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No joke: The serious role of improv in medicine

Sarah Mahoney , special to AAMCNews
January 13, 2020

Want to be a better doctor? Try talking into a banana, muttering gibberish, and tossing balls at colleagues. Medical improv transforms goofy theater games into serious skills like empathy, teamwork, and super-quick thinking.

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Improv
Health professions students at the University of Wisconsin-Madison play an improv game that hones close listening skills. Photo Credit: Bryce Richter

Ajay Paul Singh, a second-year student at the University of Wisconsin School of Medicine and Public Health, felt a little nervous enrolling in a medical improv elective. But he says one exercise alone made the sweaty palms worthwhile.

The scene started with one participant standing in front of the class of 14, pretending to be an apathetic librarian. A second student then stepped in with the mission of mimicking the first student’s emotion without knowing what it was. But that participant misread apathy for sadness, performing in a way that made the first actor say, “Whoa, you’re bringing me down!” Next, her partner portrayed a frustrated accountant, but people mistook frustration for excitement.

“It opened my eyes, in a light-hearted way, to see how often we misunderstand people,” Singh says. “It was fun and humbling at the same time.”

Communication is full of such subtleties, medical educators say, and that’s precisely why medical improv is so valuable. The exercises, which use the principles of improvisational theater to hone skills needed in medicine, range from translating gibberish to communicating through eye contact alone. Sometimes, they are adapted to reflect medical scenarios, and sometimes they’re simply standard improv techniques followed by a medicine-related debrief.

No matter how goofy medical improv exercises sometimes seem, the effects are serious. The art form turns participants into sharper listeners, better collaborators, and more empathic people — and it helps them think on their feet, says medical improv pioneer Katie Watson, JD, an associate professor at Northwestern University Feinberg School of Medicine. “The same paradox drives physicians and improvisers,” she says. “They need to prepare for unpredictability.”

Interest in medical improv has been growing in recent years, as medical schools and teaching hospitals increasingly value the skills it teaches, says Lisa Howley, PhD, AAMC senior director of strategic initiatives and partnerships. Research shows that effective communication can improve patient outcomes, and improv markedly increased communication skills in one study of pharmacy students. Now, researchers believe a new tool published this month can better measure the educational effects of medical improv. Developed by four medical schools, the scale found that participants in a six-hour enhanced medical improv course scored significantly higher than those with no improv training.

“The arts and humanities have been shown to have effects on provider well-being and on diagnostic, communication, teamwork, and leadership skills,” notes Howley. The AAMC is currently commissioning a comprehensive review and leading a broad initiative to better integrate the arts — including improv — into medical education, she adds. Meanwhile, medical improv has accumulated a solid following, says Watson. So far, she has taught the curriculum she developed to more than 180 people in “Train the Trainer” classes, many of them faculty at medical schools.

“It opened my eyes, in a light-hearted way, to see how often we misunderstand people. It was fun and humbling at the same time.”

— Ajay Paul Singh,  University of Wisconsin School of Medicine and Public Health

And medical students love the approach. A study from the Johns Hopkins University School of Medicine found that 81% of participants in a medical improv training rated their enjoyment level as “tremendous” — and  85% said it was very relevant to patient care.

“People who take these classes say they are totally different from the other ways we teach them to communicate in med school or residencies,” says Vinod Nambudiri, MD, an assistant professor of dermatology at Brigham and Women's Hospital and Harvard Medical School who co-led a medical improv session at Learn Serve Lead 2019: The AAMC Annual Meeting, which drew approximately 70 participants.

“Because it’s fun and creative, it gives the lessons about empathy a resonance,” he says. “They make a lasting impact.”

Mindfulness in motion

One of Nambudiri’s favorite improv exercises involved solving a medical problem with an ordinary object. Instructors gave students the situation — making rounds — and the object — a banana. Soon, participants offered rapid-fire suggestions. Make it a snack incentive for finishing earlier? Turn it into a pretend phone to call pediatric patients?

“It was fun to see how quickly people came up with creative solutions to a real problem. Improv forces you to think out of the box.”

group of people
Katie Watson, JD, (in red) leads future physicians at Northwestern University in an exercise she says could make medical handoffs smoother. Photo credit: Jim Brucker

Nambudiri also appreciates that improv boosts listening skills. “Improv shows you that you have to focus on the moment. You can't just interject your thought process — the scene won’t make sense unless you’re listening right now.”

And there’s real benefit in learning to be 100 percent in the moment. “It helps people free themselves,” says Robert Shochet, MD, an associate professor of medicine at Johns Hopkins  Medicine who specializes in patient-provider communication. “Medical students come to us with rich skills, but as we teach them to adopt styles of medical interviewing, that can become too rigid.”

This loosening effect is what made medical improv Anjani Pranav Sheth’s favorite course so far. “In other classes, we get scripts and templates on how to deal with patients, and I guess it’s good to cover the basics,” says Sheth, now in her third year at the Feinberg School of Medicine. “Improv taught me how to simply be in the current situation, not thinking three sentences ahead.”

In-the-moment listening skills are a profound benefit of improv, says Amy B. Zelenski, PhD, an assistant professor and director of education for the Department of Medicine at Wisconsin.

A colleague once told her about a time when a patient offhandedly mentioned that a close relative had just died. “He just went on with his questions and ignored that information,” she says, “and then later thought, `Oh, man. Why didn’t I respond?’ That’s what improv does — it teaches people to set aside their agenda for the conversation and listen.”

Discovering interpersonal strengths and shortcomings through improv is potentially transformative, Watson believes. “It lets learners identify where they need to build muscle and where they're flourishing. You'll have the person who's very eloquent but doesn't know how to be quiet. Or a person who is fine handling anger isn’t good with sadness.”

Stripping away judgment

Another educational boon comes from a classic improv exercise known as “Yes, and.” Here’s how it works: One partner makes a statement, and then the other affirms it and adds new information. “It teaches people to affirm someone else’s reality, instead of negating it,” says Watson. “We so often say, `Yes, but,’ which can be another way of saying `No.’ If you say, `Katie, let’s get Thai for lunch,’ and I respond with `Yes, but there’s this great new Mexican place,’ I’m rejecting your idea — and I’m doing it in a confusing way, because I used the word `Yes.’”

In a scenario with a tornado, for example, a person might say, “We should quickly run to the attic or we’ll die!” Using “yes and” allows the partner to add their knowledge and feelings without negating the first speaker’s contribution. “Yes, we need to work quickly to survive the tornado — and research shows basements are much safer than attics.”

That may sound like a minor linguistic tweak. But it becomes a masterful lesson in letting go of negative judgments about others. “It’s so lovely because whatever the person gives you, you just accept and add on to it,” says Shochet. “The premise is accepting what someone says without any kind of criticism.”

And while improv fosters collaboration and decreased judgment of others, it also helps students learn about and embrace their individual communication styles.

Watson loves watching students who start out shy but then begin to shine. “I call them `undercover fabulous.’ All they needed was an environment that prompts them to be spontaneous.” She notes that the more confident trainees become about their own approach, the more they can inject that into their work with patients. “It helps them step into encounters with their authentic voice as a clinician, versus having to step in and play the role of a clinician.”

In a field plagued by burnout and depression, genuine expression can also be a mental health booster. Improv is helpful in populations as diverse as Alzheimer’s patients, where it can teach new communication and coping skills, and at-risk youth, where it’s been shown to reduce anxiety. It makes sense that it’s good for doctors, too.

“I felt a lot of people drawing on personal experiences in improv exercises, opening up in situations in a relatively unprompted way,” says Nambudiri. “It pushes you to explore your feelings and where things are coming from. People find that to be very powerful.”

He also says students benefit from the collective apprehension that comes from operating a little outside their comfort zone. “Everyone wonders, `Am I going to have to do something silly or look stupid?’ Everyone is a bit vulnerable and a little at risk.”

Boosting empathy

Perhaps one of the greatest powers of medical improv is its ability to increase empathy. And that’s key, say experts, since studies show that medical training often erodes compassion for others.

One of Zelenski’s favorite examples of an empathy breakthrough comes from an exercise called “The Two-Minute Rant.” In it, partners take turns spouting off about an issue or behavior that gets on their nerves. Then, they introduce each other to the group — not by mentioning anything in the rant, but by a value that underlies it. A tirade about people who are always late, for example, might prompt an introduction that explains how much a partner respects other people’s time.

“One student said, `I get so upset when I talk to anti-vaxxers,’” Zelenski recalls. “‘This makes me realize I’ve always been arguing with them about facts, when I really should be talking about values.’”

“The whole purpose of medical training is to serve patients. But if students don't develop the communication skillsets to collaborate with patients and teammates, it's all for naught.”

— Katie Watson, JD, Northwestern University Feinberg School of Medicine

Empathy learned through improv also extends to other health care professionals, which is essential given the growing role of interprofessional collaboration in medicine.

Sheth says one exercise made a vivid impression on her. “We stood in a circle, tossing a ball in set patterns. Then we added more balls, making it more chaotic, and when someone dropped one, we just picked it up and kept going.”

The teamwork translation of so many balls in the air wasn’t lost on her. “We’re all catching as many balls as we can. When one falls, you just have to pick it up,” she says. "If the patient needs water, get him water, even if that’s not your role. I try and keep that in mind with all my day-to-day interactions.”

Such realizations, says Watson, are why improv matters so much to future physicians’ education. “The whole purpose of medical training is to serve patients,” she notes. “But if students don't develop the communication skillsets to collaborate with patients and teammates, it's all for naught.”

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