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.