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I Feel Witty, Oh So Witty

I Feel Witty, Oh So Witty Improvisational comedy—“improv”—is a form of theater, typically performed by two or more actors, in which the story, including setting, plot, characters, and dialogue, are made up in the moment, often following a suggestion from the audience.1 Improv is, by definition, extemporaneous or off-the-cuff. In contrast, standup comedy consists of scripted, often carefully rehearsed performances by an individual actor. One of the first exercises in my first improv class was called “What Are You Doing?” This was a two-person exercise in which one partner acts out a behavior or activity—riding a bicycle, perhaps—followed by the other asking, “What are you doing?” The first partner then says something like “Walking in space,” whereupon the second partner must act out walking in space. The sequence then continues. When it was my turn to participate, I asked my partner, as directed, “What are you doing?” At this juncture, as any police detective will tell you, the accounts of participants and eyewitnesses diverged. I was absolutely certain that my partner had said “Beating the cat.” This seemed a rather strange and hostile response, but I wanted to be a good student so I proceeded, with great vigor, to exclaim “Bad kitty!” and act out various abusive behaviors to an imaginary cat. Unfortunately, when subsequently I had the good sense to check with my partner to see if she had indeed said what I thought she had said, she gave me a pitying look and replied that her exact words had been “Feeding the cat.” Perhaps that is why, in our very first class together, my classmates looked at me—a psychiatrist—with utter alarm and horror as I castigated an entirely innocent imaginary feline. Sadly, “Beating the cat” turned out to be one of the most authentic and convincing performances in my improv career. Oddly enough I, like others,2-5 have found such improv experiences to be remarkably useful in the development of physician competence, professionalism, and humanism. Indeed, I suggest that improv is a uniquely powerful, instructive, and—dare I say it—greatly enjoyable tool in the service of physician development. What do improvisational comedy and the work of a physician have in common? Of course, despite many losses, traumas, and sadness, there is still much humor in medical education and practice, and there is no shortage of literature on the role of humor in healing.6-9 The relationship between improv training and the practice of medicine, however, is something different. Perhaps surprisingly, the attitudes and skills that one must master in improv reflect many of the attitudes and skills of the empathic and successful physician. The essence of improvisational comedy is the ability to collaborate with others in order to bring to fruition a shared vision. Successful improv is a work of co-creation in which each member of the comedy team perceives and responds to the attitudes, thoughts, feelings, and behaviors (both verbal and nonverbal) of his or her fellow actors. Requisite skills include attentive listening, paying attention to detail, and remembering and synthesizing what has come before. In addition, it entails emotional intelligence and empathy—the ability to understand what another is feeling or expressing—followed by an appropriate and congruent response that maintains the narrative. Improv teaches “Yes, and … ” Rather than simply saying no to the ideas of others or denying their perspective, an improv teammate learns to accept what others have offered and build on it. Good improv actors take pleasure in the success of the team, rather than self-aggrandizement; indeed, improv cannot be successful unless the whole team succeeds. The analogy with the practice of medicine is compelling. The skilled physician strives to develop a shared vision (eg, the “treatment plan”), which is created and fulfilled in partnership with the patient, family, and treatment team. All stakeholders are important in this collaboration, and each needs to listen to and learn from the others. Emotional intelligence and empathic attunement—the latter a term from the psychological literature—are critical components in a successful patient-physician interaction as well as in interactions with family and treatment team members. Understanding not just what patients and families say but also what they feel (which is often not communicated explicitly)—their hopes, fears, confusion, anxiety—is critical to a physician’s successful care of a patient. And in medicine there should be no individual winners or losers; either all the relevant parties—patient, family, and treatment team—succeed or the entire enterprise fails, typically to the detriment of the patient and family. Improv and much of medical practice come without a script; they require the ability to think on one’s feet, to improvise, to pay close attention as well as to be flexibly responsive to the situation at hand. Imagination and creativity are essential to the improvisational comedian but also to the physician who must go beyond the rigid application of what he or she understands intellectually to creative application of that knowledge in the service of an individual patient. Physicians must be able to understand and relate to their patients, and this requires much more than a sophisticated, intellectual appreciation of human disease. Understanding the experience of illness requires insight into a patient’s thoughts and feelings, wishes and dreams, anxieties and fears, and much more. Physicians in general, by temperament and training, are typically verbal, cognitive, and left-brained, but much of the important communication in life and in the examination room is nonverbal, emotional, and right-brained. How can physicians or physicians-in-training be helped to become more attentive to nonverbal communications? An improv exercise: gibberish! In this exercise, participants are allowed to speak only nonsense syllables. In order to make sense of a scene, one must attend to, and correctly interpret, others’ facial expressions, body language, and tonal inflection rather than rely on intelligible words and sentences. Physicians too must be sensitive to such nonverbal cues, not only with patients who literally cannot communicate by words (eg, patients with expressive aphasia after stroke or preverbal children) but also with those who have limited ability or willingness to express themselves verbally. “Gibberish” forces one to pay attention to nonverbal communication, to look beyond words for other clues to what someone is thinking and feeling. Just as reading a patient’s emotion is important in medical practice, so too is the physician’s expression of emotion. Although an overgeneralization, it is nonetheless true that physicians as a group are relatively emotionally controlled, often resulting, again, from a combination of natural temperament and perceived expectations for professional behavior. In order to succeed at improv and in the practice of medicine, an individual must learn how to verbally and nonverbally express emotions of great variety and intensity in ways that are contextually appropriate and easily understood by others. Indeed, how important is nonverbal communication in the practice of medicine! Sitting down or standing up when speaking with a patient, a direct gaze or downcast eyes, a touch on the arm, a smile—these are crucial components of the skilled physician’s communication toolbox. While in actual medical practice the physician should not strive to “act” rather than truly feel or relate to others, improv training gives one permission to be vulnerable and to express true feelings both verbally and nonverbally. The comedy scene may be imaginary or contrived, but the emotions conveyed are very genuine. So for physicians, improv training is an opportunity to enhance typically underdeveloped right-brain emotional life, to feel, read, interpret, and express emotions. Empathy—the ability to feel what another is feeling—as well as the ability to communicate empathy are the bedrock of improv and acting in general, and they should be bedrock attributes of every physician. The skilled physician, just like the improv actor, must be comfortable with ambiguity and uncertainty. In medicine (with patients, family members, or health care team staff), as in improv (with one’s fellow actors), one does not know beforehand how the scene will play out. An improv sketch often has to “declare itself” over time, just as might be the case with an illness that initially presents with nonspecific symptoms. Flexibility, assessing and responding in context, vulnerability, and risk-taking are integral parts of the process in improv, in the humanistic practice of medicine, and in life in general. Sometimes an improvisational comedy sketch fails; sometimes it fails miserably. The ability to accept such failures as well as to examine the causes and learn from them, and the courage and resilience to go at it yet again, are critical aspects of improv. The same is true for the physician who must accept setbacks, disappointments, and defeat in his or her work, yet persevere nonetheless. Like medicine, improv is, or should be, a lesson in courage, risk-taking, resilience, humility, and grace or poise under fire. Finally, a different take on the utility of improv training for physicians: acting with imaginary objects. Easier than it sounds, working with imaginary objects forces one to pay attention to detail. For example, if you ask someone to pretend to hold a fork, you will often note that their fingers and thumb are not correctly positioned. Similarly, when improv beginners pick up an imaginary glass of water, they often forget to put it down before moving on to another action, theoretically leaving the glass suspended in mid-air. For the physician, such improv lessons offer an experience like that of a patient who, having had a stroke as one example, can no longer take for granted movements that were once unconscious, precise, and effective. To get a better sense of this, try this exercise: pretend to tie a shoelace without using an actual shoe or laces. In so doing, there is an important lesson for the physician in understanding and empathy for those who are physically or neurologically impaired. So physicians have a lot to learn from improv training. Teamwork, emotional intelligence (including both receptive and expressive empathy), attentive and detailed listening, making connections, creativity, courage and risk-taking, handling setbacks and embarrassment, grace under fire—in short, being human! As a profession, and especially in speaking with our medical school applicants, we regularly extol the virtues of a well-rounded life. Improv training offers an opportunity to practice important skills of physicianship within the context of a challenging, but very enjoyable, nonmedical setting. My suggestion to physicians: go ahead and beat, er, feed the cat. Try it; you just might like it; and you might be a better doctor as a result. Section Editor: Roxanne K. Young, Associate Senior Editor. Back to top Article Information Correction: This article was corrected online for a typographical error in the second paragraph on February 8, 2016. Corresponding Author: Donald A. Misch, MD (donald.misch@colorado.edu). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported. References 1. Halpern C, Close D, Johnson K. Truth in Comedy: The Manual of Improvisation. Colorado Springs, CO: Meriwether Publishing; 1994. 2. Watson K. Perspective: Serious play: teaching medical skills with improvisational theater techniques. Acad Med. 2011;86(10):1260-1265.PubMedGoogle ScholarCrossref 3. Hoffman A, Utley B, Ciccarone D. Improving medical student communication skills through improvisational theatre. Med Educ. 2008;42(5):537-538.PubMedGoogle ScholarCrossref 4. Shochet R, King J, Levine R, Clever S, Wright S. “Thinking on my feet”: an improvisation course to enhance students’ confidence and responsiveness in the medical interview. Educ Prim Care. 2013;24(2):119-124.PubMedGoogle ScholarCrossref 5. Stokes TA, Watson KL, Boss RD. Teaching antenatal counseling skills to neonatal providers. Semin Perinatol. 2014;38(1):47-51.PubMedGoogle ScholarCrossref 6. Robinson VM. Humor and the Health Professions: The Therapeutic Use of Humor in Health Care. 2nd ed. Thorofare, NJ: Slack Inc; 1990. 7. Wender RC. Humor in medicine. Prim Care. 1996;23(1):141-154.PubMedGoogle ScholarCrossref 8. Bennett HJ. Humor in medicine. South Med J. 2003;96(12):1257-1261.PubMedGoogle ScholarCrossref 9. Mora-Ripoll R. The therapeutic value of laughter in medicine. Altern Ther Health Med. 2010;16(6):56-64.PubMedGoogle Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

I Feel Witty, Oh So Witty

Misch, Donald A.
JAMA , Volume 315 (4) – Jan 26, 2016
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Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2015.16758
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Abstract

Improvisational comedy—“improv”—is a form of theater, typically performed by two or more actors, in which the story, including setting, plot, characters, and dialogue, are made up in the moment, often following a suggestion from the audience.1 Improv is, by definition, extemporaneous or off-the-cuff. In contrast, standup comedy consists of scripted, often carefully rehearsed performances by an individual actor. One of the first exercises in my first improv class was called “What Are You Doing?” This was a two-person exercise in which one partner acts out a behavior or activity—riding a bicycle, perhaps—followed by the other asking, “What are you doing?” The first partner then says something like “Walking in space,” whereupon the second partner must act out walking in space. The sequence then continues. When it was my turn to participate, I asked my partner, as directed, “What are you doing?” At this juncture, as any police detective will tell you, the accounts of participants and eyewitnesses diverged. I was absolutely certain that my partner had said “Beating the cat.” This seemed a rather strange and hostile response, but I wanted to be a good student so I proceeded, with great vigor, to exclaim “Bad kitty!” and act out various abusive behaviors to an imaginary cat. Unfortunately, when subsequently I had the good sense to check with my partner to see if she had indeed said what I thought she had said, she gave me a pitying look and replied that her exact words had been “Feeding the cat.” Perhaps that is why, in our very first class together, my classmates looked at me—a psychiatrist—with utter alarm and horror as I castigated an entirely innocent imaginary feline. Sadly, “Beating the cat” turned out to be one of the most authentic and convincing performances in my improv career. Oddly enough I, like others,2-5 have found such improv experiences to be remarkably useful in the development of physician competence, professionalism, and humanism. Indeed, I suggest that improv is a uniquely powerful, instructive, and—dare I say it—greatly enjoyable tool in the service of physician development. What do improvisational comedy and the work of a physician have in common? Of course, despite many losses, traumas, and sadness, there is still much humor in medical education and practice, and there is no shortage of literature on the role of humor in healing.6-9 The relationship between improv training and the practice of medicine, however, is something different. Perhaps surprisingly, the attitudes and skills that one must master in improv reflect many of the attitudes and skills of the empathic and successful physician. The essence of improvisational comedy is the ability to collaborate with others in order to bring to fruition a shared vision. Successful improv is a work of co-creation in which each member of the comedy team perceives and responds to the attitudes, thoughts, feelings, and behaviors (both verbal and nonverbal) of his or her fellow actors. Requisite skills include attentive listening, paying attention to detail, and remembering and synthesizing what has come before. In addition, it entails emotional intelligence and empathy—the ability to understand what another is feeling or expressing—followed by an appropriate and congruent response that maintains the narrative. Improv teaches “Yes, and … ” Rather than simply saying no to the ideas of others or denying their perspective, an improv teammate learns to accept what others have offered and build on it. Good improv actors take pleasure in the success of the team, rather than self-aggrandizement; indeed, improv cannot be successful unless the whole team succeeds. The analogy with the practice of medicine is compelling. The skilled physician strives to develop a shared vision (eg, the “treatment plan”), which is created and fulfilled in partnership with the patient, family, and treatment team. All stakeholders are important in this collaboration, and each needs to listen to and learn from the others. Emotional intelligence and empathic attunement—the latter a term from the psychological literature—are critical components in a successful patient-physician interaction as well as in interactions with family and treatment team members. Understanding not just what patients and families say but also what they feel (which is often not communicated explicitly)—their hopes, fears, confusion, anxiety—is critical to a physician’s successful care of a patient. And in medicine there should be no individual winners or losers; either all the relevant parties—patient, family, and treatment team—succeed or the entire enterprise fails, typically to the detriment of the patient and family. Improv and much of medical practice come without a script; they require the ability to think on one’s feet, to improvise, to pay close attention as well as to be flexibly responsive to the situation at hand. Imagination and creativity are essential to the improvisational comedian but also to the physician who must go beyond the rigid application of what he or she understands intellectually to creative application of that knowledge in the service of an individual patient. Physicians must be able to understand and relate to their patients, and this requires much more than a sophisticated, intellectual appreciation of human disease. Understanding the experience of illness requires insight into a patient’s thoughts and feelings, wishes and dreams, anxieties and fears, and much more. Physicians in general, by temperament and training, are typically verbal, cognitive, and left-brained, but much of the important communication in life and in the examination room is nonverbal, emotional, and right-brained. How can physicians or physicians-in-training be helped to become more attentive to nonverbal communications? An improv exercise: gibberish! In this exercise, participants are allowed to speak only nonsense syllables. In order to make sense of a scene, one must attend to, and correctly interpret, others’ facial expressions, body language, and tonal inflection rather than rely on intelligible words and sentences. Physicians too must be sensitive to such nonverbal cues, not only with patients who literally cannot communicate by words (eg, patients with expressive aphasia after stroke or preverbal children) but also with those who have limited ability or willingness to express themselves verbally. “Gibberish” forces one to pay attention to nonverbal communication, to look beyond words for other clues to what someone is thinking and feeling. Just as reading a patient’s emotion is important in medical practice, so too is the physician’s expression of emotion. Although an overgeneralization, it is nonetheless true that physicians as a group are relatively emotionally controlled, often resulting, again, from a combination of natural temperament and perceived expectations for professional behavior. In order to succeed at improv and in the practice of medicine, an individual must learn how to verbally and nonverbally express emotions of great variety and intensity in ways that are contextually appropriate and easily understood by others. Indeed, how important is nonverbal communication in the practice of medicine! Sitting down or standing up when speaking with a patient, a direct gaze or downcast eyes, a touch on the arm, a smile—these are crucial components of the skilled physician’s communication toolbox. While in actual medical practice the physician should not strive to “act” rather than truly feel or relate to others, improv training gives one permission to be vulnerable and to express true feelings both verbally and nonverbally. The comedy scene may be imaginary or contrived, but the emotions conveyed are very genuine. So for physicians, improv training is an opportunity to enhance typically underdeveloped right-brain emotional life, to feel, read, interpret, and express emotions. Empathy—the ability to feel what another is feeling—as well as the ability to communicate empathy are the bedrock of improv and acting in general, and they should be bedrock attributes of every physician. The skilled physician, just like the improv actor, must be comfortable with ambiguity and uncertainty. In medicine (with patients, family members, or health care team staff), as in improv (with one’s fellow actors), one does not know beforehand how the scene will play out. An improv sketch often has to “declare itself” over time, just as might be the case with an illness that initially presents with nonspecific symptoms. Flexibility, assessing and responding in context, vulnerability, and risk-taking are integral parts of the process in improv, in the humanistic practice of medicine, and in life in general. Sometimes an improvisational comedy sketch fails; sometimes it fails miserably. The ability to accept such failures as well as to examine the causes and learn from them, and the courage and resilience to go at it yet again, are critical aspects of improv. The same is true for the physician who must accept setbacks, disappointments, and defeat in his or her work, yet persevere nonetheless. Like medicine, improv is, or should be, a lesson in courage, risk-taking, resilience, humility, and grace or poise under fire. Finally, a different take on the utility of improv training for physicians: acting with imaginary objects. Easier than it sounds, working with imaginary objects forces one to pay attention to detail. For example, if you ask someone to pretend to hold a fork, you will often note that their fingers and thumb are not correctly positioned. Similarly, when improv beginners pick up an imaginary glass of water, they often forget to put it down before moving on to another action, theoretically leaving the glass suspended in mid-air. For the physician, such improv lessons offer an experience like that of a patient who, having had a stroke as one example, can no longer take for granted movements that were once unconscious, precise, and effective. To get a better sense of this, try this exercise: pretend to tie a shoelace without using an actual shoe or laces. In so doing, there is an important lesson for the physician in understanding and empathy for those who are physically or neurologically impaired. So physicians have a lot to learn from improv training. Teamwork, emotional intelligence (including both receptive and expressive empathy), attentive and detailed listening, making connections, creativity, courage and risk-taking, handling setbacks and embarrassment, grace under fire—in short, being human! As a profession, and especially in speaking with our medical school applicants, we regularly extol the virtues of a well-rounded life. Improv training offers an opportunity to practice important skills of physicianship within the context of a challenging, but very enjoyable, nonmedical setting. My suggestion to physicians: go ahead and beat, er, feed the cat. Try it; you just might like it; and you might be a better doctor as a result. Section Editor: Roxanne K. Young, Associate Senior Editor. Back to top Article Information Correction: This article was corrected online for a typographical error in the second paragraph on February 8, 2016. Corresponding Author: Donald A. Misch, MD (donald.misch@colorado.edu). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported. References 1. Halpern C, Close D, Johnson K. Truth in Comedy: The Manual of Improvisation. Colorado Springs, CO: Meriwether Publishing; 1994. 2. Watson K. Perspective: Serious play: teaching medical skills with improvisational theater techniques. Acad Med. 2011;86(10):1260-1265.PubMedGoogle ScholarCrossref 3. Hoffman A, Utley B, Ciccarone D. Improving medical student communication skills through improvisational theatre. Med Educ. 2008;42(5):537-538.PubMedGoogle ScholarCrossref 4. Shochet R, King J, Levine R, Clever S, Wright S. “Thinking on my feet”: an improvisation course to enhance students’ confidence and responsiveness in the medical interview. Educ Prim Care. 2013;24(2):119-124.PubMedGoogle ScholarCrossref 5. Stokes TA, Watson KL, Boss RD. Teaching antenatal counseling skills to neonatal providers. Semin Perinatol. 2014;38(1):47-51.PubMedGoogle ScholarCrossref 6. Robinson VM. Humor and the Health Professions: The Therapeutic Use of Humor in Health Care. 2nd ed. Thorofare, NJ: Slack Inc; 1990. 7. Wender RC. Humor in medicine. Prim Care. 1996;23(1):141-154.PubMedGoogle ScholarCrossref 8. Bennett HJ. Humor in medicine. South Med J. 2003;96(12):1257-1261.PubMedGoogle ScholarCrossref 9. Mora-Ripoll R. The therapeutic value of laughter in medicine. Altern Ther Health Med. 2010;16(6):56-64.PubMedGoogle Scholar

Journal

JAMA – American Medical Association

Published: Jan 26, 2016

Keywords: cerebrovascular accident,ischemic stroke,exercise,emotions,empathy,intelligence,nonverbal communication,risk-taking behavior,vision,attitude,creativity,temperament,fear,anxiety

There are no references for this article.