From Odysseus to Yoda. Storytelling in medical education

Daniel Cabrera (@cabreraerdr)

I think most of us can identify with the scenario of trying to teach an important concept or a clinical pearl using a story. Several times a shift, I find myself telling my residents something like “When I was an intern, we had this X patient with his unusual Y presentation and then Dr. Z magically knew it was a rare case of W and we saved the day.”  I don’t truly remember if I was the intern, the faculty or even the patient in the stories; these parables have blended in my head and are helpful to teach the things I have learned during my 15 years as a clinician. When I look back, I regret not being a better storyteller and not having invested time improving this skill.

Storytelling is a key aspect of society. For thousands of years, humankind tried to assure the survival of civilization through the transmission of values, emotions, engagement and information using a technique that appears to be rooted in culture as much as in biology. Many neuroscientists believe our brains are designed to acquire information and emotions in a story-format, based on observations from functional imaging and neuroendocrinology. But it is hard to say whether stories shape our brains or whether our gray matter bends the information into meaningful narratives. In a simplified model, delivering emotions and information in a story format allow multiple areas of the brain be activated at the same time, simultaneously elevating the levels of neuro transmitters (e.g., oxytocin) and allowing for a more distributed, complex and persistent acquisition of the stimulus. This link between the emotion generated, the sensory perception and the unit of knowledge acquired appears to be key for usage and retrieval.

Most of our cultural reservoir is created around stories, parables, morals and jokes; our collective brain attempts to synthetize important concepts in a dramatic arc containing both the information and the cues to retrieve it. We can see this from Pinocchio teaching children not to lie to foundational myths such as Romulus and Remus. Despite the almost infinite ways we can create stories, several scholars believe in the existence of the monomyth (aka, “The Hero’s Journey”) as a master dramatic arc, which all narratives and plots derive from, including The Odyssey, Moby Dick, Star Wars, The Lord of the Rings, Terminator and a majority of TED Talks.

A simplified and adapted monomyth narrative can be helpful to understand key concepts about plot and provide a framework for narratives. The Hero’s journey usually havs three main phases, each of them with subcomponents:

Initiation

  • There is conception myth of the hero (think Batman)
  • There is call that is initially refused but later accepted usually through a mentor (think Peter Parker / Spiderman)
  • There is a departure from the past and family with initiation of the big adventure (think Frodo)

Conflict

  • The hero needs to overcome many tests and ordeals (think Odysseus)
  • There are internal and external struggles (think Ironman)
  • There is an epiphany about the true meaning of the journey (think Sarah Connor)
  • Awakening and apotheosis were the final conflict is overcome (think Zimba)

Resolution

  • There is a return home (think Gilgamesh)
  • Awareness of the change the journey produced on the hero and the world (think Harry Potter)
  • There is a personal and community atonement (think Aragorn)
  • Mastering the world and freedom to live (think Luke Skywalker)

Storytelling permeates all we do: providing care to patients, bedside teaching, lecturing, academic debates, and interactions with administrators and bosses. The main objective of these encounters is to make people remember a concept, construct a mental representation of the message (learning) and engage them to take some actions, such as following treatment recommendations, incorporating the feedback provided or obtaining a pay rise.

Storytelling is a form of persuasion causing the receptor to think, feel, remember and act.

Storytelling in medical education creates instances of introspection about medical knowledge and facilitates empathy towards patients (e.g., patients with dementia). John Sandars has published several papers about the use of (digital) storytelling in medical education, particularly how stories allow for the development of reflective learning. He recommends several steps in the creation of storytelling that are appropriate for lecturing or curriculum creation. His advice revolves around carefully selecting the topic to teach, be clear about the objectives, create appropriate media around the content, incorporate existing learning/teaching techniques and apply a relevant assessment network (See Sandars et. al Medical Teacher 2008;30:774-777). This is high-order storytelling, but not helpful in the trenches.

In the interest of utility, probably street smart story telling is more helpful for most Clinician Educators, where the technique allows for efficient delivery of information, cues self-reflection and creates engagement through entertainment. The short term objective is persuasion, to influence the patient, the learner or our boss to engage with our message, remember what was said, develop an emotional response and the willingly act on the newly constructed information.

A few tips for day-to-day storytelling drawn and adapted from the Heath brothers:

Plan

  • The concept needs to be small and discrete
  • Be absolutely clear about the core concept
  • You need to tailor your story to your audience, both in the form and content
  • Use common domains, scenarios and motifs the audience can relate
  • Build your story around the monomyth (initiation, conflict, resolution) and subplots
    • Challenge (David vs Goliath)
    • Connection (The Fellowship of the Ring)
    • Inspiration (The Empire Strikes Back)
    • Springboard (Spiderman)

Deliver

  • Don’t open with “I’m going to tell you a story”
  • Avoid centering yourself as the hero of the narrative
  • Use surprise, positive and negative feelings
  • Use simple and concreate language
  • Be sure the history is credible
  • Be simple and very explicit with the moral

The most important concept to remember about using stories to teach and persuade is how counterintuitive our traditional approach to influence people is. We spend infinite amount of hours learning the most abstract and logical approaches to the problems of our patients; trying to apply a ruthless scientific approach to the clinical and personal issues that surround us. We make the mistake when we teach, recommend, interact and convince people using a Cartesian logic, believing it will be the best weapon to obtain the desired outcome. Experience has taught many of us (although it took me years to understand) that using a parable or short story to make my interlocutor feel something is far more productive than using a chart to make my counterpart think something. People work with emotions better than abstractions. The key is to create a feeling that can cue the knowledge.

Maya Angelou

Image by Sunchild57 Photography via under Creative Commons License CC2.0

References and further reading

Aldama FL. 2015.The Science of Storytelling: Perspectives from Cognitive Science, Neuroscience, and the HumanitiesProjections. 9 (1): 80-95.

Greater Good: The Science of a Meaningful Life. Zak, PJ. How stories change the brain.  Last retrieved May 2, 2016, from Berkeley’s website: http://greatergood.berkeley.edu/article/item/how_stories_change_brain

Wikipedia. Monomyth. Last retrieved May 2, 2016, from Wikipedia’s website:  https://en.wikipedia.org/wiki/Monomyth

Palumbo D. 2008. The Monomyth in James Cameron’s The Terminator: Sarah as Monomythic Heroine. The Journal of Popular Culture. 41(3): 413-427

Sandars J. 2009. The Use of self-Reflection in Medical Education: AMEE Guide 44. Medical teacher. 31(8): 685-695.

Charon R. 2001. Narrative Medicine. A Model for Empathy, Reflection, Profession, and Trust. JAMA. 286(15):1897-1902.

McKeeR, Fryer B. 2003. Storytelling that moves people. Harvard Business Review. 81(6): 51-55.

Sandars J, Murray C, Pellow A. 2008. Twelve tips for using digital storytelling to promote reflective learning by medical students. Medical Teacher. 30(8): 774-777

Heath Brothers.  Made to Stick Success Model. Last retrieved May 2, 2016, from Wikipedia’s website:  http://heathbrothers.com/download/mts-made-to-stick-model.pdf