The Academic Surgeon

Once Upon a Time: Narratives in Surgical Education

Think of some of your favorite classic children’s stories. Stories such as The Little Engine that Could, The Giving Tree, The Rainbow Fish, Where the Wild Things Are, and so many more… These books shaped our view of hard-work, determination, generosity, acceptance of self and others, and forgiveness (and probably may more things) in ways we cannot adequately describe. Because we were so young, open, and easily distracted, we let ourselves be captivated by the story line. The authors intended for us to connect with the characters, illustrations, and eventually the emotion. When thumbing through any number of children’s books as an adult, it is easy to see the central theme or lesson.  However, as a child, you are just enjoying the story. The learning comes second as a reaction to the emotional connection to the characters and what they are facing.

Even as adults, we continue to learn through storytelling and narrative instruction. As it turns out, it is actually a very effective teaching method, especially in adult learners1. In surgery, we have been imploring this method for over a century. Although I doubt the majority of surgery faculty members have realized it or saw its full potential as a teaching method. One example of narrative instruction common in surgical education programs is the Morbidity and Mortality Conference (M&M). In these conferences, residents typically present a patient’s story and hospital course with the intention of identifying a process or area of improvement to help others not fall into the same mistake or trap. I would propose that M&M is also a narrative learning opportunity to make connections and reflect on our own past experiences, as well as to learn new information to help improve care for future patients.

I can remember as a third year medical student sitting in M&M on my second week on service. I was so excited to be there and had enough supplies in my pockets to care for a small army. The first case presented was a patient mortality from the general surgery service. The third year resident stood at the podium, he looked flushed and sad. He began his story telling us about the patient. She was a 28 year old female with a history of IV drug use and HIV/AIDS who presented to the ED after being assaulted. She had a hemothorax and several broken ribs on the right side. He reviewed her vitals, labs, and imaging. Even with my limited knowledge at the time, I remember thinking that nothing about the case seemed like this patient should have died. He went on to explain how he inserted a 36 French chest tube on the right side, and in his own words said something “wasn’t right.” The chest tube output returned dark red blood at a pace that was surprising; it filled up the canisters and the patient became unstable. The resident clamped the tube and called for help. The patient was emergently taken to the OR and ultimately expired. The chest tube was placed too low in an attempt to ensure adequate drainage of the hemothorax and was actually inserted into the liver, terminating in the IVC. The resident presenting the case was remorseful and visibly upset with his actions. He admitted to the technical error and took responsibility for the woman’s death.

This story has never left me.  For narratives to be an effective teaching tool, the learner must be emotionally engaged and the story must allow “the learner to embed every part of the problem in a useful context, including the integration of the new and the unfamiliar… 2.” Before hearing this story, I had physically seen a chest tube, but had not witnessed one being placed or placed one myself.  Yet, when it came time to mark landmarks for my first chest tube insertion as an intern, this patient’s story was with me. I still tell this story to other residents as part of my pre-procedure ‘soap box’ when I am teaching them how to place chest tubes. I highlight that although the resident in this story was a more senior resident who had confidently and successfully placed lots of chest tubes unsupervised, he made a mistake that cost someone’s life. As a third-year medical student, I had the realization that one day that resident could be me. My practice and approach to several bedside procedures has been shaped by the emotional response I had to that patient’s story.

Not all stories that shape our training are tragic. In fact some may argue that the joyful stories are even more impactful. And in true surgery fashion with our love for brevity and directness, we have started to utilize narrative instruction in an even shorter format through twitter- #ShareAStoryInATweet. In this movement, surgeons tweet a story in 280 characters or less about an experience. Many of these tweets are inspiring or uplifting, yet some are heartbreaking. Nevertheless, on a subconscious level everyone reading them will compare them to past experiences and reflect on a patient’s story.

So to all the Academic Surgery leaders out there, please continue to share your stories. In this simple act, you can leverage adult learning theories and continue educating those around you. Someone is always listening and it may shape them and their future decisions.

References

  1. Rossiter, Marsha. Narrative and Stories in Adult Teaching and Learning. ERIC Digest https://www.ericdigests.org/2003-4/adult-teaching.html
  2. Szurmak J & Thuna M. Tell Me a Story: The Use of Narrative as a Tool for Instruction. Association for College and Research Libraries. 2013. http://www.ala.org/acrl/sites/ala.org.acrl/files/content/conferences/confsandpreconfs/2013/papers/SzurmakThuna_TellMe.pdf

 

Samantha Baker

Samantha Baker is a third-year General Surgery Resident at the University of Alabama at Birmingham. She is currently completing a research fellowship through the Veterans Affairs Quality Scholars Program focused on Quality Improvement and Health Services Outcomes Research. Samantha is also passionate about Surgical Education Research and is obtaining a Masters in Science in Health Professions Education through Massachusetts General Hospital Institute for Health Professions.

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