There is something about the ER—especially the night shift—that thrives on spontaneity.
It's just past 2 a.m. I meet him for the first time in a hallway stretcher—one step past the waiting room and any number of hours before he inherits a bed with privacy. The patient is a 50-something Caucasian man with salt-and-pepper hair, battered glasses, a three-day beard, and an air of frustration. He wants to know why—why the long wait, why he’s constantly in pain, and why we can’t immediately comply with his request for narcotics.
I start to gather information as we are trained to do. I utter some version of “what brings you into the ER today?” I carry on with more questions, registering each answer on my mental checklist.
“Look, I really don’t want to be here right now,” he says with defeat.
I tuck away my pen and paper—and with them, my persistence.
"You know, to be honest, I wouldn’t mind being at home in my own bed right now either,” I offer.
Surely someone would suggest I had sidestepped decorum and political correctness. It had been a long, relentless shift. Still, a doctor isn’t supposed to seem anything less than overjoyed to serve, in any situation, at any time of day.
He turns to face me, musters up the strength to smile, and prompts me to continue. “Let’s get going then.”
I’m happy to see a change in his demeanor, to see him less guarded, more at ease. I’m glad there is no misinterpretation.
I’m glad that only he heard me.
Doctors in training are still judged first on memorization—of anatomy, physiology, pathology, and pharmacology. During clinical rotations, we become hoarders of checklists, templates, and algorithms to be recalled at a moment's notice. There’s still no algorithm for patient interaction, but medical educators have attempted to create one with the aid of standardized patients (SPs): actors trained to portray "classic" patient types with common chief complaints—the angry patient with back pain, for example.
Medical students are critiqued on posture, eye contact, and use of strategic pauses. We learn to avoid potentially bothersome habits and disfluencies, such as saying “uh” and “um.” Discussion arises around the categories of human touch—a supportive hand on a patient's arm is appropriate but the same gesture on a patient's thigh may not be. We are coached to acknowledge feelings with "I understand" or "I am sorry to hear that."
The use of standardized patients began in the early 1960s, with the primary goal of evaluating physical-exam maneuvers that students perform. Over 90 percent of U.S. medical schools now use SPs to broadly assess students’ communication skills, often as preparation for the now controversial clinical skills licensing exam. Although SP encounters encourage students to reflect on their interpersonal skills, many experts worry that this training doesn’t translate into effective clinical practice.
In medical school, interpersonal skills are de-personalized. Students are taught structure and essentially given a script. Traditional educators view improvisation as a risk.
Yet, the practice of medicine is spontaneous and, often times, risky. And, if educators teach students to tread carefully even in simulated encounters, how can physicians be expected to form genuine relationships with their patients?
In undergrad, I enrolled in an improvisational acting class that taught the “Meisner” technique—to “live truthfully under imaginary circumstances” and to be “firmly rooted in the instinctive.” Through this and subsequent experiences with sketch and standup comedy, I came to appreciate that improvisation is less about acting and more about reacting—to others in a scene, to the audience, to the present. I discovered that skilled improvisation is merely the interpersonal equivalent of having insight and being adaptable.
A few thought leaders have started to see the potential value of such improvisational techniques in medical education. At Northwestern University's Feinberg School of Medicine, for example, one seminar utilizes improvisational theater practices to improve communication, cognition, and teamwork. Katie Watson—an assistant professor of medical education at Northwestern, a faculty member at Chicago’s famed comedy theater Second City, and the medical improv seminar's founder—contends that while physician-patient encounters may be structured, every interaction is, to some extent, improvised.
One focus of Watson’s efforts is with medical students’ use of emotion. While most students have good innate interpersonal skills, medical school makes it difficult for some to “clearly articulate their own emotional point of view and accurately perceive that of others,” Watson says. She adds, “our job is to help retain and harness the power of the innate skills that people bring.” However, improvisation doesn’t mean a lack of discretion. Watson emphasizes that you can’t just “be yourself.”
As with any skill, improvisation must be practiced. Watson acknowledges this irony; she describes her seminar as highly structured—militaristic, even. One exercise she adapted from traditional improv games is called “Cut to the Chase”: two students are told to enact a short scene for one minute. They must then immediately replay the scene with the same message and pace, but in just 30 seconds, and again in 15 seconds. This process forces students to edit their dialogue, a lesson in efficient two-way communication.
Medical schools are increasingly adapting improv tools to enhance patient interviewing, simulate difficult conversations, and facilitate learning in medical teams. Improv classes have already been welcomed into other higher-education classrooms. One pharmacy school has introduced improv exercises in addition to SP encounters to help students polish communication skills such as listening, observing, and responding. Business schools, too, are using improv to refine students’ ability to collaborate and think on their feet, whether in important client conversations or formal presentations.
If the ultimate goal of this type of communication training is to advance patient care, early adopters of medical improv are poised to see good results. Research has shown that such training can enhance physician-patient communication, and thus improve diagnostic accuracy, patients’ adherence to treatment, and overall patient satisfaction. Furthermore, improved communication with patients can reduce physicians’ job-related stress, burnout, and litigation risk.
The goal of medical improv, of course, hasn’t been to train medical professionals to be performers or to be funny with patients—at least not yet. Still, improv’s fundamental principles—honesty and spontaneity, to name two—can naturally produce humor. And, as one improv-trained physician has pointed out, “there is no shortage of literature on the role of humor in healing.”
That I went “off-script” that early morning in the ER wasn’t by chance. From the moment I met that patient in chronic pain, I sought to understand what he wanted and didn’t want—another visit to the hospital and still no relief. I wasn’t only recording his answers, but also his emotions, expressions, and mannerisms. With all this in mind, I spoke extempore and was rewarded with a smile and a willingness to proceed. Our conversation instantly went from combative to collaborative.
Improvisation may not be without risk, but interpersonal skills cannot be summed up by a formula. Medical educators are starting to adopt novel techniques aimed at teaching students how to approach situations and people, rather than what specifically to say or do. A new priority is arising—to inject the person back into interpersonal—whether at 2 a.m. in the ER, or in daily life.
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