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ORIGINAL ARTICLE
Year : 2019  |  Volume : 60  |  Issue : 2  |  Page : 80-86  

In what ways might stories and anecdotes impact upon the quality of small group teaching in obstetrics and gynecology?


Department of Obstetrics and Gynaecology, Delta State University Teaching Hospital, Oghara, Delta State, Nigeria

Date of Web Publication31-Jul-2019

Correspondence Address:
Dr. Onome Ogueh
Department of Obstetrics and Gynaecology, Delta State University Teaching Hospital, Oghara, Delta State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nmj.NMJ_32_19

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   Abstract 


Objectives: The aim of this study was to find out how stories and anecdotes might improve the quality of the daily morning obstetrics and gynecology (O and G) teaching and determine if the emotions generated by the stories and anecdote deepened the understanding of medical topics. Materials and Methods: The overarching approach to this study was action research. On two occasions, I told stories using PowerPoint presentation during the morning teaching in the O and G seminar room to 10 and 11 learners instead of the traditional factual presentation of a medical topic. The learners ranged from the 3rd-year medical students to 4th-year specialist trainees in O and G and a consultant anesthetist. Each learner completed a feedback questionnaire at the end of the teaching session. I noted the learners' comments and analyzed written feedback. Results: More than 90% of the learners agreed or strongly agreed that the stories were appropriate for their level of training, and on both occasions, every single learner agreed or strongly agreed that the stories improved the quality of the morning teaching. On both days all but one learner agreed or strongly agreed that the stories improved their understanding of the medical topics, and a senior O and G trainee wrote that the story was: “useful – improved my understanding of situation involved.” The stories generated a lot of emotion in the learners, emotions that deepened their understanding of the topic covered. Conclusion: Stories and anecdotes appear to improve the quality of teaching, and this was the case regardless of level of training and experience of the learner. Hence, stories and anecdotes may be an excellent teaching tool in a setting like the morning teaching where the learners are quite varied.

Keywords: Qualitative action research, stories and anecdotes, teaching


How to cite this article:
Ogueh O. In what ways might stories and anecdotes impact upon the quality of small group teaching in obstetrics and gynecology?. Niger Med J 2019;60:80-6

How to cite this URL:
Ogueh O. In what ways might stories and anecdotes impact upon the quality of small group teaching in obstetrics and gynecology?. Niger Med J [serial online] 2019 [cited 2019 Aug 19];60:80-6. Available from: http://www.nigeriamedj.com/text.asp?2019/60/2/80/263839




   Introduction Top


As a consultant obstetrician and gynecologist, I teach and train medical students, midwifery and nursing students, postgraduate doctors, and nurses and midwives in clinics, operating theaters, and on ward rounds at the Princess Royal Hospital, Haywards Heath (PRH). I also oversee the learning at the morning teaching of obstetrics and gynaecology (O and G) postgraduate medical trainees and medical students that take place at the PRH from 8.30 to 9.00 am before the start of clinical duties. There are usually about ten learners present, one of whom presents a topic that forms the basis of discussions, supervised by the consultant on duty for emergencies that day. I supervise the morning teaching on average once a week when I am on-call.

The number of learners varies depending on leave and postings, and they change every 2–4 weeks (medical students), every 4 months (General Practice [GP] trainees), and every 6 months to 1 year (O and G trainees). The learners are at different levels of training and experience, and a major challenge is to ensure that all learners benefit in the same session; from the 3rd-year medical student to the senior O and G trainee. I would like to improve the learning opportunities for all learners using the same structured approach every time. But how do I ensure that the educational content of the teaching is appropriate and adequate for all the learners? This is a real challenge for differentiation!

In January/February 2012, I ran a Student-Selected Component (SSC) module for 12 2nd-year medical students. Feedback on the module suggested that the aspect that learners found most rewarding were the stories that I told them. The stories brought the topics to life for them because they concerned patients as real people. Stories or narratives evoke emotional responses, rather than simple reports of what individuals do or what is done to them.[1] Feelings and emotions should be part of teaching and learning, because we remember things better when we are emotionally involved.[2]

The study of narrative offers a possibility of developing understandings that cannot be arrived at by any other means.[1] Narratives are often memorable, as they are grounded in experience and might encourage reflection.[1] In fact, medical students rely on anecdotes of extreme and atypical cases to develop the essential ability to question expectations, interrupt stereotypical thought patterns, and adjust to new developments, as the case unfolds.[1],[3] Stories and anecdotes are used widely in medical education, and a majority (66%) of GP trainers use anecdotes in their teaching either often or very often.[4] In 88% of GP narratives, the anecdotes emerged spontaneously either often or very often.[4]

Stories and anecdotes arguably represent the most effective vehicle that we use to communicate the meaning of an existentially important experience to one another. Narrative of illness offer glimpses into the subjective experience of illness and may stimulate mediated empathic associations and responses in the listener even in the absence of the individual who suffers.[5] A key aspect of empathy is empathic distress, defined as the psychological discomfort that one feels when encountering someone who is suffering.[6] Empathic distress gradually matures into concern for the other person and motivation to comfort oneself and eventual transformation into a desire to help.[6]

Therefore, the aim of this study was to find out:

  1. How stories and anecdotes might improve the quality of the daily morning teaching
  2. How stories and anecdotes enhance the understanding of medical topics by the learners at the daily morning teaching and
  3. If the emotions generated by the stories and anecdote deepens understanding about medical topics.



   Materials and Methods Top


The overarching approach to this study was Action Research. The project is a study of my practice as a teacher, specifically looking at whether the introduction of stories and anecdotes may improve the quality of my daily morning teaching. Hence, I was at the center of the research looking at my own practice. In general, individuals improve and educate themselves, and education is what people do to themselves when they decide to take action to improve their own learning.[7]

Therefore, undertaking an Action Research project was an opportunity for me to take action to improve my learning and create knowledge to improve my practice as a teacher. Action research is practice based and focuses on improving learning and knowledge creation. It is collaborative but requires people to hold themselves accountable for what they are doing and accept responsibility for their own actions.[7]

On two occasions, I told stories during the morning teaching, instead of the traditional factual presentation of a medical topic. The stories were decided beforehand and I told them using PowerPoint presentation. My hope was that the stories would bring medical concepts to life in a meaningful way to drive home the lessons embedded in the story. Before I started the stories, I explained to the learners that the session was part of my Action Research Project. I designed a Feedback Questionnaire [Appendix 1] that I gave each learner and requested that they kindly complete it at the end of the morning teaching session.

I used a questionnaire because it may be easier to obtain feedback from the learners in a structured way and enable both a quantitative and qualitative analysis. However, questionnaires are not neutral, they may influence respondents and alert them to ideas that they had not thought of, and their responses can often be misleading.[7] The questionnaire used for this research had a mix of open and closed questions and open questions can provide responses that can be diverse and rich in ideas. Although interviews are more personal and may provide more raw data, they are more time-consuming, and more difficult to arrange, standardize, and analyze than feedback questionnaires. Nevertheless, Action Research Methodology permits the use of multiple data collection methods.

I told the first story on October 24, 2012; it was about Mrs. ZD a 37-year-old married civil servant with a rather difficult obstetric history [Appendix 2]. The story generated a lot of discussions about medical concepts including antenatal screening and diagnosis of chromosomal abnormalities, recurrent pregnancy loss, counseling, and both verbal and nonverbal communication in clinical encounters. The second story was of prenatal diagnosis [Appendix 3], and I told it on November 8, 2012. It related to two women who were screened for Down syndrome, their reaction to Down syndrome screening, and the outcome of their respective pregnancies. The stories generated a lot of debate with learners seeking clarifications and contributing to the overall learning of the group. I noted the learners' comments and analyzed written feedback after the presentation. The richness of the debate generated by the stories may have been more fully captured by audio and visual recording of the morning teaching, and transcription of the recordings.

Presentation of data

The story of Mrs. ZD on October 24, 2012

All 10 learners who were present completed the feedback questionnaire. There were three final year medical students: two GP trainees and five O and G trainees (2 specialty trainee [ST] 1, 1 ST2, 1 ST4, and 1 clinical fellow). I read and reread the feedback questionnaire responses several times and coded the responses into broad themes. The themes that emerged were:

  1. Medical concepts of antenatal screening (4) unbalanced chromosomal translocation (3), and miscarriage (3)
  2. Emotional response of empathy (2), sorrow (3), and sadness (9) and
  3. The importance of communication (3), counseling (4), and patient's choice (2).


Further data are presented in [Table 1].
Table 1: Learners feedback on the story of October 24, 2012

Click here to view


The story of prenatal diagnosis on November 8, 2012

There were 11 learners on November 8, 2012, and they all completed the feedback questionnaire. The learners included two medical students (1 3rd year and 1 final year), two GP trainees (GPST2), six O and G trainees (3 ST1, 1 ST4, and 2 clinical fellows), and one consultant anesthetist. The themes that emerged from the feedback were:

  1. Understanding antenatal Down syndrome screening and diagnosis
  2. The importance of communication, counseling, and informed choice and decision-making
  3. Thought-provoking and encouraging debate
  4. Sadness, empathy, and compassion.


Further data are presented in [Table 2].
Table 2: Learners feedback on the story of November 8, 2012

Click here to view



   Results Top


Analysis and findings

Teaching on two occasions was more than adequate for a qualitative research, especially as a total of 21 learners were involved. My approach to the two sessions using patients' stories was similar, as the narratives were planned beforehand and delivered by PowerPoint presentation by the same person in a similar manner. However, the sessions were on different days, and 2 weeks apart, the stories were different and some of the learners were different. These differences will have impacted on the data generated from the two sessions.

All but one learner (90%) agreed or strongly agreed that the story was appropriate for their level of training on October 24, 2012. The learner who was neutral was an ST4 O and G trainee. On November 8, 2012, all learners including the consultant anesthetist agreed or strongly agreed that the stories were appropriate to their level of training. Hence, stories and anecdotes appeared to be an excellent teaching tool in a setting like the morning teaching where the learners are quite varied and at different levels of training, as it may minimize the need for differentiation. One learner said the story was: “very engaging – interesting and relevant.”

On both occasions, every single learner agreed or strongly agreed that the stories improved the quality of the morning teaching. The stories brought the medical concepts to life and all learners recognized the medical concepts that were being taught. The stories generated a lot of debate about the antenatal screening for, and diagnosis and management of women with chromosomal anomaly and recurrent pregnancy loss. There was also learning about the important generic medical concepts of communication, counseling, informed choice, and decision-making. A 5th-year medical student wrote that her key take-home message was: “need to give women clear options but in the end must emphasise that it is their choice,” and an O and G trainee wrote: “pleased that the patient was able to make informed decisions and that she did not have any regrets.” A GP trainee wrote: “clear communication with patients is always vital.” On both days, all but one learner agreed or strongly agreed that the stories improved their understanding of the medical topics, and a senior O and G trainee wrote that the story was: “useful – improved my understanding of situation involved.”

The stories were thought provoking and generated a lot of emotion in the learners. The overwhelming emotion in most learners was sadness, sorrow, and empathy. After the story on October 24, 2012, one GP trainee said: “A powerful story – felt very sorry for the lady involved” and an ST1 in O and G said: “It was thought provoking – a sad story for this family.” A final year medical student said the story: “opened my eyes to such delicate issues, made me think a lot and try to put myself in the situation.” Hence, stories generate empathy that is at the core of patient-centered humanistic approach to medicine and is based on the vicarious identification with another individual's suffering.[5]

Ninety percent of learners agreed or strongly agreed that their emotions deepened their understanding of the topic covered on October 24, 2012, but this dropped to 55% on November 8, 2012. The difference may be because the story on October 24, 2012 generated more emotions, as it involved the difficulty of losing six out of seven children in a 4-year period. The other learners were neutral. On October 24, 2012, an ST1 O and G trainee wrote: “very emotional story which had a lot of thinking/learning points to think about in future consultations.” Emotions drive attention which in turn drive learning and memory,[8] and memories formed during a specific emotional state tend to be easily recalled during a similar emotional state later on.[8]

On both occasions, all the learners agreed or strongly agreed that they would recommend using stories and anecdotes for the early morning teaching.


   Conclusion Top


Stories and anecdotes appear to improve the quality of the morning teaching, as the emotions generated deepened the understanding of both specific and generic medical topics. This was the case regardless of level of training and experience of the learner. Hence, stories and anecdotes may be an excellent teaching tool in a setting like the morning teaching where the learners are quite varied, from the 3rd-year medical students to senior trainees and consultants, as it may minimize the need for differentiation.

Action Research involves changing the ideas and actions of others who share in the constitution of social and educational practices by their thought and action.[9] Accordingly, I will encourage those who teach in a clinical setting similar to our O and G morning teaching to adopt the use of stories and anecdotes. Introducing stories and anecdotes as the morning teaching, and in the curriculum of medical schools and residency training programs, may enable learners to be equally skilled in understanding both the complexities of clinical medicine and the personal, cultural, and psychosocial aspects of illness and its care.[10]

Action Research should not only aim at improving techniques of teaching but also see these as connected to the broader questions about education of learners for a better society,[10] and the future research should include audiovisual recording and transcription of the morning teaching to capture the richness of the debate generated by the stories and anecdotes and show learners' understanding and participation in the crucial developmental tasks (including education) confronted by society.

Furthermore, this is essentially a preliminary study, and the future studies should compare this method of teaching using stories and anecdotes with didactic classroom style of teaching and test objectively the level of learning and understanding from either method of teaching.

Acknowledgment

This Action Research Project was in part fulfillment of my MA Medical Education from the University of Brighton in 2015.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


   Appendices Top


Appendix 1:

Action Research Feedback Questionnaire

The purpose of this feedback form is to provide data for Dr. Ogueh's Action Research on storytelling and medical education. Your frank and objective feedback is highly appreciated.

Where appropriate, please answer the statements according to the following 1 to 5 scale:

1 = Strongly Disagree, 2 = Disagree, 3 = Neutral, 4 = Agree, and 5 = Strongly Agree

1. What is your job title/Level of training?

………………………………………………………………

……………………………………………………………………

2. What medical topic/concept have you learnt about this morning?

…………………………………………………………………

…………………………………………………………………………

3. How did the story make you feel?

………………………………………………………………………

……………………………………………………………………………

4. The story improved my understanding of the topic 1……2……3……4……5……

5. The story was appropriate to my level of training 1……2……3……4……5……

6. The story improved the quality of teaching 1……2……3……4……5……

7. What were your predominate emotions after hearing the story(s)?

…………………………………………………………………………………

…………………………………………………………………………

8. The emotion(s) were very strong 1……2……3……4……5……

9. The emotions deepened my understandings of the topic (s) covered 1……2……3……4……5……

10. What key messages have you gained from the story?

…………………………………………………………………………

…………………………………………………………………………

11. I would recommend using anecdotes/storytelling for the daily morning teaching?

1……2……3……4……5……

Please return your completed feedback form to Dr. Ogueh at the end of today's presentation.

Thank you!!!!!

Appendix 2: The story of Mrs. ZD

Mrs. ZD is a 37-year-old married civil servant who I first met in 2008 during her first pregnancy when she was 33 years old.

In those days, we screened everybody for Down's syndrome using the nuchal translucency (NT) evaluation, but we now carry out the combined test of NT and 1st-trimester biochemistry of ßhCG and PAPP-A.

Mrs. ZD was found to have an NT of 5 mm at 12 weeks gestation, and this increased her risk of having a baby with Down syndrome from an age-related risk of 1 in 394 to an adjusted risk of 1 in 4. What discussion will you have with her? How will you explain the result to her? Show me? Let me be the patient.

Following counseling, she went on to have a chorionic villus sampling (CVS) that showed that the baby had an unbalanced translocation with trisomy of the short arm of chromosome 8 and monosomy of the long arm of chromosome 6. She also had a fetal echocardiography that confirmed a ventricular septal defect. She went on to have a medical termination of pregnancy at 17 weeks gestation in December 2008. What other investigation/test will you perform?

The couple had genetic testing and Mrs. ZD was found to have a balanced translocation of the long arm of chromosome 6 and the short arm of chromosome 8. This is associated with a 10% risk of live-born with unbalanced translocation with severe physical and mental disability and 20%–30% risk of miscarriage. On account of this, Mrs. ZD requested referral for preimplantation genetic diagnosis (PGD). What is PGD?

She was referred but subsequently decided not to attend the appointment. What is the alternative?

Her second pregnancy resulted in a full-term normal delivery of her son William in December 2009. She had a CVS that was normal and he is doing very well.

Her third pregnancy resulted in a complete miscarriage at about 7-week gestation in February 2011, and her fourth pregnancy resulted in a complete miscarriage at about 9-week gestation in June 2011. Her fifth pregnancy resulted in a missed miscarriage at 9 weeks gestation, and she went on to have a medical evacuation of retained products of conception in September 2011. What are you thinking now? What should you be doing?

On account of the history of recurrent miscarriage, she had a thrombophilia screen that confirmed her heterozygosity of Factor V Leiden mutation.

Because of the above history, during her sixth pregnancy, she was placed on Clexane 40 mgms daily from conception, but she unfortunately had a missed miscarriage at 7 weeks gestation for which she had a medical evacuation of retained products of conception in February 2012.

In her seventh and most recent pregnancy, she was placed on Tinzaparin 4500 units daily from conception and on October 11, 2012 when she was 12 weeks pregnant, she had a CVS, and this unfortunately showed that the baby has an unbalanced chromosomal translocation with trisomy for the translocated segment of chromosome 8 and monosomy for the translocated segment of chromosome 6. I met with her and her husband on October 18, 2012 to discuss the results. During that meeting, her husband said that they knew something was wrong during the CVS on October 11, 2012. He said that I behaved differently from the way I behaved during the CVS for their son in 2009. He said that I was more “chatty” and gave them photos of the baby. I confessed that I thought something was wrong because the NT was very big at 10 mm, and asked them a few times if they wanted to see the baby, but Mrs. ZD said no. I got the impression then that the husband wanted to know.

We should be aware that patients watch our every move and do not just listen to what we say but how we say what we say. We must be aware of our nonverbal communication. I wanted to stay neutral during the meeting, but it would appear that I failed. Should I have been more honest with them?

She reminded me that I had referred her for PGD after her first pregnancy, but she did not attend. She requested another referral and said she will be willing to pay for it if it is not funded by the NHS now that she already has a son. Accordingly, I referred her again.

She elected to have a medical termination of pregnancy, and this was arranged and completed on October 21, 2012.

Appendix 3: The story of prenatal diagnosis

I first met Miss. CL in 2003, she was 24-year-old and 12 weeks into her first pregnancy. She had just had Down syndrome screening using the NT evaluation. Her baby had a NT of 3.8 mm which increased her risk of having a baby with Down syndrome from the background age-related risk of 1 in 956–1 in 26. She attended with her partner. When I explained the findings and implications to them, she said calmly that she did not know that the ultrasound scan she had for Down syndrome screening. She said if she knew she would not have the test. We discussed diagnostic tests such as CVS and amniocentesis that will give a definite answer, but she declined further testing because she would be happy with whatever baby she got.

Mrs. PB was a 42-year-old woman with 2 children. On January 11, 2012, when she was 12 weeks and 1 day into her third pregnancy, she had a combined test for Down syndrome screening. The combined test uses a combination of NT and serum beta-human chorionic gonadotropin and pregnancy-associated placenta protein-A. This increased her risk of having a baby with Down syndrome from the background age-related risk of 1 in 59–1 in 3. After counseling, she elected to have an amniocentesis with the associated 1% risk of miscarrying an otherwise normal baby. On February 9, 2012, when she was 16 weeks and 2 days pregnant, she had a CVS following a failed attempt at amniocentesis. The results confirmed that the baby had Down syndrome on February 14, 2012. She decided to continue with the pregnancy and a fetal echocardiography was arranged because of the association of Down syndrome and congenital heart defect.

On February 27, 2012, when she was 18 weeks and 6 days pregnant, Mrs. PB had a fetal echocardiography that confirmed that the baby had atrioventricular septal defect. On account of the additional anomaly, she elected to terminate the pregnancy, and this was completed on March 3, 2012.

When Miss CL was 36 weeks pregnant, she presented with a history of no fetal movement for 2 days. An ultrasound confirmed an intrauterine fetal death. Labor was induced and she had a stillbirth. She declined a postmortem examination but agreed to karyotyping which confirmed that the baby had Down syndrome.

Women who have had a Down syndrome pregnancy are concerned about recurrence, and this in 1 in 200 up to age 35 years, and subsequently double the age-related risk at the time of delivery.

Miss CL declined Down syndrome screening in her second pregnancy and went on to have an uncomplicated pregnancy and delivery in April 2004.



 
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