Word Pictures as a teaching tool for residents and medical students

Jeri A. O’Donnell, MA, LPCC, Director, Clin- ical Behavioral Science, Doctors Hospital Family Practice, 2030 String- town Road, Third Fl., Grove City, OH 43123-3993.

E-mail address: odonnej@ohiohealth.com.

The concept of word pictures is as old as ancient times and has been used in every society. The prophets, for ex- ample, were masters at using word pictures to teach their followers. One of the most familiar scriptural passages, the Bible’s 23rd Psalm, describes Christ as a shepherd caring for his sheep.1 Historical figures such as Abraham Lincoln and Benjamin Franklin often used word pictures. Lincoln, for example, described character like a tree and reputation like a shadow.2 Franklin used word pictures in his speeches and writings. One of the best examples was the epitaph he wrote for his own tombstone: “The body of Benjamin Franklin, printer, like the cover of an old book, its contents torn out and stripped of its lettering and gilding, lies here.”3 Many opportunities to teach the use of word pictures can occur while precepting residents. A dramatic example oc- curred recently while precepting a third-year resident who presented a case of a 42-year-old white female with a chief complaint of lower back pain, headaches, nausea, vomiting, and generalized fatigue, with an onset of one year prior. The patient was diagnosed with major depression and prescribed a selective serotonin reuptake inhibitor antidepressant, in addition to the tetracyclic antidepressant trazodone at bed- time. She had a complete work-up, which was noncontrib- utory.

The resident expressed frustration with this patient be- cause she was not responding well to his medical care and he was tired of filling out her requests for time off. I took the opportunity to introduce the resident to the concept of word pictures to help him reframe his approach to the patient. I asked him to picture a tree and to describe its parts. He gave me the typical description of the standard leaves, branches, and tree trunk.

I asked him what was he dealing with during each visit with this patient, and he described her symptoms. I replied that her symptoms were like fallen leaves of the tree and that all he had been doing thus far is raking those leaves. I suggested to him that in order to help this patient he was going to have to stop raking leaves and break ground to the root system where her problems really lay. The resident understood this picture immediately. He even shared the word picture with his patient and received a positive re- sponse, and she gradually opened up to him about some of her psychological issues, and treatment then became more effective. Through a word picture, the resident made a

‌The use of word pictures as an effective means of com- munication is an easy educational tool to learn or use. When shaping messages, it is helpful to remember that the mind likes to think in associations and word relationships to experiences, or the images in the mind and the idea of something that can be related to context. If you hear the word dog, you immediately think of a dog you own or owned or have seen recently; You do not think of the word, but rather the animal.

Some other examples of using word pictures to educate patients about some disease states include describing COPD by having the patient picture an inflated balloon that deflates as soon as it is inflated, emphysema by having the patient picture the lungs as a paper bag that holds the air and is not elastic, urinary incontinence as a dripping faucet, urinary obstruction as a balloon with a clip on the stem, or Alzhei- mer’s dementia as a computer whose hard drive has been disabled by a virus.

Sometimes a word picture can be made even clearer by using examples that fit the type of work a patient does or a particular interest a patient has. For example, a gardener may relate to hypertension being described as a constricted garden hose.

Another example of relating the word picture to an in- dividual’s work is represented by the case of a 48-year-old white male with uncontrolled type 2 diabetes mellitus. He had been a difficult and generally noncompliant patient. On one visit he presented for diabetic care and had not followed through on any recommendations from his previous visit.

I asked him what it would take for him to realize how his lack of blood sugar control was destroying his body. I then asked him what line of work he was in. He responded that he was an auto mechanic. I then decided to use a word picture to help him gain a better understanding of his dis- ease. When asked if he had ever seen a car battery that was leaking acid, he said yes and described the destruction that occurred to the surrounding structures. I told him that is exactly what was happening to his eyes, heart, kidneys, and blood vessels from failing to control his diabetes. It was like a light bulb came on and from that point his compliance began to improve.

Word pictures can be an effective tool in physician- patient communication by giving the patient a concrete image of their disease process or helping them identify roots of a problem. The physician can be creative in tailoring word pictures to fit the needs and interests of the patient. This technique is particularly relevant to the osteopathic philosophy and its belief in holistic treatment. As a profes- sion, we understand that our patients are complex beings composed not only of body, but also of mind and spirit. It is this complexity that can make patients a challenge to treat. Using word pictures allows us to tap into the complexities of our patients and communicate in ways that will enhance their understanding of our health messages. As you work with your patients, try using word pictures to help them see what you are trying to convey.

References

1. Smalley G, Trent J: The Language of Love. Colorado Springs, CO: Focus on the Family Publishing, 1991

2. The Quotations Page: Quotation 29760 from Classic Quotes [Abraham Lincoln, from Lincoln’s Own Stories]. Available at: http://www. quotationspage.com/quote/29760.html. Accessed June 27, 2009

3. The Franklin Institute, Resources for Science Learning: The epitaph of young Benjamin Franklin. Available at: http://sln.fi.edu/franklin/ timeline/epitaph.html. Accessed June 27, 2009

4. Geiger BM, Behr GG, Frank LE, et al: Evidence for defective mesolim- bic dopamine exocytosis in obesity-prone rats. FASEB J 22:2740-2746, 2008