Anecdote And Evidence A Comparison Of Student Performance Using Two Learning Referents

Chiropractic Journal of Australia
Volume 40 Number 2 June 2010 63
INTRODUCTION
The assumption that health care practitioners would
unquestioningly embrace the principles and practice of
evidence-based medicine (EBM) has proven to be ill founded.
Whilst it was assumed those at the coalface would find the
scientific rationality of EBM irresistible, evidence that the
evidence was on shaky grounds did not take long to appear.
Whilst several barriers to the implementation of EBM in
primary practice have been identified1,2
it seems practitioners
are fundamentally unwilling to disregard, much less abandon
less formal sources of knowledge to inform their activities.
Evidence acquired through their personal and the collective
clinical experience of their colleagues is both highly regarded
and used extensively by practitioners.3
The refashioning of
what constitutes EBM to include clinical acumen and patient
preference; what Trish Grennhalgh4
has called a retreat to
EBM Mark 2 (and 3) is welcome.
A similar course has been charted when it comes to the
education of health professionals. The once frantic calls for
educators to imbue the curriculum with the principles and
philosophy of EBM, whilst well founded are now balanced
by an appreciation of the benefits the exposure of learners
to other forms of information can provide. Increasingly we
acknowledge the fact that the experience of well-versed
practitioners exposes students to a broad range of knowledge
Anecdote and Evidence: A Comparison of Student Performance
Using Two Learning Referents
BARRY DRAPER and PHILLIP EBRALL
Barry Draper, BAppSc(Chiropractic), MSc(Phil), FACC
Senior Lecturer in Chiropractic, RMIT University.
Phillip Ebrall, BAppSc(Chiropractic), GradCert Tert Learning Teaching,
PhD, FICC, FACC
Adjunct Professor, International Medical University, Kuala Lumpur
Received 3 November 2009, accepted with revisions 15 December 2009
ABSTRACT: Objective: To test and discuss the worth of anecdote as a pedagogical tool when used in the
undergraduate teaching of chiropractors. Method: Students undertaking the course Integrated Assessment and
Diagnosis were exposed to 2 methods of teaching: one emphasising the personal experience of the lecturer
as the primary learning referent and the other emphasising contemporary journal articles, internet websites,
a prescribed text and other reference textbooks as the primary learning referent. Results: When examined,
students who were exposed to course material which emphasised the lecturer’s personal experience as the
primary learning referent obtained higher scores than when examined on material utilizing contemporary journal
articles, internet websites, a prescribed text and other reference textbooks as the primary learning referent. In
addition, a greater number of students provided comments which could generally be regarded as supporting
the teaching style in which the lecturer’s personal experience was emphasised as the primary learning referent
in comparison to those which did not. Conclusion: Teaching with anecdotes appears to be both an effective
and popular means of delivering undergraduate education. The personal stories of experienced practitioners
should not be overlooked in the teaching of undergraduate chiropractors.
INDEX TERMS: EDUCATION, CHIROPRACTIC; EDUCATION,
CHIROPRACTIC/AUSTRALIA; CLINICAL COMPETENCE;
ASSESSMENT, EVIDENCE-BASED CHIROPRACTIC. Chiropr J Aust 2010; 40: 63-8.
and skills that reference to formal sources of literature alone
may obscure. The use of stories and anecdote by experienced
staff is also an effective teaching strategy.
This paper reports on the results of a study conducted within
the Discipline of Chiropractic at RMIT which compared
student performance when examined on information
presented in a manner which:
1. utilised formal sources of information pertaining to a
disorder such as prescribed textbooks, journal articles
and internet resources as the primary learning referent;
and
2. utilised the personal or anecdotal experience of the
lecturer in dealing with a disorder as the primary
learning referent.
We argue the results of this study demonstrate the efficacy of
storytelling and anecdote as pedagogical tools and provide a
theoretical account for this effect. Whilst we make no claim
that the use of anecdote should be utilised in an uncritical
manner, we argue that through its ability to bring context,
authenticity and a sense of ownership to the learning
environment, the valuable personal accounts of experienced
clinicians are an invaluable feature of education in the health
sciences.
METHOD
Students enrolled in the sixth semester course, Integrated
Assessment and Diagnosis, were invited to participate in
the project. As part of the Bachelor of Complementary
Medicine (Chiropractic) program at RMIT the course consists
of a series of 12 one hour lectures in which information
presented in basic science components of the program
such as pathology and microbiology is integrated with that

64
Volume 40 Number 2 June 2010
presented in assessment components such as orthopaedic and
general physical examination. As a preparatory offering for
students entering the clinical phase of their studies, the course
objective is to engender students with a systematic approach
to assessment which is reinforced through the analysis of
selected clinical disorders.
A typical class presentation provides information on
the aetiology, demographic, subjective findings, objective
findings, management and the prognosis of a common or
important clinical disorder.
As part of the project students were presented with
information on 10 clinical disorders over a 5 week period.
Information on five of the disorders (Group A, Table 1)
was presented in a manner which utilised contemporary
journal articles, internet websites, a prescribed text and
other reference textbooks as the primary learning referent.
Information was presented as factual and decontextualised in
terms of the enunciation of any personal experience or views
held by the lecturer pertaining to the disorder. The lecturer’s
narrative typically took the form
“Smith and Smith inform that MS ...”
“According to Brown, individuals with Pleurisy ...”
“75% of patients with MS show signs of ... according to
Jones.”
Information on the remaining 5 disorders (Group B,
Table 1) was presented in a manner which emphasised the
lecturer’s personal clinical experience with and opinions
regarding the disorder. Whilst students were not restricted
from consulting other sources of information, no explicit
reference to additional sources was made. Here, the narrative
was typically of the form
“My first experience with Spontaneous Pneumothorax was
...”
“The patients I have seen with Migraine have shown ...”
“The first patient I saw with a malignant brain tumour was
in the typical age group, a 50 year old man ...”
In week one of the lecture series students received
notification that 2 pedagogical styles would be used but
were given no overt reference as to which disorder would
be presented in either style. Care was taken to maintain
consistent style in terms of verbal inflection and tone, clarity
of voice, pacing, grammar and language use, body language
and posture etc in all lectures. Care was also taken not to
provide conflicting or contradictory information pertaining
to the disorder between the lecturer’s personal account and
that available in other sources such as the prescribed text.
PowerPoint presentations for both groups of disorders utilised
the same master slide scheme. A disorder from each group
was presented in each lecture and the order of presentation
of each group varied across lectures.
At the completion of the presentations students were
advised that an examination of the subject matter would
take place two weeks hence forth. Students were further
advised that the examination did not contribute towards
their final grade and that participation in the examination
was optional.
The examination consisted of multi choice questions,
each with 5 possible responses, a) to e); response e) in each
question being “none of the above are correct.” Each question
contained only one correct response. Ten questions were
posed for each of the 10 disorders, totalling 100 questions.
A time of two hours was allocated for completion of the
examination. Knowledge of the following domains was
assessed for each disorder:
Aetiology (1 question)
Demographic (1 question)
Subjective findings or symptoms (3 questions)
Objective findings or signs (3 questions)
Management (1 question)
Prognosis (1 question)
At the completion of the examination students were invited
to provide written comments as to the sources of information
and methods of teaching they found most useful in learning
about the disorders. Instructions to students read “In the space
below please write your thoughts on the two styles of teaching
which you have experienced over the previous 5 weeks.”
RESULTS
Of 82 students 70 chose to participate in the examination
with 31 offering written comments.Total correct and incorrect
examination scores are given in Table 2. This reveals a
greater number of correct responses were elicited when
the style of teaching emphasised anecdote and storytelling
in comparison to that in which more formal sources of
ANECDOTE AND EVIDENCE
DRAPER • EBRALL
Table 1
DISORDERS BY GROUP
GROUP A GROUP B
1. Multiple Sclerosis 6. Pneumothorax
2. Pleurisy 7. Migraine
3. Bowel Cancer 8. Brain Tumor
4. Cluster Headache 9. Motor Neurone Disease
5. Prostate Cancer 10. Diverticulitis
Table 2
TOTAL RESPONSES USING THE TWO LEARNING
REFERENTS
LEARNING REFERENT
TOTAL
CORRECT
RESPONSES
TOTAL
INCORRECT
RESPONSES
Disorders emphasising
the lecturer’s personal
experience as the primary
referent
3149 351
Disorders emphasising
formal sources of information
as the primary referent
2449 1051

information constituted the primary teaching and learning
referent. Students also provided a greater number of correct
responses in all domains when examined on disorders which
emphasised the lecturer’s personal experience as the primary
referent. This was particularly evident in the questions
assessing knowledge of the subjective and objective findings
of the disorders as expressed in Table 3.
A total of 31 students responded to the opportunity to
provide written comments comparing the 2 learning styles
by recording comments on the examination paper at the
completion of the examination. 29 respondents provided
comments which could generally be regarded as supporting
the teaching style in which the lecturer’s personal experience
was emphasised as the primary learning referent.
DISCUSSION
Anecdote and Storytelling
Storytelling can clearly be viewed as the foundation of the
teaching profession.5
The use of stories and anecdote in higher education is
widespread.6,7
Engaged in such diverse fields as the teaching
of statistics,8
psychology,9
and mathematics,10
the use of
anecdote in both the training and everyday practice of health
care professionals such as nurses and medical practitioners
has also been extensively observed.11-17
As Steiner18
alerts,
physician’s lives are immersed in stories.
In spite of this, the charge that the inherent subjectivity
of the anecdote does not allow for cross verification or
systematic tracing is difficult to defend. Whilst it may
indeed seem heretical to some educators, criticism of the
use of anecdote and storytelling must however be balanced
by an acknowledgement of the benefits their use brings
to the learning environment. In the education of health
professionals, anecdotes provide insight into individual
responses, exceptions to the rule and the human and emotional
elements of the clinical world, all of which may be obscured
from view when this world is evaluated by other means. We
argue that there are also specific pedagogical benefits to be
gained through teaching with anecdote.
DRAPER • EBRALL
Table 3
CORRECT RESPONSES (n) PER DISORDER BY DOMAIN AND GROUP
DOMAIN
GROUP
A
Disorders emphasising formal sources of
information as the primary referent
B
Disorders emphasising the lecturers’ personal
experience as the primary referent
Disorder number: 1 2 3 4 5 6 7 8 9 10
Aetiology
(‘A’ n=245; ‘B’ n=276)
48 65 69 54 56 57 55 58 70 57
Demographic(‘A’ n=232; ‘B’
n=388)
52 59 59 49 48 62 59 62 64 61
Subjective findings Q1
(‘A’ n=243; ‘B’ n=332)
32 36 38 38 17 60 61 61 60 61
(‘A’ n=247; ‘B’ n=327)
48 43 24 42 33 54 58 60 55 58
(‘A’ n=220; ‘B’ n=331)
38 45 25 43 29 51 59 60 52 59
Objective findings Q1
(‘A’ n=242; ‘B’ n=334)
31 38 29 36 32 60 64 54 68 62
(‘A’ n=212; ‘B’ n=321)
29 32 26 26 37 60 59 54 61 60
(‘A’ n=237; ‘B’ n=316)
45 28 20 27 35 51 67 64 47 67
Management
(‘A’ n=327; ‘B’ n=335)
60 52 63 68 60 63 61 63 65 56
Prognosis
(‘A’ n=245; ‘B’ n=289)
56 68 59 63 61 63 55 68 65 70
Mean: 245 316

66
Teaching is more than the transmission of packets of
information between educator and student.19
Learning is
more than the memorization of abstract facts. The exploration
of how and why students learn and how this may best be
achieved is of fundamental concern to all educators.20,21
The
results of this study support the supposition that when used
as a primary learning referent in higher education, anecdotal
accounts may be an effective pedagogical mechanism. Whilst
not wishing to overstate the statistical or mathematical
significance of the results, students obtained a numerically
higher score (total number of correct answers) to examination
questions assessing their knowledge of disorders presented
as anecdotal accounts in comparison to those which did not.
Students also obtained a higher number of correct responses
to each of the individual categories or question domains
e.g. etiology and demographic, when information provided
through anecdote was assessed. More importantly, students
expressed a high level of satisfaction for learning this way.
We suggest the interrelated themes of authenticity, context
which has both cognitive and emotional dimensions and
ownership can be drawn together to account for the efficacy
and satisfaction of learning through the use of story and
anecdote.
Authenticity
Learners respond best to information which they consider
to be authentic.22
Student comments reflect this appeal:
“It’s much better when you talk about your experience in
practice, it makes it more believable because I know it’s
actually happened to someone.”
“We get taught about this stuff but to actually know that
chiros (sic) see this sort of thing in practice is great.”
Anecdotes are told by a lecturer personally known to the
learner and presently standing before them, are about a patient
personally known to the speaker and are about a unique
individual patient whom the speaker has personally dealt
with (adapted from McNauthgon).23
This actually happened;
straight from the horse’s mouth, students are granted direct
access to the source of the knowledge; they see him/her and
hear him/her with their own eyes and ears. There is no break
in the chain of transmission of information, nothing to dilute
or mutate the integrity of the account. Learners bare witness
to the individual who has actually touched and spoken with
the patient, has seen the signs, performed the tests and is now
reporting directly to them. Whilst this does not irrefutably
distinguish the authenticity of an account from its veracity,
it is the ability of an anecdote to fashion the perception that
information is real which sharpens this pedagogical effect.
This rhetorical capacity gains additional strength when
the anecdote pertains to the experience of a trustworthy and
convincing presenter. The personal relationship between
facilitators and learners is a crucial factor in fashioning the
effect of teaching and learning.24,25
The credibility of the
presenter or storyteller is the essential determinant in making
a story stick in learner’s minds.26,27
“It is great being lectured by an experienced clinician who
has treated lost (sic) of people. It makes it seems more real.
I learn best like this.”
The testimony of a policeman witnessing an accident is
furnished greater credence than that of an ordinary citizen:
A Judge’s report of a UFO sighting is likely to attract more
attention than that of a child. The tales of an experienced
and respected clinician/lecturer will bring hush to a bored
or disruptive classroom. Nothing is more effective to make
an audience sit up and pay attention. Those constructing
scientific prose endeavour to conceal its human origins by
installing nature as the sole informant. Notwithstanding the
rhetorical strength of this manoeuvre, there remains a special
appeal to the eyewitness account of a trustworthy reporter.28
A first hand account conveyed by a credible storyteller
engenders an authentic quality to the information at hand;
a quality of anecdote Shor describes as an “illumination of
reality.”29
Context
The pedagogical efficiency of anecdote is also evident in
its capacity to contextualise the information at hand. Context
helps us determine the interpretation of discourse; context
helps make meaning clear.
Students wrote
“It’s much better when you tell us your stories about
practice, it makes it much easier to understand what’s
going on.”
Anecdotes are holistic; abstract snippets of information are
weaved together into a meaningful whole allowing learners
to connect and organize knowledge.30,31
Like a good crime
novel we cannot put down, our attention is held from start
to finish. Intensely we follow the detective/clinician as they
join the dots, through the murky labyrinth of mysterious
symptoms and signs to skilfully and expertly uncover the
murderer/diagnosis and punishment/prognosis.
The natural progression and inherent logic of the anecdote
links categories which may otherwise occupy disparate and
singular dimensions. A demographic, age 20-30, females;
a symptom, scattered and episodic parasthesiae and a sign,
hyperreflexia, may be discretely assigned and evaluated.
When part of a story, however, each is embedded as one in
the learner’s mind. Replacing an inventory of disengaged
facts represented as text on a page, is the mental image of a
young woman sitting in an examination room, talking about
the recurring pins and needles in her hands and legs and
wondering what is wrong. We visualise what she looks like,
the colour of her hair, the clothes she wears and how she
sounds. We see her forearm suddenly jerk as the doctor taps
her biceps tendon, we see her being shown an MRI revealing
white patches in her brain and her reaction to a shocking
diagnosis delivered in sympathetic tones. Now more than
words on a page or figures in a table, information appears to
us as real, moving in time and space. Through anecdote we
learn why, when and where the patient presented, what she
told the doctor and what he observed and did.
Students comment
“I like the way the stories bring everything together
otherwise we’re just hearing about facts and figures about
a disease.”
“Its sometimes hard to remember all the stuff about the
clinical disorders but when lecturers tell us about their
experience it makes it seem like its all connected.”
DRAPER • EBRALL

Anecdotes are a powerful way of conveying complex
multidimensional ideas.32
By assembling a comprehensive
description of the circumstances and conditions which
comprise the event and in a manner which connects, anecdote
shapes the way we understand.
Context also shapes an emotional dimension facilitating
effective learning. This synergy has been variously evaluated
from an evolutionary, physiological, psychological and
even metaphysical perspective. Regardless of the analytical
workhorse, the starting point for each is the same; we best
remember information which provokes in us an emotional
response. Emotions profoundly influence learning in higher
education33
and are significantly related to students’academic
achievement.34
The use of anecdote brings a humane
and emotionally charged dimension to the information at
hand.35
Students comment
“It was really sad to hear about the patients with terrible
diseases like the lady with motor neurone disease. I don’t
think I will ever forget that story.”
“The conditions where the patient has a fatal or terminal
condition are the ones which stick most in my mind.”
In stories the human elements of a clinical disorder are
brought to life. No longer faceless references, all of the actors
within the anecdote become known to us and we relate to their
fears and anguish. The numbing conclusion that the diagnosis
is one of a terminal disorder is made all the more tragic
when it concerns someone we have come to know through
story. We have heard who they are, what they have felt and
why they came to see the practitioner. We have followed
them through histories, tests, investigations and now learn
that everything points to a condition without cure. Whilst a
clinical trial informs us that a typical case of MND shows
a 5 year mortality rate of 90%, it cannot tell us this typical
case was married with two young children, enjoyed running
and working out at the gym and now and over a short time
has become unable to walk unaided or drive her car. Through
story we come to know the patient not as a case or member
of a control group, but as an individual.
Yet it is not only patients whose pain we feel. We share
the shame and fear of the practitioner before us as we learn
of their incorrect diagnosis or botched procedure resulting
in a tragic outcome for their patient. We cringe at their
embarrassment and regret as they explain how they went
wrong and what they have learned from their mistakes and
pay careful attention as they advise how we can avoid the
same. Such information comes to light in few forums other
than as part of a story shared amongst the initiated.
“Thanks for telling us about the mistakes you’ve made. I
admire you for that.”
However the emotions fuelled by stories do not have to be
negative. Stories can also be enjoyable. Usually hidden from
view in formal descriptions of the health workers’ world,
learners may share the sense of accomplishment felt by a
practitioner who has made the early discovery and initiated
the successful management of a potentially fatal pathology.
The pride a clinician feels having helped a patient who has
come to them as a last resort finds expression nowhere else
than when shared as a triumphant yarn amongst those sharing
a common interest. Stories can make us feel good about
what we do and inspire us to practice our trade. An artfully
constructed tale of success can make learners champ at the
bit to leave the classroom and get out into the real world
to apply their craft with pride. Education works best when
it is inspirational. Stories are most effective when they are
fun.14
It is the permeation of events with emotion that makes
them memorable.36
Rossiter’s30
assessment summarises
this effect and is worthy of lengthy quotation: “The learner
involvement factor is also related to the power of stories to
stimulate empathic response. It is the particularity of the story
– the specific situation, the small details, the vivid images of
human experience – that evokes a fuller response than does
a simple statement of fact.”
Ownership
A sense of ownership promoted by the use of anecdote
further enhances its pedagogical efficacy.
“Hearing stories about what happens in practice makes
me wonder what I would do in that situation.”
Embedded within an anecdote is a personal, lived
experience, that of the storyteller. Unlike an abstract
description of events devoid of its human and emotional
context, information contained in anecdote exists as a holistic
phenomenon. Once rendered public, however, listeners are
invited to share the phenomenon, to in effect, become a co-
owner of that experience. Like a confidant invited into the
internal world of a secret holder, the learner is now invited
to make the story their own. It is only through story that such
an invitation is extended. Whilst data can be transferred from
teacher to learner, it is the human, emotional and holistic
qualities of the anecdote which make the true sharing of
information between the two possible because it is only
through story that the account has become some thing which
can be shared.
Whether the listener takes up the offer of ownership is,
however, their prerogative. They may choose to ignore it,
to be unimpressed, not believe it, to refuse the invitation. If
the invitation is accepted, however, the new owner is now
free to do with the story what they wish; to interpret and
deal with the information as they see fit. They can picture
themselves as doctor or patient, may construct their own
narrative and form their own conclusions about what should
or should not have been done. Stories may not lead to a
singular logical conclusion yet this is not a shortcoming as
a world of possibilities are opened up. Learners may ask
“how would I have reacted, what course of action would I
have taken?” Through providing a sense of ownership, stories
allow listeners to resonate with their own experiences14
and
to locate and manoeuvre their own thoughts and experiences.
Stories allow us to explore the “what if” in the safety and
privacy of our own mind.
“The lectures using personal experience teach us what it
is like to be a chiro (sic) in the real world. This is great
because it makes me think about what I’m going to be up
against when we finish.”
McGill places this effect eloquently, “The tales gain a
presence, a present reality where we become a part of that
DRAPER • EBRALL

68
experience, albeit vicariously.”37
The construction of stories
encourages students to actively engage in making sense of
their experiences, to present stories from different viewpoints
and to reflect more deeply about the world. Rather than
passive recipients of information, learners may construct their
own individual response and at the same time expanding their
knowledge of time and events.
CONCLUSION
Health care workers do not make exclusive use of a strict
evidence-based approach to practice, one which involves only
information from clinical trials and other formal sources; nor
do they utilise an approach which emphasises their personal
experience alone, to inform their activities. This is a false
dichotomy.4
Practitioners can and will utilise what they think
is best to get the job done. No less a choice need apply to
pedagogy. Teaching styles which emphasise formal sources
of evidence as well as those emphasising personal experience
and anecdote as learning referents may be freely used. The
two are not mutually exclusive. This study demonstrates the
efficacy of one such style; teaching through the use of story
and anecdote.The tales of experienced lecturers and clinicians
are an important part of education in the health sciences.
This study demonstrates their pedagogical worth should not
be underestimated.
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