How Medical Improv Can Improve Physician/Patient Communication

Podcast Transcript

Dr. James K. Stoller:

Hello, and welcome to MedEd Thread, a Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise. 

Dr. Tony Tizzano:

Hello, welcome to today's episode of MedEd Thread, an Educational Institute podcast exploring the role of improv as an educational tool. I'm your host, Dr. Tony Tizzano, Director of Student Lerner and Health here at Cleveland Clinic in Cleveland, Ohio. Today, I'm very pleased to have Dr. David Harris, a palliative and supportive care physician, associate program director in the Palliative Medicine Fellowship and associate director of communication skills at the Cleveland Clinic Lerner College of Medicine. Welcome, David. 

Dr. David Harris:

Hi, nice to be here. 

Dr. Tony Tizzano:

Pleased to have you. Also with us today is Dr. Katie Neuendorf, also with the Department of Palliative and Supportive Care. Katie, welcome. 

Dr. Katie Neuendorf:

Thanks for having me. 

Dr. Tony Tizzano:

And finally, I have Dr. Nivaas Thanoo, Chief Resident in Internal Medicine. Nivaas, welcome to the podcast. 

Dr. Nivaas Thanoo:

Pleasure to be here. 

Dr. Tony Tizzano:

To get started, if each of you could tell us a little bit about yourselves, what brought you to Cleveland Clinic, or your current trajectory thus far, and your role here at the clinic. David, we can start with you. 

Dr. David Harris:

Well, I came to the clinic to do a palliative medicine fellowship and actually improv is part of the story because on my interview day, I met Katie Neuendorf, and she did some improve exercises, and said that this would be part of the training if I came here. And it really stood out to me, and I thought, "I wanna learn more about this." So that's how I got here, and then I've stayed here. This is my sixth year here, and it's just been wonderful.

Dr. Tony Tizzano:

Excellent. Katie? 

Dr. Katie Neuendorf:

I joined Cleveland Clinic in 2010 and joined really because I wanted to make a difference in the palliative care department. I saw that this was a department that was very symptom management heavy and communication skills were not as big of a focus, and I wanted to be able to bring that. In my career here, I was able to direct the Center for Excellence in Healthcare Communication, so that was a large part of my career. And in doing that, we brought improv into some of the training exercises and that was a game changer. It was a lot of fun. So that's a part of my career journey. I've left the Office of Patient Experience at this point in time, and I'm back doing palliative care full-time and enjoying all of the teaching that that offers. 

Dr. Tony Tizzano:

Perfect, and we're just so happy to have you. And finally, but certainly not least, Nivaas. 

Dr. Nivaas Thanoo:

Yeah, so I joined the clinic initially as a resident. [inaudible] here in 2020, which I can't think of anything else big that was happening that here and kinda through my rotations worked in palliative medicine with both Dave and Katie where we realized that we had a little bit of a joint interest in medical improv, which I had first explored during medical school and was introduced to it then. And since then, we've had a chance to really kinda work together on some different educational opportunities surrounding that. 

Dr. Tony Tizzano:

Excellent. So in today's segment, as you've heard, we're going to explore how medical improv transforms lighthearted theater games into serious skills like empathy, teamwork and super quick thinking. And when we were first being introduced to this topic, and you were educating me, I must say it took me a little bit to get a hold of it. But now that I understand it, I'm just amazed at the impact it can have. So Katie, to get started, can you frame h- how these principles of improvisational theater are being employed to hone skills needed in medical communication? 

Dr. Katie Neuendorf:

Absolutely. If you think about what improvisation is, a lot of people know it is comedy, but it doesn't have to be funny. In improvisational theater, you have actors. They have an idea of what their role is, but there's no script. So they don't necessarily know what they're gonna say. They don't know what the other person is gonna say. You go into the scene, and you build it together, and I don't know anything that describes a medical encounter better than that. I have an idea of what my role is. I have an idea of my patient's role, but what we're gonna build together, what each of us is gonna say is new, and fresh, and different every time. 

For improvisation to work well, you have to listen deeply. You have to be in the present moment. You have to be able to connect with the person, and you take everything that they say as a gift or as an offering to you, and you try to find that commonality. So a lot of people know of yes/and as one of the core tenets of improv because whatever you say, I'm going to find a way to agree with it. And so, that if we had every physician out there deeply listening to their patients in the present moment, accepting everything that the patient said as a gift, I think our communication with patients would be a lot different, and all of that leads to a place of empathy as well. 

Dr. Tony Tizzano:

Yeah, I can't agree with you more. And the piece i took away from our initial conversation was yes/and. And I've put that into practice, and there is no two ways about it. It engenders further conversation and no one gets standoffish. You're agreeing. Even if you're not sure you agree, you wanna hear more, and you're not gonna understand what you want until you get that other piece. So for all of you, what was the catalyst for your interest in this? David, did you see a lacking and then said, "Hey, I need to do something with this?" What was the impetus for all of this? 

Dr. David Harris:

Well, I've always been very interested in how we talk to patients. I think when I look back early in my training at the most challenging cases, they all had to do with the communication element and trying to get on the same page. So I've been interested, how do we do this well? How do we teach others to do it well? And one of the things I notice is that when we teach communication, there has always been a focus on the specific phrase to use or the specific thing to say. And for learners, that can end up feeling a little disingenuous or even a little robotic. And it feels like medical improv is the antidote or the other end of that where not only are you trying to learn more effective language with your normal communication skills training, you're also learning how to put this together and how to be in the moment like Katie was saying earlier, and that felt really important as an additional element to bring in. 

Dr. Tony Tizzano:

Okay, I get that. Nivaas, what would you say to this? 

Dr. Nivaas Thanoo:

My initial experience with it came actually from my time in medical school at Northwestern with Katie Watson who is kind of one of the pioneers of medical improv and improv as a tool in medical education. I had done an elective with her across 10 weeks and that was where I was first introduced to it. And funny enough, it was before I had actually had more clinical experience in medicine because it was before our clinical rotations at the time. And I felt that having had that experience with medical improv, then going into my clinical rotations really opened up a world of possibilities in every encounter with a patient in terms of communication. 

Dr. Tony Tizzano:

Okay. Do you think that the EMR, the electronic medical record also perhaps takes us a step back because we have a tendency to want to click through the next part of that smart set and the next part, but what we are bringing is something that's going to be new and fresh, as you mentioned Katie, each time? Do you think there's an element of that that makes it even more necessary given the electronic medical record? 

Dr. Nivaas Thanoo:

I think so. The electronic medical record does a fantastic job at what it's supposed to do, but at the same time it almost puts, you know, guard rails on a conversation with the goal of, I need to get to this next part of the smart phrase, and complete my note, and make sure it's the appropriate things for billing. And that kinda limits the possibilities of what a conversation could entail and what you could actually garner from a patient in those communication aspects. 

Dr. Tony Tizzano:

Yeah, I, I can certainly agree with that. So David, the interest in medical improv had certainly grown in recent years as medical schools and teaching hospitals increasingly value the skills it teaches. Is there evidence to show that improv training increases not only the communication skills but can also improv patient outcomes? 

Dr. David Harris:

Well, there's been a lot of studies on improv and it's very challenging, I think, to study something in medical education and in particularly, something like communication skills because there's so many variables involved. When I look at the literature, there were quite a few studies in the format of medical improv curriculum and then measuring the learner's self-report, so what... Did they find it valuable? Would they recommend it to another person? Was it relevant for patient care? And those studies were strongly positive. There were some studies that looked a little further. So there were some studies that looked at after this medical improv curriculum, what happened to their scores on an empathy scale? And those studies were also positive. It looks like after you take some medical improv, it's easier to feel empathy. You feel more of it. How long does that last? It's not clear, but at, at least immediately afterwards. 

And then there was one study, a randomized study by Dr. Grossman, who looked at half of the students getting medical improv and half not, and then going in to talk to standardized patients. And the standardized patients rated them as listening more carefully, explaining information more clearly, and being globally more skilled. Is there something that's looked at real patient outcomes? Now that I've seen. We do know that physicians who show more empathy have better patient outcomes in many different areas, even things like patients having improved symptoms after a more empathic visit. So there's a wide and deep field of literature looking at the impact of empathy, but there isn't something that really connects the different steps there. 

Dr. Tony Tizzano:

Yeah. Well, I can't agree more with that. Katie, you're nodding your head. Is there something you'd like to add to that? 

Dr. Katie Neuendorf:

I think the piece that I wanna add is that there's lots of different medical education pieces that I think are vitally important to the patient experience and what we need to do every day, and not all of them are fun. (laughs) So what I love about improv is that not only do we have studies that show that empathy can be increased, that there are standardized patients who can notice a difference in the communication skills, but at the same time it's fun to learn it. 

Dr. Tony Tizzano:

Yeah, absolutely. And of course, we're talking to three, you know, palliative and supportive care physicians who are already good at this. You know, having seen you in action, you know, in my lifetime, I can certainly say that I thought your communication skills were superb, and so you're seeing even with your career backgrounds that you have something to add. Nivaas, I understand that you've integrated medical improv into the internal medicine training program. How's it been received? 

Dr. Nivaas Thanoo:

Yeah, so we had an opportunity to put this into one aspect of our internal medicine curriculum here, what's called Contemporary Topics in Medicine, kinda focusing on some of the things outside of medical knowledge that really make a well-rounded physician. And I had an opportunity to partner with both Dave and Katie on both making the curriculum and delivering the curriculum to the residents. And we did a quick, you know, pre/post survey in terms of, how did you feel your communication skills were before this, after this, and do you feel like this is something that's readily applicable to the bedside? And overwhelmingly, the residents felt that it was applicable to the bedside, that they were able to understand how it could be applied to empathic situations with patients, and then they also felt that they were more energized after the actual activity. 

Dr. Tony Tizzano:

Yeah, I have to think that at the point when I was a medical student, knowing what to say with a patient was not always easy. You know, you were learning. You know, you were hoping you were doing a good job. You were j- usually sent into the room de novo to get a history and that you'd present later. And just being able to say yes/and and to have a, a crutch almost to elicit further conversation, sounds like that's a, a superbly important tool. 

Dr. Nivaas Thanoo:

Absolutely, and I think... I wanna touch on one aspect of what you said, actually, which was knowing what to say with the patient. And I think it's interesting because a lot of what medical improv is about is actually increased comfort with uncertainty and not knowing what the next part of that conversation is going to hold, but knowing that I'll take whatever is given to me, and I'm gonna roll with it. And I think that's a beautiful part of medical improv too. 

Dr. Tony Tizzano:

Yeah, I... So it's the yes, and tell me more. 

Dr. Nivaas Thanoo:

Absolutely. 

Dr. Tony Tizzano:

You know. You, you can just elicit further and further conversation. So Katie, I also understand that the Association of American Medical Colleges is leading a broader initiative to better integrate the humanities, including improv in a medical education. What might the goals of this initiative be? 

Dr. Katie Neuendorf:

I think there are a lot of goals that I've seen in terms of help for the physician in the moment. And so, what I mean by that is one of the things that I've seen in communication skills is that when a physician feels like they're in an encounter and that they have some control over the outcome of that encounter in terms of what happens and that control can come from the words that come out of their mouth. They leave feeling more empowered. So Dave was saying before that a lot of the challenges that he ran into in his medical training so far were communication related, and I think that's true for a lot of people. 

You're in a conversation with a patient or a family member. It's not going well. There's a tough time, and you're trying to think, how do I get out of this? Too often, I think, we're taught that it's the patient's fault (laughs) in some way, shape or form. Like, well, this patient's difficult. This patient's in denial. This patient, what have you. And there's something to be said if you can say, "Oh, actually, let me try this new skill." I'm in this challenge. Let me try this thing and it becomes a fun exercise rather than something where you can leave the room feeling that you're against your patient instead of in it together. So I think that's a small part.

I think from a humanities standpoint, we just want to make sure that the human aspect of medicine, seeing a person for who they are, realizing that what we see in the church is not their story. You know, there's a lot out there that says, what we end up asking in terms of our checklist of, you know, what's your level of pain? That's not the story of their pain. It's not the story of their illness, and improv can help us get to a place of the story of their illness. And I think the last piece of that, it also keeps us connected to our humanity. There's a piece in my own career where I feel like I got to a part where I felt like I was playing a role. I wasn't being as genuine, but I also felt like I had these parameters around what I was and wasn't allowed to say as a physician, and improv helped me step out of that. So I felt like I got to be m- a more real human being but still in my role and finding a great place with patients, and that over time is just sustaining for a career. 

Dr. Tony Tizzano:

Yeah, these are great points. You know, I feel like I've just gotten to sit under the wisdom tree and got to shake it a little bit. And, you know, I don't-

Dr. Katie Neuendorf:

(laughs) 

Dr. Tony Tizzano:

...think it's limited to just that patient interaction. 

Dr. Katie Neuendorf:

Mm-hmm. 

Dr. Tony Tizzano:

I think that we probably also can apply these same tools to communication with our peers-

Dr. Katie Neuendorf:

Mm-hmm. 

Dr. Tony Tizzano:

...and leadership to try to bring people in and give them a sense of belonging. Do you see anything there for any of you? 

Dr. David Harris:

I definitely see the skills of improv being applicable outside the patient room and even outside the hospital because in the end, we're just people talking to other people. And it doesn't matter whether I'm a doctor talking to a patient, I'm a peer talking to a peer, I'm an employee talking to my boss, it's all the same on some basic level, and that's the level where improv touches. 

Dr. Katie Neuendorf:

Yeah. What I would say to that, Tony, is that some of the examples that you set are where I feel like people have very clear, scripted ideas of who they're supposed to be, and improv helps you step out of that a little bit more. So a leader conversation to somebody that you're leading, sometimes as a leader you feel like, this is exactly who I'm supposed to be, and I feel that, or I've felt that in my career as a physician. This is who I am supposed to be, and I'm gonna play this role, and I'm not gonna step out of this role. But improv lets you bend those edges. 

Dr. Tony Tizzano:

Yeah, very well said. 

Dr. Nivaas Thanoo:

And I would almost argue that it's even more widely applicable than even conversations. It's something that allows you to be more adaptable as a person. It allows you to think outside the box, which I think is something easy to say but not always easy to implement. And so, getting into that improv mindset of saying, "Okay, I'm gonna take this scenario and roll with it or see what comes to me rather than trying to fit a maybe square peg into a round hole." 

Dr. Tony Tizzano:

Yeah, and it gives you time to think about what you might wanna say next or to develop the next idea. You know, I can't help as I think about the humanities and medicine, and history as part of that, I look at, you know, the history of medicine for the last few centuries. You know, 1900s and before, or 1800s and before, it was surgical technique. It was procedures. We didn't have any good medicine. We had no imaging. 20th century was therapeutics and imaging. You know, we had medicines that actually worked. We had X-ray. We had MRI. We had CT scan. And now, I feel, in the 21st century, we're looking at the psychosocial aspects of medicine, you know, patients first, you know, taking the physician, flattening the hierarchy, putting the patient on the pedestal. And all the other considerations that we may not have spent so much time thinking about but now that we have this toolkit already from prior centuries, it's time to polish the delivery. And I think this is a great opportunity. I hope our listeners listen to some of these things and think about it in their own lives because you're right. I think it extends well beyond the hospital. So since we've been engaging our medical students in this, have you seen progress that you can actually gauge, Dave? 

Dr. David Harris:

Well, that's something I'm really interested in, Tony. I'm really interested in how are our learners thinking about their learning? Are they able to, to sort of assess their skills and make changes? And part of that improv mindset that Nivaas was talking about is related to that. So with our fellows, we use medical improv regularly with them and my hope is that over the year they become more comfortable and spend more time in that improv mindset. And we're measuring using some skills we found, their metacognitive skills, metacognitive, meaning their ability to think about their thinking. And we don't have enough data to say, but I think in a few years, we'll be able to track that over time and see after a year of self-reflection, of improv training, what happens to our ability to think about our thinking, to think about our learning, and I'm very interested to see what that shows. 

Dr. Tony Tizzano:

Yeah, that's interesting. I always felt that even with public speaking, when you know your topic well enough that you can think while you're talking, is a threshold. You know, initially, you get out there, and you feel, I have all these factoid I have to communicate. But if you can start to think, and you can look at the audience and see how it's being received, all of a sudden you can tailor this. Do you think that by doing this we can kind of set aside our own agenda and maybe have a better sense of the patient's agenda when they come to a visit for any of you? 

Dr. Katie Neuendorf:

I think that's absolutely true. One of the reasons that improv to Cleveland Clinic more formally is that in the Office of Patient Experience under the leadership of Dr. Toby Cosgrove and Adrienne Boissy, there was a effort for communication skills training here. And we put almost 5,000 people through a communication skills training program, and then there was this piece of, okay, like, any skill unless we keep practicing it, it's gonna be lost. And that's where improv came in because we wanted to find a technique that after watching 5,000 people communicate, we see some of the pitfalls that we make all the time. 

There's pattern recognition of, oh, wow, if I could just show physicians that they're doing this thing, and they're doing this thing in a well-intentioned manner, but it's getting in their own way, that would be a win. And there are probably five, six major patterns that I feel like we fall into all the time. And we were looking for a technique. How do we maintain these skills, sustain these skills in a way that's new because the other thing we know about physicians is that you don't want to learn the something that you've already learned 'cause you feel like you already know it (laughs) even if it is skill-based. And we wanted it to be time-efficient and improv really gave us that vehicle. And so, in doing that, that's a roundabout way of saying that absolutely in these encounters with patients, if we can start paying attention to the pitfalls that we get into unintentionally, avoid them or when we're in them, pivot to something different, we are going to be in an encounter where the patient feels heard more, they feel understood and at the end of the day empowered to take care of themselves. 

Dr. Tony Tizzano:

Yeah. I always feel that we're in kind of a time warp, that we're always under time pressure, and that we have to get through all these pieces. And rather than really listen, we're thinking of the next three things we're supposed to say, perhaps, or questions that we should be asking. Do you think this helps us slow down a little bit and listen more thoroughly and, you know, that saying, if you just listen to the patient, they will (laughs) tell you what's wrong with them? 

Dr. Katie Neuendorf:

I think there's that whole piece about, you know, slow down to speed up. I'm an efficiency junkie. (laughs) I really am. Nivaas and Dave are chuckling 'cause they know that about me. And there is something about the fact that if you can effectively communicate as quickly as possible, your entire encounter is better and more efficient, and faster. And so, I do think that there's a way that these skills can show you that slowing down can help you get the answers that you need more quickly. 

Dr. David Harris:

There's another element that I was thinking of as you were saying that, which is that it feels like what my brain does when I'm under time pressure is the opposite of what my brain does after I've done some improv. And I see that when I'm under pressure, and I'm thinking about the next 10 things that I have to do, that I lose that efficiency with the patient, and that I'm not patient focused. So I think that yes, improv does help me get out of that mindset and at the same time the realities of our current medical care is that I'm often pushed away from that mindset and there's that challenge there. How much can I stay in this open place where I can be listening to my patients? 

Dr. Tony Tizzano:

Yeah, well said. So Nivaas, you know, there are experts who would contend that the very nature of medical training erodes compassion for others. How is empathy enhanced through improv and does it extend beyond patients to the team around them? 

Dr. Nivaas Thanoo:

That's a great question. I think that the nature of medical training, especially in the last, I don't know, 10, 15 years has been a focus on we have to fit the trainee in the bucket that they're in onto the pathway that they're in, you know. There's certain decisions that every trainee has to make, you know. Are they gonna go into medicine or surgery? Are they gonna go into a specialty? Are they going to apply to these programs? Are they gonna... I- it all fills into a regimented pattern and a pathway. But the thing that sometimes gets lost is that we all go into this field to help people. And medical improv does a great job of, like, everyone has kinda stated so far, of placing the patient back on that pedestal in a way that allows them to be the center of the focus of attention. And medical improv does a fantastic job of bringing that focus back and allowing learners to understand that that's the focus of everything that they've been doing and empathizing with the patient allows for greater learning to happen too. 

Dr. Tony Tizzano:

It sounds like we're almost talking about a more collaborative environment with the patient and perhaps with the whole team because Lord knows, we can't do it by ourselves anymore. It's a, it's a team approach for everything and that's one of the strong suits certainly of the clinic. Any thoughts from the others on that? 

Dr. David Harris:

I think that one of the things I remember from being a trainee, and I notice today, is just that there's so much you have to learn, and you're constantly being thrown into these new environments. You're constantly being thrown new information and that puts you in a certain frame of mind. And I think that frame of mind where you're focused on learning, where you're focused on all these new things you're seeing, I think that's what limits the ability to show empathy because that's not where your mind is. Your mind is at all the things you're learning. And I think that comes back once people have had a moment to just be in their role where they're not constantly changing from one year of training to the next year of training from one setting to another setting. So a lot of that, I think, gets better on its own and at the same time, it would be nice if you could have empathy the whole time, nice for you and nice for the patients. So I think there is that role for medical improv there. 

Dr. Tony Tizzano:

Yeah, it makes perfect sense. And I wish I had these reflections earlier in my career, but I certainly am having them now, and I think of the benefit it would've been for me to have them at the beginning (laughs) when more people would've benefited from it. So, Katie, we've talked about all the importance, and we can begin to see the impact that it has. So what do these medical improv workshops look like and might you be willing to demonstrate a typical exercise for our listeners? 

Dr. Katie Neuendorf:

Yeah, absolutely. Let's do an exercise because I do think those of you listening and that are interested, it will be helpful just to hear it. So what we're gonna do is a yes/and exercise. We're gonna start with Nivaas. You're gonna start a conversation with Dave. And Nivaas, I want you to make a statement about sports. It needs to be a declarative statement, any statement that you want. And from then on, you guys are gonna go back and forth for maybe 10, 20 seconds with a sentence that starts with no every time, all right? Got it? So, Nivaas, why don't you start? 

Dr. Nivaas Thanoo:

Dave, did you see the ending of the game last night? That was crazy. 

Dr. David Harris:

No, I, I don't really watch sports and, uh, you know, I just think it's a little tiresome. (laughs) 

Dr. Nivaas Thanoo:

No, I, I hear what you're saying. It can be kinda tiresome, but there's some cool parts about it too. 

Dr. David Harris:

No, I, I don't know if cool is the right word. I mean, I just like to be doing rather than watching. (laughs) 

Dr. Nivaas Thanoo:

No, but it's hard to... Yeah, it just feels like the conversation breaks down. (laughs)

Dr. David Harris:

(laughs) 

Dr. Katie Neuendorf:

[inaudible] I will stop you. You've stopped yourself-

Dr. David Harris:

All the-

Dr. Katie Neuendorf:

...but I will stop you. 

Dr. David Harris:

All the sports lovers are gonna come at me. (laughs) 

Dr. Katie Neuendorf:

Yeah, right. (laughs) So we're gonna have a different conversation. Dave, I want you to start this conversation. It's gonna be about pets. And again, make it a declarative statement, any statement that you want. It could be, you know, everybody should have a dog, everybody should have a cat, nobody should bring animals inside of four walls. And then, Nivaas, you're gonna go. You're gonna start and respond to that with a yes/but statement, and then the two of you are gonna go back and forth, starting every sentence that you have with yes/but. 

Dr. Tony Tizzano:

So before they get started, I hope our listeners could see how the conversation got shut down immediately. 

Dr. Katie Neuendorf:

It did. (laughs) 

Dr. Tony Tizzano:

With the, no/but. I mean, you didn't know where to go next. So imagine you're meeting someone for the first time, and you have this conversation. They know each other. I mean, it would be even more impactful. So go ahead. 

Dr. David Harris:

So it's just so much fun to play with dogs, and they just make you so happy. 

Dr. Nivaas Thanoo:

Yeah, but dogs can also, you know, bring so much dirt and dust and all that into your home. 

Dr. David Harris:

Yeah, but the energy you get from playing with the dogs, i- it's not even a big deal to clean that up. 

Dr. Nivaas Thanoo:

Yeah, but, I mean, you add that on top of all the other costs associated with a dog, whether it's food and, you know, taking them to the vet. 

Dr. David Harris:

Yeah, but did you know they lower your blood pressure? It might save you on your medical costs in the end. 

Dr. Nivaas Thanoo:

Yeah, but my blood pressure's a little low already. 

Dr. David Harris:

(laughs) 

Dr. Katie Neuendorf:

All right, I'm gonna time us out. 

Dr. Nivaas Thanoo:

(laughs) 

Dr. Katie Neuendorf:

(laughs) 

Dr. Tony Tizzano:

(laughs) 

Dr. David Harris:

Now I wanna learn about Nivaas' blood pressure. 

Dr. Nivaas Thanoo:

(laughs) 

Dr. Katie Neuendorf:

(laughs) 

Dr. David Harris:

(laughs) 

Dr. Katie Neuendorf:

So that's that conversation. Let's do one more, and we're gonna do it with yes/and, and then we're gonna come back, and we can talk about all three of those conversations a little bit more as well. So Nivaas, I want you to start this out. You're gonna make a declarative statement about a vacation, all right. And then you're gonna go back and forth with yes/and. And if for whatever reason yes/and doesn't fit, you can change that to, "I appreciate you said that because... Sound like a good plan? 

Dr. Nivaas Thanoo:

Absolutely. 

Dr. Katie Neuendorf:

All right. Go ahead, Nivaas. 

Dr. Nivaas Thanoo:

I just came back from a vacation, and I think that it's so much fun to take a vacation where you can just fully relax. 

Dr. David Harris:

Oh, yeah. And with everything that we have to plan and go through every day, just spending time not having anything on the to-do list is so nice. 

Dr. Nivaas Thanoo:

Yeah, and having a chance to just breathe almost for a little bit. With how much we have to do at work, it's just so, so relaxing. 

Dr. David Harris:

I appreciate you said that because that's something that I've been feeling a lot too, is just the stress from all the things that I've got going on and it makes me think that maybe a vacation would be the perfect thing. 

Dr. Nivaas Thanoo:

Yeah, and even-

Dr. Katie Neuendorf:

I'm gonna stop you. 

Dr. David Harris:

(laughs) 

Dr. Katie Neuendorf:

All right. I hope that our listeners hear that. So one of the things that we would do in an improv workshop is we would do a scenario like that, and then we would stop it, and then we would have people talk about it. How did those three conversations feel? And so, Tony, you already mentioned, you know, the no conversation, it gets shut down pretty quickly. It's even hard to continue that. I would argue that most of the people listening, you don't hear a ton of no conversations out there. The conversation that is probably very familiar to most of us is the yes/but conversation. 

Dr. Tony Tizzano:

Absolutely. 

Dr. Katie Neuendorf:

And when we have people break that down, how did that feel, how did that go, a lot of what they say is, well, actually a yes/but conversation's quite easy 'cause all I'm doing is I'm listening (laughs) for my rebuttal. Isn't that interesting that that's probably one of the conversations that is most recognizable that we have in medicine in one way, shape or form? And it's the conversation that th- to get that conversation going is you just listen to the thing that you wanna refute that the other person said. And I would say that in a lot of workshops, the yes/and conversation can actually be quite difficult. And it's interesting, and it's one of the reasons to bring this skill, is because to have somebody say something that maybe there are parts of it that you agree with, maybe not the entire thing, and still to force you to find something in there that you either agree with or that you appreciate, that's actually a very vital and important skill for people to learn. 

Dr. Tony Tizzano:

Yeah, I think that's spot on. And the other thing I caught is it began to draw out conversation that was more personal. You began to say how you felt or an issue that you might be having in that moment that you might not otherwise have brought to the surface had you not had this, you know, they agree with me with this piece. I wonder if they'll feel the same way about the next piece. And you begin to allow yourself maybe to be more vulnerable in the conversation. Is that fair? 

Dr. Katie Neuendorf:

Yeah, I think that's fair. What we would do oftentimes is that we would then take it to a medical context. So we might take a conversation... In the palliative world, it would be a... maybe a patient who has cancer that is at the end of treatment options. And, you know, the patient side of things is very much yes, but isn't there a clinical trial? Yes, but I fought so hard. Yes, but I can't imagine that we're really at the end. And we have people see the difference of refuting that with a yes/but or taking a moment, I appreciate you said that because I know how hard you fought. Or, you know, maybe it's not a yes/and, but maybe it's empathy or a reflection, and showing them that that's actually gonna get you to the place that you wanna go. Let the patient know that you care. Let the patient know that this really is the truth of the matter and that you're not trying to talk them out of something (laughs), you know, that... It's a tough conversation to have, but this is one of the patterns that we recognized in the communication skills training that was extremely important and helpful, I think, to bring to the physicians. 

Dr. Tony Tizzano:

Yeah, these are wonderful points. So for all of you, what lies on the horizon? What's next for this type of important work? 

Dr. David Harris:

You're both looking at me like I'm supposed to answer that one. (laughs) 

Dr. Nivaas Thanoo:

(laughs) 

Dr. Katie Neuendorf:

Yeah, no, no. Do you wanna answer? I don't... Um... (laughs) 

Dr. David Harris:

(laughs) 

Dr. Katie Neuendorf:

It's getting it to as many people as possible. (laughs) 

Dr. Nivaas Thanoo:

Yeah. I think at least one thing I'd be interested in, in trying to do for the next year would be bringing it to a workshop at a national conference, you know, trying to s- spread the idea of it around as much as possible, get more people interested in it, and see where that takes us. 

Dr. Tony Tizzano:

Yeah. So you're doing this currently with fellows and so forth, but if you began this in the first year of medical school even before you're interfacing with patients, but introduced the topic for communication among your peers, might that spill over into that clinical years, those clerkship years? 

Dr. Katie Neuendorf:

I hope so, yeah. There are definitely places out there that are doing this in medical school. The program that Nivaas went to, it was an elective. 

Dr. Tony Tizzano:

Mm-hmm. 

Dr. Katie Neuendorf:

There are places out there that are trying to incorporate this into their curriculums in medical school. We'd love to do it more in the training years, and so we're trying to do that as well. There's a community of improvisational artists who work with people in medicine, so those are exciting pieces too. 

Dr. David Harris:

I'm really interested in two things. The first is communication skills are taught in these day long, multi-day long workshops and it's so hard to have the time to do that. So one of the things that's exciting about medical improv to me is that yes/and exercise that took five minutes. That's the five-minute shock talk of communication skills. And I would love to be developing more versions of that where a team that's rounding can do something that A, helps develop their communication skills in five minutes and B, helps them get into that mindset. Because the other thing, I think, is that even just from this conversation, I think I'm viewing medical improv less as a do it and you're done thing, and more as a practice, like, a continued practice to keep you in that place of not being stuck in your role as Katie was saying or being open, like, Tony, you were saying with patients being open to what's coming out of their mouths. So I think that making it smaller and making it a continuous practice is what I'm interested in. 

Dr. Tony Tizzano:

Yeah. That, I think, is clear. That's clear to me from what all of you have said. So are there some other areas or questions that I should've asked or didn't pursue that you feel are, are important for our listeners to know? I think you've covered a lot. 

Dr. Katie Neuendorf:

The great part about these exercises as well, different than what Dave was saying where, you know, sometimes it has to be a small group with, you know, one facilitator to a c- a certain number of patients, you can do these skills in large audiences. I was able to bring them to our medical community and afterwards somebody came up to me and said, "Not only do I feel like I gained skills that I can learn, but this entire session was energizing." And in a day that time is such a commodity, to get a session where I'm learning skills, gaining insights, and feel like I have more energy at the end of it than I did at the beginning, that in and of itself is a huge win. And I would say that that's the connection, you know, that there's something about human connection, being in the moment and finding fun (laughs), that can bring a lot to learning. 

Dr. Tony Tizzano:

I think we can all appreciate that. Well, David, Katie, Nivaas, thank you all so much. This has been a fascinating and enlightening of MedEd Thread. To our listeners, thank you so very much for joining, and we look forward to seeing you on our next podcast. Have a wonderful day. 

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, SoundCloud, Stitcher, Spotify or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread and please join us again soon.