understanding: Guides us to identify what is central to us
- Growth: A extension of our experiences
- Appreciation: A re-sensitization to our (re) discovery of our sensitivity to look at old in a new way. Perspective.
| Developing the Voice of our Storytellers|| |
Our patient experience storytellers may have presented their stories many times. Considering storytelling an iterative process and journey, we invite them to be open to the experience of writing. We offer three iterative writing experiences to help them develop their voice. These writing exercises are the stream of consciousness, 55-Word Story, and facilitated writing with office hours with the faculty to receive feedback and ask questions.,,, These writing exercises are designed to first help the storyteller identify the many possible themes of their story. Secondly, the 55-Word Story is offered to help the storytellers find the essence of the message they wish to convey to their audience. The facilitated writing sessions are then designed to help the storyteller craft their story of 500–800 words with the considerations of our encouragements that will be discussed later. An overview of our process can be found in [Figure 1].
| Stream of Consciousness|| |
In this exercise, we ask the storytellers to take pen in hand and consider their subject and story and just write. Our instructions: “Write whatever comes to mind. If you are like me, you likely have a desire to plan your writing out and adjust the text as you go. Just for these exercises, please stop it. Just don't. Use paper and pen and forget about spelling and grammar. I would suggest that this exercise is about turning off your strategic mindset and listening to your inner poetic voice. Don't correct or cross out. Don't worry about punctuation. Don't worry about anything that remotely has to do with proper writing. Don't worry about putting some emotions into words on the page. Just write what comes to mind. Just do it. Just write. Don't let the pen come off the page. Do this for a set period of time. I typically recommend 5–20 min. When the time has elapsed take a moment in silence to read back over the piece you have written and circle 5-8 words that stand out to you and give you meaning. Identify themes that you discovered through writing. Now reflect on those and perhaps share these with the friends and partners accompanying you on your journey.” We then take time to debrief the themes that have emerged as we prepare for the 55-Word Story exercise.
| 55-Word Stories|| |
The 55 Word Story is another writing tool that participants have valued to help them articulate the essence of what they are hoping to convey in their story. Some patient partners have remarked that this is a great platform for creating their introduction to their story.
Our instructions are: “The 55-Word Story is very much a similar writing exercise and I would encourage you to start with pen to a blank sheet of paper and just write. Just like in the Stream of Consciousness exercise write without regard to spelling, grammar, and perpetual self-editing. Just write. Typically, I encourage people to write for 10–20 min and then break when it seems like time to break. There are no rules. When you are ready, take what you have written and condense it down to 55 words. Keep only what matters. Simplify and simplify again. Good Luck! When completed share your story with those trusted individuals that will give you honest feedback. You can do this as a group activity and learn from others.”
Through writing exercises, informal cancer caregivers identify many themes in their stories: Perceptions of the disease, biographical breakdown, relationships, transformation of the sick body, the informal caregivers' role, encounter with death, and strength of memory. Through writing, indigenous people living with cancer in Saskatchewan identified two main themes in living with cancer: Trust and world view. They also identified 8 subthemes and the four themes under trust are: Mistrust with diagnosis, Western treatment after cancer therapy, protection of indigenous Medicine, physician expertise with treatment recommendations. The four subthemes under world view are: Best of both worlds, spiritual beliefs, require to be strong for family, and importance of knowing indigenous survivors.
| Our Encouragements|| |
Storytellers are offered space and time to develop their stories on the written page with support from each other and the faculty with considerations of encouragements. We offer them encouragement in three main areas: The audience, the story, and the storyteller. The objective is to allow them to be intentional about how they craft their stories so that their message has the best opportunity to serve their audience and themselves through the lens of artistry.
The encouragements are meant to offer a pause to our patient experience storytellers to foster intentionality and confidence in what they include in their story, how they tell it and what language they use to speak with their audience. We encourage them to apply the encouragements as concepts and tools as they see fit. These concepts and tools are mere suggestions. The essence of the encouragements is to be relatable to the audience and use language to partner with the audience as the audience is illustrating the storyteller's story as they are reliving it. We encourage the storytellers to think of the images that come to their mind and consider how they share with the audience so they may hear, see, and understand the characters in the story.
Our encouragements for the storyteller to consider regarding themselves fall in three categories: Being relatable, considering the use of dialogue and narration, and giving gifts to their audience. Our encouragements for the storyteller to consider about the audience fall in four categories: Engagement, offering essential tools, considering language choices, and playing the last piece and dosing the themes of the story. Lastly, our encouragements for the story itself are four-fold: Considering subject versus story, crafting the story so characters are seen, heard, and understood, inviting the audience into the story, and testing parts of the story against the “so what” question. These can be found in [Figure 2].,,,,,,, (REF from STWB.) Before completing the storyteller training, we provide the participants with a checklist and didactic on how to prepare to present and facilitate so that they have a few guidelines of how to vet, accept and reject invitations to share their story.
In summary, storytelling bridges the worlds of patients, families, clinicians, health systems, policy makers, communities, cultures, and traditions to help us find common understanding to create experiences that match our expectations and improve the lived experience of giving and getting patient-centered healthcare. Storytelling lends a rich opportunity for meaningful academic productivity in research, community engagement, and quality and safety improvement.
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Conflicts of interst
There are no conflicts of interest.
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[Figure 1], [Figure 2]