Family Medicine Vital Signs

By Kirsten Stoesser, MD

We all want what is best for our patients. We want to provide them with the best evidenced-based medicine, that we have spent years (or, let’s be honest—sometimes just frantic minutes) researching, reviewing, assessing, and filtering, so that they can make informed, relevant, and appropriate decisions about their health. We hope that they will look to us as fountains of knowledge and sage guides in their journey toward health. Which is why we can be so crestfallen when our patients don’t always heed our advice, and tell us, “well, my friend/neighbor/sister said that treatment didn’t work for them, so I don’t want to try that.”  Or, “I read online about people being cured by this new herbal remedy, and I’m going to use that instead.”   Or simply, “We don’t do vaccines.”

Why is it that all the best evidence in the world, piles of convincing statistics, and recommendations from a health care provider can’t beat a story? Listening to and learning from stories is our shared heritage;  it is how we evolved.  It is doubtful that early people sitting around the campfire said, “Hey, I just invented writing and numbers and I’ve been keeping meticulous records for the past 2 years.  I have noticed that after someone eats the red berries, only 1 out of 1000 times do they die. Those red berries are actually pretty safe. Here, let me show you these charts and bar graphs.”  Instead, we can be relatively certain the story was, “Hey! Did you hear what happened to Gorg yesterday?  He ate a whole bunch of red berries and he died. Don’t eat those!”

The exalted “N of 1,” that which we have been instructed, again and again, through years of medical training, upon which to never base decisions.  Yet, it is how we have learned for millennia.  Numbers, especially unfathomably large numbers, about things and people we don’t know and maybe don’t understand, are easy to discount, to brush aside and ignore. There is no emotional connection. But tell me a story about one person—get me to emotionally connect to that person, to feel what they feel, to worry that their horrible fate could become mine (or to hope that their cure against all odds could become my good fortune as well), and now I am convinced.

A few years ago I was seeing a prenatal patient, trying to convince her of the safety and benefit of a flu vaccine during pregnancy.  I was giving my typical spiel and using all of my strategies, including, “The CDC recommends the flu shot for all pregnant women, and it is safe for baby during any trimester of pregnancy”, “you can’t actually get the flu from the flu vaccine”, and “pregnant women can become much more sick than other people if they get the flu” all to no avail.  In an act of desperation, I heard the words come tumbling out of my mouth before I could stop them, “A colleague of mine had a pregnant patient who did not get the flu shot, and she ended up getting the flu, and needed to be in the intensive care unit for a week.”  The patient thought about this for a moment, and said, “OK, I guess I’ll get one.”

This was a bit of an epiphany for me as I realized that there can be a benefit to telling these “N of 1” stories when they serve a greater purpose.  When they actually represent the statistics and why we recommend what we do.  I tell this little story now to many of my pregnant patients who are hesitant about getting the flu vaccine. I don’t convince all of them, but I’d say in about half of the instances I persuade someone to get the vaccine.  I will say that I have a bit of guilt about doing this as well, feeling as though I am somehow going against patient confidentiality by revealing this story. However, logically I know this is not the case, as there are no patient identifiers in this information.

Despite my discomfort, I have started using stories at other times when it will be a benefit. I really don’t want my vasectomy patients to have severe post-operative pain, swelling, and bleeding. So to the usual counseling of, “Make sure to rest for 48 hours afterward with intermittent icing,” I always add,  “A  colleague of mine knew about a patient who went out and played basketball the first day, and his scrotum swelled up to bigger than the size of a grapefruit.” I have yet to have a patient be too active in those first 48 hours.

It has not escaped me that I tend to use stories I have heard from other physicians.  Not because I don’t have ones from my own practice I could use, but because it seems to me more indirect this way and somehow, perhaps more acceptable. These stories are verbal case reports untraceable to their original subject, because not even I know who they are.

I am not, however, above using myself as an example in these stories. I have read the conclusions of various studies, that we should not tell stories about our own medical issues to patients. Apparently, patients don’t like it. But still…maybe every once in a while in the right circumstance it is OK.  Just last week I was seeing a 2 year old girl whose mother was a refugee for a hernia. I referred her to pediatric general surgery for evaluation. The mother expressed concern for the safety of a hernia repair surgery. I assured the mother that it is a very safe surgery and that surgeons do this kind of surgery all the time.  I explained that an uncorrected inguinal hernia in a child could quickly become a surgical emergency, and that it was recommended to repair it before this point.  I could still see the fear and worry in her eyes.  Again, I decided to speak, even though the other half of my brain was telling me not to share too much; “I had hernia surgery when I was a child.” That was it. That was my story. And I didn’t even need to finish it because the rest of the story was obvious.  I was here.  And I was fine.  The relief the mother expressed was palpable, and she was agreeable to taking her daughter in for a surgery consult.

By ignoring or discounting these ‘N of 1’ stories and their impact on our patients we are going against human nature.  By using them appropriately we can enrich our experiences with our patients, and help to support our facts and numbers in a manner which is much easier understood and remembered.  And, we may even impact behavior just enough to better the health of our patients (but I have no statistics on that).  Perhaps these stories I have shared will inspire you to become a storyteller with patients as well.

Kirsten Stoesser, MD is a clinical associate professor in the Department of Family Preventive Medicine at the University of Utah School of Medicine.