By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Yes, and…”

– A fundamental tenet of improvisation: “Yes” means to accept or affirm what is offered to you by others; “and” means to contribute something new that builds upon that offer.

 

Busy primary care clinicians talk and listen to patients for many hours a day.

Over the years, we learn how to efficiently gather the information we need to make a diagnosis, use language to convey this to the patient along with a suggested treatment plan, all while showing professionalism and empathy, and adapting our communication based on the verbal and non-verbal cues we pick up from our patients.

On our own, human beings who gain skill and proficiency in an activity find a comfortable pattern that works pretty well, and then we lock in habits related to that activity, looking for growth and challenge in other areas (or maybe not). Think about your proficiency with a second language, or with driving, or with your favorite weekend sport.

Continuing to hone any skill requires a desire to improve, a way of evaluating our current performance against a higher standard, and a willingness to test out new methods. This doesn’t need to be an all-consuming activity, even a few minutes or a few hours can make new habits that make clinical communication better. We only must be humble enough to realize that further improvement is always possible and desirable, no matter how strong our communication is to begin with.

If you are in that frame of mind, take a moment to pause and think about a different way to think about clinician communication.

It builds on an understanding of the role of the mirror neuron system as the root of human empathy, covered in 2022. In 1963, long before the mirror neuron system was first described, theatre teacher Viola Spolin summarized her life’s work in the influential book: Improvisation for the Theater. In it, she describes a series of exercises for aspiring actors to help them gain skill in improvisation (commonly shortened to just “Improv”), where actors instantaneously absorb the mood, power structure, intent of other actors and respond quickly and appropriately. This use of the term Improv is more expansive than Improv Comedy, one application that is commercially popular (The Second City was founded in 1959 by Viola Spolin’s son, Paul Sills).

Decades later, in his third book, If I Understood You, Would I Have This Look on My Face?, Actor Alan Alda made the connection between improvisation and the mirror neuron system. Alda promotes the use of Viola Spolin’s exercises as a way for humans in all fields, from Engineering to Medicine to Economics and the Humanities to deeply listen and understand those we interact with, promoting deeper, more bilateral relationships as we become better communicators. Think of Improv exercises as training to hone the capability of our mirror neuron systems.

A description of one of the theater games will illustrate. In this activity, presciently called “Mirror,” two students face each other standing or sitting. First, one student is the “initiator” and the other is the “reflector.” The initiator makes movements and the reflector attempts to be a mirror, making the same motions as the initiator as close to being a mirror as they can. The “initiator” bears some responsibility for making the movements slow enough and smooth enough to make it easier for the “reflector” to match. After they gain proficiency in this, they switch roles, perhaps going back and forth a few times so they become more and more attuned to what movements and speeds each other uses. Then comes the Ouija-board moment, when the students are both “initiators” AND “reflectors” at the same time. Their mirror neuron systems are linked and result is amazing to watch.

In the last decade, several studies of health professions students suggests that a curriculum adapted from the traditional theater training can improve communications skills. A three year study at the University of Michigan Medical School used trainers from the Alan Alda Center for Communicating Science to train all students at the beginning of their third year, with a 2.5 hour Improv-based curriculum, using exercises specifically chosen for applicability to patient-clinician interactions.

One improvisation exercise selected for the training is called “The Rant.” Working in pairs, students take turns ranting for two minutes each about a subject of their choice, and then their rants are translated by the listening students to focus on the underlying values and needs of the ranter.

University of Michigan medical students reported substantial increases in insights regarding their role as a physician, ability to demonstrate effective communication, and teamwork. Most students reported applying the skills they learned to their clinical interactions with patients.

An Empathy and Clarity Rating Scale was developed and validated by four medical schools in the Mid-west and Eastern United States, which showed that a 6-hour Improv training for first year medical students (named with a new term: Medical Improv) made medical communication more empathic and clear. A news article from the American Association of Medical Colleges describes some of the exercises: “talking to a banana, muttering gibberish, and tossing balls at colleagues” summarizing, “Medical Improv transforms goofy theater games into serious skills like empathy, teamwork, and super-quick thinking.”

These theater exercises are meant to be experienced with other people. Local actors may be available to do in-person trainings, and on-line trainings are a low-cost option for individuals and those further away from cities. Each summer (except during the depths of COVID in 2020 and 2021), Northwestern University hosts a 5 day train-the-trainer workshop for Medical Improv. The next one is scheduled for July 20 through July 24.

Formal studies of the effect of Improv training in primary care residencies and for practicing physicians have not yet been published. However, many existing trainings in communication skills are more intellectual, not improving the actual default neural pathways our brains use. For example, many articles on medical communication focuses on using acronyms to remember how to organize communication content. For example, see this article for a summary of SBAR, the GREAT technique, the LAURS technique, the VALUE framework, and the SPIKES technique.

The changes brought about through the COVID pandemic and by the rise of the smart phone are associated with some major changes in how we communicate empathy and understanding with each other. Offering practicing clinicians training in Medical Improv offers a fun and possibly more effective path towards better communication skills.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Focused Action Beats Brilliance”

– Mark Sanborn, U.S. Author

Coming out of the COVID pandemic, the shortage of primary care and specialty clinicians that has been building over the prior 2 decades has become noticeably more acute.  Early retirements, some deaths and disabilities related to COVID contributed to this, as well as a changing expectation of a better work-life balance which means that the average clinician coming out of training is working less hours per week and expects less-intense on-call responsibilities.  Graduate Medical Education training slots funded by Medicare have been stagnant since the late 1990s, so the supply is getting progressively constrained relative to a growing population, and the average age of physicians is higher than ever as a result.

For many specialists, the most common payer is Medicare, so the stagnant Medicare physician reimbursement rates of the past 25 years (actually a 26% decline when adjusted for inflation) have led to a trend of less specialists in private practice, and more working for medical groups or hospitals.  In rural areas, where there are less groups and hospital employment options, some specialties have been especially impacted.  When the number of specialists drops in a community, the remaining specialists end up taking more call for ED and hospital consultation, making their practice more exhausting and causing a feedback loop of additional retirements.

In the past decade, some factors have alleviated the specialist shortages somewhat, but they do not resolve the underlying issues.

1. Wider use of video telemedicine
2. Primary care clinician using eConsult services to avoid referrals or make the referrals more streamlined.
3. Primary Care Clinicians use UpToDate and other resources to care for their patients without a referral or make referrals more targeted and efficient.
4. Some specialist physicians have hired Nurse Practitioners or Physician Assistants to be Specialist Extenders for initial consultations and ongoing care.
5. Artificial Intelligence-assisted transcription services make documentation and communication more efficient when deployed by specialists.
6. Changing documentation requirements in 2022 has alleviated the burden of inefficient, low-quality clinical documentation.
7. Partnership’s Transportation Benefit allows access to specialists who are further away, when no specialists are available locally.
8. Some tribal health centers, rural health centers and tribal health centers have begun contracting with specialists directly.

What can primary care clinicians do to help?

1. Good workups before referral. Primary care clinicians, especially the growing number of primary care Nurse Practitioners and Physician Assistants, can alleviate specialty demand further by developing systems to ensure that all referrals are warranted and well worked up.  Reserving specialty referral for patients that cannot be cared for by primary care clinicians frees up specialty visits for those patients who need to see specialists.  Send over good documentation with the referral to make the specialist’s workup more efficient.
2. Use telemedicine where possible. Sign up for, use, and embrace Partnership’s specialty telemedicine program.
3. Target specialty referral to the specialist most appropriate to the patient’s needs. Don’t send many referrals to several specialists for the same patient, and clog up the referral system.
4. Have conversations with impacted specialists and their specialist coordinators in your community. These help set expectations and prioritization, as well as standard procedures.  This makes the referral process more efficient for everyone: primary care, specialists, and patients.   Partnership hosts “referral roundtables” in each community: be sure to send your referral staff to these events.

What policy interventions are needed?

1. Medicare Rates: First and foremost, having the U.S. Congress change the Medicare reimbursement system from automatically generating cuts to physician rates to one that inflation-indexes future rates (H.R. 2474).  Related to this, short-term relief by actually generating Medicare rate increases is also important (H.R. 6683). Physicians should coordinate communication with their elected representatives with the American Medical Association, being sensitive to how legislative staff respond to arguments that paying physicians more is key for specialty access.
2. Graduate Medical Education: A dramatic increase in funded GME slots nationally is needed in specialties with the greatest shortages (gastroenterology, cardiology, rheumatology, endocrinology, ENT, neurology) as well as for primary care (H.R. 2389 and S. 1302).
3. Ballot Initiative in California to Lock in MCO Tax link to Medi-Cal Rates. While DHCS plans to increase specialist rates for Medi-Cal starting in 2025, a planned ballot initiative would lock these into place for the future.

What more can be done?

Although there is a broad shortage of specialists, the shortage is more acute for some specialties in some communities.  In these cases, the local hospital may be willing to subsidize recruitment to ensure hospital coverage of the specialist.  A local Health Center may be willing to bring in a specialist under their umbrella.  Partnership is working to track the shortages in each geographic area and to work with community partners to focus energy on these.  Please reach out to your local Partnership regional leadership if you want to help with this effort.