Can storytelling of women’s lived experience enhance empathy in medical students? A pilot intervention study

Abstract

Purpose

This pilot study aimed to investigate the acceptability and efficacy of a patient storytelling intervention (live and recorded) on empathy levels of medical students.

Materials and methods

Medical students participated in a storytelling intervention that had three components: listening to live or recorded stories from women with abnormal uterine bleeding, reflective writing, and a debriefing session. Empathy scores of students pre- and post-intervention were measured using the Jefferson Scale of Empathy-student version (JSE-S). Students also completed a feedback survey. Descriptive and inferential statistics were used to analyse quantitative data and content analysis was used for text comments.

Results

Both live and recorded storytelling interventions had positive effects on student’s empathy scores post intervention. Overall, students were satisfied with the intervention and reported that it improved their understanding of life experiences of women. Suggestions were made for an in-person storytelling session and interactive discussion after listening to each story.

Conclusion

A storytelling intervention has the potential to improve medical students’ empathy and understanding of lived experience of women with health conditions. This could be valuable when student-patient interactions are limited in healthcare settings, or to enable stories of small numbers of patient volunteers to reach students.

Keywords:

• Patient storytelling
• medical education
• lived experience
• empathy
• acceptability
• women’s health curriculum

Background

Abnormal uterine bleeding (AUB) contributes to poor physical, social, mental and emotional wellness for women, and negatively impacts their quality of life, family and work commitments (Karlsson et al. 2014). However, nearly half of women with AUB do not seek medical care (Fraser et al. 2015). A literature review identified that a lack of empathic communication from health care providers was a barrier to women with AUB accessing healthcare (Henry et al. 2020). When disclosing sensitive sexual and gynaecological health concerns, women value an empathic doctor-patient relationship and prefer doctors who are understanding and compassionate (Brandes et al. 2015). Supporting the development of empathy and non-judgemental communication in doctors is therefore a priority to improve the experiences of women when they seek care for gynaecological issues such as AUB. These skills and qualities should begin to be learned and developed as a medical student (Ekman and Krasner 2017). In the New Zealand context, women with AUB reported negative experiences with doctor-patient communication, such as a lack of validation of the nature and seriousness of symptoms (Henry et al. 2020). Specifically, Māori (New Zealand Indigenous) women reported communication barriers when consulting for uterine bleeding symptoms which influenced their healthcare-seeking behaviour (Cook et al. 2018).

Practice points

• A patient storytelling intervention has the potential to improve empathy in medical students in a women’s health setting.

• Listening to stories of women about their experience of health conditions and their health care (via live or recorded videos) and reflecting on the stories can improve the understanding of the impact of these experiences on women’s lives.

• While in-person stories were preferred for more personalised interactions, storytelling intervention via live/recorded videos can be useful for medical students when access to patients is limited in health care settings.

Empathy is conceptualised as a multidimensional construct consisting of cognitive (understanding another person’s experiences and perspective), affective (emotional connection to another person within therapeutic limits), and behavioural (a capability to communicate the response) components (Samarasekera et al. 2023). An empathic doctor-patient relationship is known to enhance a trusting caring rapport, feelings of being listened to, disclosure of symptoms, patient satisfaction, compliance and health outcomes (Derksen et al. 2017; Ekman and Krasner 2017). Interventions such as reflective writing, workshops on communication or interpersonal skills, simulation role-plays, patient interviews, using illness narratives or stories, and experiential learning have been shown to enhance empathy in medical students (Milota et al. 2019; Bas-Sarmiento et al. 2020). Storytelling is a well-established teaching tool in healthcare education and is derived from the experiences of educators, students, simulated patient actors, or real patients (Kumagai 2008; Haigh and Hardy 2011). The term ‘Patient stories’ or ‘patient storytelling’ is used when people with a particular diagnosis or healthcare experience are involved in re-telling and reflecting on their experiences of their health-related problem and their interaction with health services (Job et al. 2019). Stories from patients (as opposed to stories retold by actors) are considered particularly valuable to promote patient-centered care and empathy in medical students (Hendriksz 2016; Wong et al. 2020). Furthermore, in Māori culture, storytelling has traditionally been used as a means of passing on knowledge (Mark and Boulton 2017). In summary, storytelling is appropriate to explore as a learning intervention, particularly in the New Zealand context.

While empathy is considered important for medical students, there is limited use of empathy-promoting interventions in teaching programmes (Díez-Goñi and Rodríguez-Díez 2017). In New Zealand primary medical education there is little curricula time devoted specifically to enhancing empathy in medical students for women’s health care. There is no research to indicate which educational interventions may be effective in enhancing empathy towards women seeking gynaecological health care (Bas-Sarmiento et al. 2020). As women in New Zealand with AUB report poor experiences of their doctor-patient relationship, this seems a priority condition for educational intervention in our gynaecology curriculum. This pilot study aimed to investigate the efficacy of patient storytelling for increasing empathy in medical students and to evaluate the acceptability of the intervention in our medical degree women’s health programme. We also compared aspects of live storytelling with a recorded storytelling intervention.

Method

Design: a pilot two group pre-test, post-test study design

Recruitment of medical students: Medical student participants were in their 5th year (Advanced Learning in Medicine) completing their women’s health rotation in the Department of Obstetrics, Gynaecology and Women’s Health, University of Otago Wellington, New Zealand. Six cohorts of students attend women’s health rotations in a year. All students in the first cohort (February-March 2022) were invited to participate in the live storytelling intervention and all students in the second cohort (March-April 2022) were invited to participate in the recorded storytelling intervention.

Recruitment of women to tell their stories: We invited women over 18 years of age who attended gynaecology clinic, Wellington Hospital with AUB. During the recruitment period (June 2021-November 2021), an advertisement flyer regarding the study was displayed on the clinic notice board. Women with AUB were identified from the gynaecology clinic appointment roster and personally approached by researchers (PK and CH) in the waiting room. A brief description about the study and study information sheet was provided. Women could choose to participate in either live or recorded intervention. Women were requested to contact the researcher (PK) if interested in the study. We invited women from a variety of ethnic backgrounds so the impact of culture on life experiences and the need for culturally appropriate communication would be highlighted to the students (Schouten and Meeuwesen 2006; Wilson 2008). A Māori researcher (STW) on our team reviewed the study participant information sheet and storytelling guide to ensure the documents were culturally appropriate for Māori women. We intended to recruit eight women for the study with at least two Māori women.

Out of 34 women identified from the roster, four did not attend the appointment, three had a comorbid condition, four were in stress or pain, one believed her bleeding was not abnormal, and 15 were not interested due to reasons such as other commitments, not willing to sharing personal issues and not comfortable talking to a group. Eight women expressed interest for participating in the study including one woman who approached us after considering the displayed advertisement flyer. Consent was obtained from women who expressed interest in participating in the study. To support women in sharing their stories, we provided them with a storytelling guide (Supplementary Appendix A) and offered a preparation session with a researcher (PK). The storytelling guide was adapted from the work by Morrise and Stevens (2013) and the principles of the Hui Process framework (Lacey et al. 2011) to make it inclusive for Māori women.

For the recorded storytelling intervention, we recorded stories of four women using Zoom). The recording was then edited to an approximately 10 min video. Women reviewed the edited videos to ensure that their story was accurately represented and changes were made to the videos as indicated by women.

Ethics approval was obtained from the University of Otago Human Ethics Committee (Health)-H21/007.

Intervention

The interventions were conducted following a scheduled AUB lecture. The storytelling intervention had three components 1. Students watched a panel of women tell their stories live via Zoom (First group) or watched recorded stories of women (Second group) for approximately 45 min. 2. A guided reflective writing session (10 min) where students reflected on the stories and wrote answers to two questions: a) How does abnormal bleeding affect women’s quality of life, psycho-social health, work, and family commitments? b). What are your strategies to improve patient engagement in consultations?). 3. A debriefing intervention where a facilitator, who is an Obstetrician and Gynaecologist and teaches in the Department (JO), summarised the learnings from the stories and answered questions raised by students. Additionally, the students in the live intervention group had the opportunity to ask the women questions with moderation by the facilitator.

Outcome measure and analysis

The effectiveness of this intervention was assessed at Kirkpatrick’s level 1 (students’ reactions and feedback to intervention) and level 2 (impact on students’ empathy scores) (DeSilets 2018). To measure empathy, the medical students completed the Jefferson Scale of Empathy–Student version (JSE-S) pre-intervention and post-intervention. The Jefferson Empathy scale is a widely used, validated self-report tool to measure empathy among students in a health care context (Hojat et al. 2001). Outcome assessments pre and post interventions were collected by researchers PK and TG.

When interpreting the scores, the JSE user guide states only that ‘Higher values indicate a higher degree of empathy’ (Hojat et al. 2016, p.50). Therefore, the scores were considered to exist on an ordinal scale and were analysed by a statistician (RW) using ranks. The pre-intervention scores for both group samples were combined and ordered to represent the hypothetical population of pre-intervention scores. These scores were then assigned normalized ranks from 0 (lowest) to 1 (highest), which exist on an interval scale. Each post-intervention score was then assigned a rank in relation to the ranks of the pre-intervention scores. The measured effect-size for a student, x, is the difference between their pre-intervention normalised rank and their post-intervention normalised relative rank. This difference exists on an interval scale, so sample means are meaningful.

The statistical inference was carried out using confidence intervals. The measured effect-size for students is not normally distributed, so an analysis of the individual ‘live’ and ‘recorded’ group was conducted using an adjusted t-test designed for samples from asymmetric distributions (Willink 2005). Inversion of the test enabled calculation of 95% confidence intervals for the population effects for both interventions. This involved calculation of the sample mean effect size x̄, sample variance s and sample skewness c for both the live and recorded storytelling group samples.

To compare the mean effect size of live and recorded intervention groups, the Welch two-sample t-test was used because the adjustment for asymmetry was not available for the comparison of two effect sizes. The directions and degrees of asymmetries for the interventions were similar, which implies that the effect of asymmetry would largely cancel on subtraction in the comparison, so a standard test could be used.

To explore students’ reactions or acceptability, we conducted a two-part survey, a rating of statements using a 5-point Likert-type scale that included a rating of content, design, facilitation, duration, learning, and overall satisfaction (with options ranging from anchors of strongly disagree to strongly agree). This was followed by questions about the impact of the session and suggestions for improvement in the intervention with free text response. Researcher PK used descriptive statistics to analyse multichoice Likert questions and content analysis for free text comments which were then discussed with researchers JO and RG for accuracy.

Results

All students approached consented to participate in the study. Ten students (Female 7, Male 3, aged 21–24 years) participated in the live storytelling intervention and 12 students (Female 7, Male 4, Gender neutral 1, aged 21–31 years) participated in the recorded storytelling intervention. Four women (aged 49, 50, 51 and 53 years) shared their stories live on Zoom as part of live storytelling intervention and four women (aged 23, 35, 45 and 61 years) provided recorded stories which were played to students as part of the recorded storytelling intervention. The women’s lived experience of AUB ranged from 2 to 10 years. Women identified their ethnicity as NZ European (3), Māori (1), NZ European and Māori (1), NZ European, Māori and Samoan (1), Sri Lankan (1) and Filipino (1). Table 1 shows the students’ JSE scores before and after the intervention, the derived ranks relative to the set of pre-intervention scores, and the differences in normalised ranks.

Table 1. Analysis of JSE scores of student participants in live (L, n = 10) and recorded (R, n = 12) intervention.

Student	Pre-intervention JSE score	Rank	Normalised rank	Post- intervention JSE score	Relative rank	Normalised relative rank	x
L7	98	1.0	0.045	104	4.0	0.182	0.136
L3	103	2.5	0.114	117	11.5	0.523	0.409
L8	103	2.5	0.114	101	1.5	0.068	−0.045
R2	104	4.0	0.182	101	1.5	0.068	−0.114
L4	106	5.0	0.227	106	5.0	0.227	0.000
R12	109	6.0	0.273	124	19.5	0.886	0.614
R5	110	7.0	0.318	110	7.0	0.318	0.000
L1	112	8.0	0.364	122	18.5	0.841	0.477
R3	114	9.5	0.432	127	22.5	1.023	0.591
R7	114	9.5	0.432	117	11.5	0.523	0.091
R4	114^a	11.0	0.500	113	8.5	0.386	−0.114
R6	118	12.5	0.568	120	16.5	0.750	0.182
R10	118	12.5	0.568	123	18.5	0.841	0.273
L10	119	15.0	0.682	123	18.5	0.841	0.159
R9	119	15.0	0.682	126	22.5	1.023	0.341
R11	119	15.0	0.682	119	15.0	0.682	0.000
R8	121	17.0	0.773	128	22.5	1.023	0.250
L6	121^a	18.0	0.818	128^a	22.5	1.023	0.205
L9	124	19.5	0.886	127^a	22.5	1.023	0.136
R1	124	19.5	0.886	129	22.5	1.023	0.136
L2	125	21.5	0.977	124	19.5	0.886	−0.091
L5	125	21.5	0.977	127	22.5	1.023	0.045

^aRounded after substitution of average values for missing values.

Normalised rank, rank divided by 22 to obtain a scale from 0 to 1.

Relative rank, rank relative to pre-intervention scores.

x, Difference in normalised rank pre-intervention and normalised relative rank post-intervention.

For the live intervention group, the sample mean effect was x̄ = 0.143 (n = 10, s = 0.185, c = 0.726). The 95% confidence interval for the population mean effect is [0.03, 0.31]. Therefore, there is 95% confidence that the live intervention increases the empathy of the student by between 3% and 31% of the population of pre-intervention levels. For the recorded intervention group, the sample mean effect was x̄ = 0.188 (n = 12, s = 0.242, c = 0.608). The 95% confidence interval for the population mean effect is [0.05, 0.37], which indicates an increase of between 5% and 37%. When comparing recorded and live intervention, the effects size estimates for recorded intervention group (x̄ = 0.188) was higher than the live intervention group (x̄ = 0.143) in our sample. However, the evidence in differences between groups for population mean effect is inconclusive with 95% confidence interval of [−0.15, 0.23] by Welch method.

When the effect-sizes for the students were ordered based on the gender (7 males and 14 females), males and females appear to be affected differently ‘MFFMMFFFFFFFFFFFMFMMM’. There is a strong indication of greater spread for male students (some males had less and some had more effect of stories when compared to females).

The student responses are summarised in Supplementary Appendix B. All students in the live intervention and the majority of students in recorded intervention (83.3%, 10/12) were satisfied (agreed or strongly agreed) with the storytelling intervention. More than half of the students in the live (60%, 6/10) and most students in the recorded intervention (91.6%, 11/12) agreed that the intervention should be included in the curriculum. Most students in the live (80%, 8/10) and recorded intervention (83.3%, 10/12) agreed or strongly agreed the intervention improved their understanding of the life experiences of women with abnormal bleeding. Most students agreed or strongly agreed that the content, design and duration of the intervention were appropriate. While 8/12 (66.6%) of students agreed that the recorded intervention stimulated their interest in women’s health care, only 2/10 (20%) of students in the live intervention agreed with that statement.

Students’ comments regarding the session are provided in Table 2. Students in both groups reported that the intervention improved their understanding of women’s experiences and how gynaecological conditions significantly impact a variety of aspects of women’s lives. They reflected on the importance of listening to patients and that everyone is different and experiences pain differently. Some example quotes from student participants is given below:

Table 2. Students’ comments to live intervention (L) and recorded intervention (R).

Categories	Student	Sample quotes
Improved understanding of women’s experiences	Student 2 (L)	More aware of everyday/personal things that can be expressed-note to be empathetic for even minor conditions
	Student 4 (L)	This session reinforced how gynaecological conditions have significant effect on women across many aspects of their lives
	Student 5 (L)	Reminded me that everyone has a different lived experience and important to be an ally to patients and allow them to talk to you
	Student 5 (R)	It made me realize that listening to a patient and hearing the impact on the day to day can change appropriate management. I did really enjoy the session and it made me want to make the topic of periods more normal to discuss so that it is easier for women to get solutions to their problems and stresses involved with periods
	Student 7 (R)	The variability in one’s life and experience with these issues can be far more encompassing than I imagined. Whether it be the impact on infringing on their work and social habits. It brought to my attention the need for compassion, understanding (even as a male) and appropriate empathy in walking along the patient journey. There often seems to be a lot of misunderstanding around their experiences and lack of appreciation for what they are dealing with. I realise that there are many deficiencies that exist in women’s health be it in the community or hospital level care, hopefully I can make a positive impact on experiences which were not so pleasurable for these patients.
	Student 10 (R)	It is clear that women who have problems with their period are often dismissed by physicians and clearly women’s health care has a long way to go in terms of providing the best care. I hadn’t realised this before the session.
In-person session	Student 1 (L)	In person session would be more impactful and more personalised
	Student 2 (L)	Not on Zoom- have structured/targeted not shared. A lot was medical history > experiences
	Student 6 (L)	Listening to stories face to face (may not be possible due to (COVID/omicron)
	Student 9 (L)	Have in person. May be can use more imagery if on zoom to relate to the speakers on ZOOM. But on Zoom in afternoon is tricky with audio issues, some personal trouble concentrating. Otherwise, would be really good even with pictures if possible of women’s lives, time in hospital
	Student 9 (R)	Good to have a Q&A with any volunteers who would want to attend in person/zoom. Its one thing to have a lecture on abnormal bleeding vs actually hearing their experiences with it. Nothing beats lived experience
Interactive discussions	Student 1 (R)	I think if you had a discussion after each video it would help to bring up more point
	Student 4 (R)	Perhaps discussion in small groups or pairs, especially for male students

While a few students suggested that in-person stories would have been more impactful and personalised, they also acknowledged the practical issues of doing a face-to-face session due to COVID-19 restrictions. Notably, some students in the live storytelling intervention specifically reported that a shared Zoom setting could limit in-depth personal experiences. The students in the live storytelling intervention had the opportunity to ask questions to women after each story. This was not possible for the recorded storytelling intervention. Students in the recorded storytelling intervention suggested an interactive small group discussions after each video would be beneficial.

Discussion

This pilot study examined the efficacy of a patient storytelling intervention on changing the empathy of medical students towards women with lived experience of AUB. Overall, the empathy scores of students increased for both live and recorded storytelling interventions. Students reported a positive impact of both interventions on their understanding of women’s experiences. The majority of students were overall satisfied with the storytelling intervention.

Our study reported higher post-intervention empathy scores in medical students following the patient storytelling interventions and improved student understanding of patient perspectives. Our study findings resonate with other studies where storytelling interventions enhanced reflective thinking, empathy and facilitated transformative patient-centered care in medical students (Kumagai 2008; Haigh and Hardy 2011; Hendriksz 2016; Job et al. 2019; Moreau et al. 2018; Milota et al. 2019; Bas-Sarmiento et al. 2020; Wong et al. 2020). A recent study showed that reading narratives of patients has the potential to improve shared decision-making skills in medical students (Eggeling et al. 2021). We used a guided reflective writing component with reflective questions, which is one of the methods used to generate reflective thinking in narrative medicine and has the potential to improve the empathic response by reflecting on human experiences and increasing the understanding of patient lives from multiple perspectives (Chen and Forbes 2014). A recent narrative review on interventions to improve empathy identified that a combination of different pedagogical methods could be more effective for learning than a single method (Samarasekera et al. 2023).

Listening to the lived experiences of real patients is valuable when patient interactions in health care settings may be reduced for any reason (Cleland et al. 2020). Student participants in our study had their rotation impacted by COVID-19 restrictions which reduced their clinical exposure. Furthermore, student experiences vary based on the clinical placements across different medical schools, populations and the presenting complaints of the day of placement. Our interventions could ensure all students are exposed to the experience of women with AUB and have the opportunity to learn from their stories and cultural experiences. The use of real patients for storytelling instead of simulated patient actors allows students to appreciate patients’ genuine illness stories. Real stories are powerful and can lead to better engagement and retention of learning messages (Kumagai 2008). There is the potential for storytelling health experiences to cause distress in women. They were provided with a storytelling guide and requested to share only information that they were comfortable to do so. Hospital health support services were available to women if required but none of them utilised these services.

Strengths and limitations

A strength of this study is that it engaged Māori women and their illness stories for medical student learning. However, we were unable to assess the impact of women’s diverse stories on cultural awareness on students. Patient stories are known to improve cultural awareness and understanding of how culture impacts access to health care services (Haththotuwa et al. 2011; Wain et al. 2012). Another strength of the study is that we used a ranking method to minimise the reliance on the properties of the JSE scale. This enables our results to be communicated and interpreted without reference to any specific local empathy scale. A recent review reported that use of different empathy instruments made it challenging to compare and derive conclusions from the studies included in the review (Samarasekera et al. 2023). Gender differences in empathy scores have been reported for reasons such as social learning and genetic predisposition (Hojat et al. 2016). In this, study, male and female students had differences in the effects of intervention, with males exhibiting a wider range of responses. Several other factors are known to influence empathy scores such as personality traits and socio-demographic variables (Hojat et al. 2016). A limitation of this study is that we did not collect demographic details of student participants.

Both live and recorded storytelling interventions have the potential to improve student empathy and understanding of lived experiences of women with AUB. Storytelling interventions are particularly valuable when student-patient interactions are limited in health care settings. The findings in this pilot study should be confirmed in a larger study. Our study intervention focussed on the cognitive component of empathy and future studies could include a skill training component and measures of communication, cultural awareness, behavioural change and quality of patient care in outcome assessment. A future study comparing in-person storytelling and online storytelling interventions could shed light on preferred empathy training interventions for medical students.

Acknowledgments

The authors thank nurses and doctors at the women’s health clinic, Wellington Hospital, New Zealand for helping us with recruitment of women to tell their stories. Thanks to Mr Luke Pilkinton-Ching, videographer, University of Otago Wellington for helping us with the videorecording and editing of women’s stories. Thanks to Ms Jackie Bell and Mr Rhys Mulholland-Winiata, teaching coordinators at the Department of Obstetrics, Gynaecology and Women’s Health, University of Otago Wellington for their help with organising the intervention sessions. We particularly thank the women and medical students who participated in our study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Otago Medical School - Medical Education Research Grants, University of Otago, New Zealand and the Lottery Health Research Postdoctoral Fellowship, New Zealand Lottery Grants Board.

Notes on contributors

Parimala Kanagasabai

Parimala Kanagasabai, BPT, MPT, PhD, is a Research Fellow at the Department of Obstetrics, Gynaecology and Women’s Health, University of Otago Wellington, New Zealand.

Judy Ormandy

Judy Ormandy, MBChB, Dip Obs, MClinEd (Hons), FRANZCOG is a Senior lecturer at the Department of Obstetrics, Gynaecology and Women’s Health, University of Otago Wellington. She works as an Obstetrician and Gynaecologist at the Te Whatu Ora-Health New Zealand (Capital, Coast and Hutt Valley).

Sara Filoche

Sara Filoche, BSc (Hons), MSc, PGDip (Gen Med), PhD is an Associate Professor and Head of Department at the Department of Obstetrics, Gynaecology and Women’s Health, University of Otago Wellington, New Zealand.

Claire Henry

Claire Henry, Bsc (Hons), PhD, is Research Fellow at the Department of Obstetrics, Gynaecology and Women’s Health, University of Otago Wellington.

Sarah Te Whaiti

Sarah Te Whaiti, Ngai Tahu, Ngati Mamoe, Waitaha, MBChB, PG Dip Obs, is a clinical lecturer at the Department of Obstetrics, Gynaecology and Women’s Health, University of Otago Wellington. She works as an Obstetrician and Gynaecologist at the Te Whatu Ora- Health New Zealand (Capital, Coast and Hutt Valley).

Robin Willink

Robin Willink, BSc (Hons) PhD, is a Senior Research Fellow and Biostatistician at the University of Otago Wellington, New Zealand and is an Adjunct Scientist at the Measurement Standards Laboratory of New Zealand.

Tehmina Gladman

Tehmina Gladman, BA(Psych), PGDip (Ed), MSc(Psych), PhD(Exp Psych) is a senior lecturer and education advisor at the University of Otago Wellington, New Zealand.

Rebecca Grainger

Rebecca Grainger, MBChB, PhD is a Professor at the Department of Medicine and Associate Dean Medical Education, University of Otago Wellington. She works as a Rheumatologist at the Te Whatu Ora-Health New Zealand (Capital, Coast and Hutt Valley).