Medical Improvisation: Impact of Training on Medical Students’ Experience with Communication on Clinical Rotations - A Single-Center Mixed-Methods Study

doi:10.21203/rs.3.rs-3588327/v1

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Medical Improvisation: Impact of Training on Medical Students’ Experience with Communication on Clinical Rotations - A Single-Center Mixed-Methods Study

https://doi.org/10.21203/rs.3.rs-3588327/v1

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Background: Effectively preparing medical students to communicate with patients, families, and teams remains a challenge in medical education. Although techniques from medical improvisation have been introduced to teach communication skills in this context, limited evidence exists regarding how such training elicits student involvement, impacts clinical students’ communication skills, and affects medical students’ authentic clinical care interactions.

Objective: To implement a medical improvisation-based educational training in the pre-clinical year and gather medical students’ reflections following one year of clinical rotations.

Methods: We recruited medical student volunteers to participate in an established medical improvisation curriculum, complete course evaluations, and provide progressive reflections as they began and continued their clinical medical training. Course duration was 2 hours per week for 5 weeks, prior to beginning clinical rotations. Participants completed anonymous, electronic evaluations via Qualtrics software before and after the course, which included structured (closed-ended) and open-ended questions. One year later, after students completed core clinical rotations, we conducted semi-structured interviews and performed thematic analysis on transcripts.

Results: 23 of 24 recruited students completed the course and surveys. Pre/post-course comparison survey data show significant improvements in reported comfort with different communication situations. 11 students (48%) participated in follow-up interviews. All interviewees reported they found the course valuable and, universally, would recommend it. In interviews, students noted that skills improved by medical improvisation included flexibility, “yes, and” approach, accepting mistakes, listening, and confidence in unknown situations. Many interviewees felt medical improvisation was helpful to their professional development, gave them strategies for challenging conversations in real-life practice, and supported personal growth and wellness and building friendships.

Conclusion: Medical students exposed to medical improvisation prior to clinical rotations noted both immediate benefits in communication skills and long-lasting improvement in specific domains of communication.

Though interpersonal and communication skills are an Accreditation Council for Graduate Medical Education core competency,¹ effectively preparing students to communicate with patients, families, and teams remains a challenge for medical education. Some approaches, such as simulated patient encounters, offer the opportunity for experiential learning; however, such approaches are resource-intensive. In addition, students may experience these simulations as lacking the complexity, authenticity, and resonance of actual clinical practice.

Improvisational theater, or “improv,” is a performance-based discipline which embraces creativity, spontaneity, and expressing and reflecting authentic emotions. Though improv performances are unscripted and unrehearsed, the training is methodical and disciplined.² Improv training uses games and exercises that emphasize foundational communication skills including listening, cooperation, adaptability, fluidity of thought, and empathy. Extended practice and reiteration leads to greater development of these skills and ultimately a shift in thinking and behavior. Through this training, improv performers improve their flexibility, communication, and teamwork skills, which are then leveraged to enable them to respond productively to unanticipated moments.² Given its ability to cultivate interpersonal abilities, many teaching institutions outside of the performing arts, including schools of law, business, as well as medicine, have recently adopted these innovative techniques to meet the educational needs that bely the impact of didactical lecturing.³

Medical improvisation, or “medical improv,” represents a feasible means to address the challenges of teaching communication skills to medical students.⁴ It is theadaptation of improvisational theater exercises to enhance skills essential to patient care, team dynamics, and interdisciplinary professionalism encountered by physicians and trainees in practice. A recent scoping review, examining 30 articles published between 2020 and 2022, reported that improv and other theater techniques positively impact communication skills among healthcare providers.⁵ Nine of the articles reported on interventions that taught improv techniques to medical students exclusively,^6–14 and seven were multi-week courses.^7–11,13,14 Although single workshops have shown positive results, concerns remain about the degradation of single-session communication skills over time.¹⁵

Based on the current literature, it is unclear what long-term impact improv has on communication skills and real world physician-patient interactions. Our study sought to assess both the immediate impact of a multi-week medical improv course on communication skills delivered to pre-clinical students, and how the course impacted their perceptions of their communication skills during and after their clinical rotations.

Recruitment

We notified eligible medical students in their second year about the project via email and provided a lunch information session with free food to explain details about medical improv, the course, and the research study. More than 50 medical students who attended the lunch session volunteered. Volunteers were randomly assigned to the course or on the waitlist. Some students withdrew due to scheduling conflicts when course dates were finalized. Of the remaining students, 24 enrolled, and 23 completed the course. Participants received a $20 gift card upon completion of the course and associated surveys and refreshments were provided at each session.

Curriculum

The medical improv course followed the established curriculum “Playing Doctor” developed by Watson.¹⁶ This included weekly two-hour sessions for five weeks, with multiple improv exercises in each session centered around a unifying topic. The first week features a foundational introduction to improv, including explanation and demonstration of key principles of improv, such as “yes and” (accepting and building on other’s ideas and contributions) and giving and receiving “gifts” (providing and using information that supports co-creation). The second session focuses on storytelling and character, reinforcing the collaborative nature of improvisation and encouraging perspective-taking. The topic of the third week session is thinking and responding on one’s feet and juggling multiple goals. Exercises in this session emphasize listening, flexibility, and focus. The fourth week highlights recognizing and responding to emotion and coping with ambiguity. The fifth and final week session explores applications of medical improv to clinical practice, as well as exercises and discussion centered around differences in status.

In addition to the improv exercises themselves, pre- and post-exercise discussions are integral to framing the learning objective in the real-world context. Pre-game discussions may prime learners’ attention to the dimensions of the problem or situation and encourage them to consider what is difficult about the specific communication task, to set the stage for the activity. Following the activity, post-game debriefings center on what was learned in the game, and how that lesson and insight can be applied to the real-world situation. It is important to highlight that expertise in facilitation of the exercises as well as the discussions is critical to success in medical improv. Unfamiliarity with improv exercises may lead to leading the exercises in a way that fails to highlight the intended skills; likewise, unskillful facilitation of the discussions may pose the risk of debriefing in a style that is too cognitive or prescriptive to achieve the intended goal. The course facilitators (SK, BB, NR) had experience in both healthcare and improv techniques, SK had undergone a train-the-trainer workshop to teach the “Playing Doctor” course.¹⁷

Participants were divided into two group cohorts of 12 participants each, with each group meeting once per week. Sessions were held two evenings per week. Although groups were generally consistent, students occasionally switched groups for a single session when schedule conflicts arose on their assigned night. In addition to the weekly sessions, the full group also attended a live improv performance at a local theater as part of the training, as well as completed assigned readings and reflections between sessions.

Evaluation

Participants completed evaluations before and after the course, which included structured and open-ended questions about their experiences with clinical rotations and the improv course (Supplement 1).

Semi-Structured Interviews/Materials

We conducted semi-structured interviews with 11 student volunteers approximately one year after the students had started clinical rotations (August to September 2018). We developed and refined the interview guide with input from SK, BB, and BZ, and questions focused on communication skills they encountered on clinical rotations and their perceptions of the improv course (Supplement 1). The interviews were conducted in-person. The medical students received an additional $20 gift card at completion of the interview. The interviews were audio recorded and transcribed. The duration of the interviews ranged from 16 to 55 minutes.

Data Analysis

For the survey data, we calculated average (mean) ratings and percent agreement with the pre- and post-survey Likert-format scale items. We also statistically compared pre- and post-survey responses using the Mann Whitney U test.¹⁸

For the interviews we created de-identified interview transcripts for coding. We then conducted thematic analysis of the interview transcripts guided by Braun and Clark's approach.¹⁹ This type of analysis considers themes robust when they are distinct, coherent, and cohesive relative to the coded extracts and the entire data set. The primary researchers (SKK, BB) identified and refined codes and themes, which were then further refined through discussion with additional team members. All interviews were independently read and coded by three researchers (SKK, BB, PBM).

Research Team and Reflexivity

To ensure reflexivity, the research team was comprised of interdisciplinary members, including a practicing physician and bioethicist (SK), a social worker and public health professional (BB), two medical students (NR, CT), a professor of health communication and medical decision-making (BZ), and a professor of medical anthropology and medical education research (PBM).

This project was approved as exempt from further review by the University of Michigan Health Sciences and Behavioral Sciences Institutional Review Board (HUM00018003).

Twenty three of 24 recruited students completed the course and both surveys. Table 1 summarizes the medical students’ demographic profiles, as well as their self-indicated interests for their careers in medicine. On the post-course survey, 8 (35%) students rated the course as “above average” and the other 15 students (65%) ranked it as “excellent.” Table 2 summarizes the medical students’ pre- and post-course evaluation responses. Students reported significant increases in agreement with the statements “I can successfully manage multiple verbal and cognitive tasks when a professional situation requires this of me,” “I excel at reading the body language of others,” “I think I have whatever ‘stage presence’ is necessary to excel in my professional life,” and “I am comfortable communicating my true feelings when that’s appropriate in my professional role.” Likewise, they reported significant increase in agreement with statements that they were comfortable with explaining medical concepts to patients, the healthcare team, or other experts in the field. (Table 2)

Eleven students (48%) participated in follow-up interviews. All interviewees reported the course was worth their time and eliciting their engagement; students also consistently reported they would recommend the course to others. When asked to describe their experiences with communication on clinical rotations, students reported that they regularly used the skills of “building rapport with patients,” “fostering trust with the medical team,” “responding to questions when they did not have answers,” and “reading body language” (representative quotes in Table 3A). They noted that they used these communication skills frequently, felt comfortable and confident in their ability to use them, and perceived that competence in these skills was expected from them as medical students. In contrast, communication skills that students reported as challenging included “responding to emotions,” “avoiding jargon,” “giving serious news,” and “managing conflict” (representative quotes in Table 3B).

Students also described skills they felt were improved by their participation in the medical improvisation course (Representative quotes in Table 4). Nearly all students interviewed reported their experience with the medical improvisation course improved their ability to be flexible and think in the moment, and that this skill was helpful in interactions with patients while on their rotations (Table 4A). Similarly, multiple students described that the concept of “yes, and,” which is one of the primary principles of medical improvisation, as memorable and useful long after the course. The students characterized this collaborative mindset as facilitating their ability to find common ground with patients in situations of disagreement (Table 4B). Acknowledging mistakes and interpreting them as opportunities for growth is another key principle of improv. Several of the interviewed students explained that their participation in the course had helped them when they made mistakes, both with answering questions posed by their attending physicians in front of their peers and with missteps in communication that happened with patients and other team members (Table 4C). Many students also characterized their participation in the course as affecting how they perceived the importance of listening, both in conversations with patients and with medical team members on the wards (Table 4D). Finally, several students described that, following the course, they perceived themselves as more confident in conversations that seemed intimidating (Table 4E).

Reflections on the Course

All interviewed students reported that they considered the medical improv course valuable and engaging. The students concurred that they would recommend it to other students. Although few of the interviewed students cited specific exercises a year after the course was complete, many reported that the training was helpful to their professional development (Table 5A). They expressed that feeling more comfortable with communication would make them better physicians and enhance their ability to give quality patient care. Likewise, several students noted that rather than teaching specific language to use, their improvisation experience gave them tools for challenging conversations in real-life practice. Students also reported benefits in personal growth and wellness and building friendships (Table 5B). Many students commented on how improv and the sense of community it created was helpful in countering the stress of medical school. In response to the questions promoting the students’ reflections, many interviewed students offered suggestions and opportunities to use medical improv training going forward. Common themes included holding repeated medical improv sessions while on clinical rotations, as well as timing the session differently in the context of their medical school training (Table 5C). They also proposed expanding the opportunity for medical improv training to more medical students or to trainees of other disciplines and professions (Table 5D). Multiple students, however, described barriers like time constraints and scheduling challenges as likely prohibitive to repeat sessions or scheduling the course at a different time in their medical school curriculum (Table 5E). A few students also noted possible barriers to engagement, such as that since attitude of participants is critical to the success of the intervention and that participation may be impacted if the course is not voluntary.

Our applied empirical research study of medical improvisation adds to the evidence supporting the potential benefits of this approach, by both assessing the impact of a multi-session course for pre-clinical medical students. We measured its longitudinal effect on students’ communication skills during their clinical rotations using mixed quantitative and qualitative inquiry. Based on pre- and post-course survey results, our study found a significant improvement in students’ comfort level with communication of feelings and medical concepts, ability to interpret body language, and manage multiple tasks. In follow-up interviews, students described specific domains of communication they encounter regularly and find challenging during their clinical rotations. Although one year later most students did not specify individual exercises in the course that they found especially helpful, the students consistently reported that the medical improvisation course as enhancing their communication skills in terms of flexibility, having a “yes, and” approach, accepting mistakes, listening, and having confidence in unknown situations. Students also noted a positive effect on professional development and personal wellness.

Positive change from pre- and post-evaluations for medical improv trainings have also been noted in other studies.^{8,11,15,20,21} These, however, have not always correlated with long-term skill acquisition.¹⁵ Interestingly, the major themes that arose during these semi-structured interviews included flexibility, listening, and accepting mistakes - themes which did not show statistically significant differences on the related survey questions. Instead, our pre- and post-course survey results show significant changes in comfort level in discussing medical topics with patients, experts, and broad audiences, which is similar to prior studies.^9,21 Students did not remark in the interviews that the improv course had made them more comfortable explaining medical concepts to others. The incongruence between survey results and semi-structured interviews may suggest that the lasting impact of medical improv on real world communication skills may be different than those reported in pre- and post-course surveys.

Like prior studies of medical improvisation, students in our study noted improvements to flexibility or the “ability to think on one’s feet,”^10,13 as well as skills related to fundamental principles of improv including “yes, and”^6,9,10,15 and accepting mistakes,⁶ listening skills,^8,11,22 and confidence.^7,8 Also similar to past studies of improv-based training, students rated our course highly,^{6–10,22–24} perceived a positive impact on their professional development,^6,11,22and experienced benefits to their wellbeing.^11,22 With the rising mental health burden among healthcare providers,²⁵ the importance of identifying training strategies that positively impact professional development, wellness, and personal growth cannot be overstated. Medical improvisation may be a valuable tool to help fight burnout and increase resilience and connectedness.¹¹

Although substantial literature exists investigating medical students’ perceptions of improv-based courses and other approaches to communication education,^{8,11,14,26–29} there appears to be a relative paucity of evidence around medical students’ perceptions of actually using communication skills in the medical setting. During their pre-clinical years, medical students are expected to learn valuable communication skills including how to build rapport and interview patients.¹⁴ However, we were unable to find any studies investigating how students perceive these communication skills in the clinical setting, or how they are learned and fostered. Likewise, the students’ reflections around “not having all the answers” and its inherence in their roles as students appears to be a novel finding. Medical students often grapple with the uncertainty intrinsic to medicine,³⁰ and navigating through the acquisition and application of knowledge and development of a professional identity is largely the goal of medical training. Finding the balance between knowing the limits of one’s own expertise and being impeded by self-doubt is a struggle for physicians throughout their careers.³¹ Our findings suggest, however, that improv can be a tool to assist with handling this uncertainty and discomfort. The communication skills that students found challenging echo those previously reported in the limited existing literature exploring this topic.^32–34 Medical improv may again be useful in building confidence in these communication skills, as it has previously been utilized to teach skills around empathy,^{9,12,13,15,22} clear communication,^2,9 serious news disclosure²⁰, and conflict resolution.²⁴

Strengths/Limitations:

Our study has several limitations. We enrolled medical students from a single center. Also, our course was fully voluntary and not formalized as part of the medical school curriculum. This meant that the participating medical students did so on their “free time,” likely selecting for students who were eager to engage in the sessions. However, it is important to note that far more students were interested in participating than had been anticipated, and this allowed us to facilitate the course for twice as many students as originally expected. Our students’ high completion rate of the course and surveys (23/24, 96%) was a notable strength. Even with twice as many participants as anticipated, our cohort size was relatively small, limiting the survey’s ability to detect effect and the generalizability of the qualitative results. Bias may also impact the follow-up interviews, deriving from which of the students were willing to be interviewed. Additionally, the students were interviewed by one of the course facilitators (BB) which may have influenced their honesty in answering. We also acknowledge that our qualitative analysis was performed by several members of the team who also taught and facilitated the course, though several members of the research team had not (CT, BZ, PM). To minimize potential bias, team members with different backgrounds and diverse expertise assisted with the qualitative analysis to promote reflexivity.

The decision to hold the course for pre-clinical medical students and assess them after their time on the wards was deliberate, though it is unclear whether it was optimal. In part, this allowed for easier scheduling, as it is harder to identify a weekly time that all participants can meet once they begin having clinical responsibilities. We also felt that this timing could prepare them before they began experiencing communication in the clinical context. While many students appreciated having this opportunity to practice communication before they had these conversations in “real life,” several noted in the interviews and surveys that they could not relate some of the exercises and debriefs to actual clinical situations. The optimal time to engage students in improv-based communication training, and on what intervals this training should be reinforced, remains to be determined.

Medical student participants in a multi-week improv course reported immediate benefits in managing multiple tasks, reading body language, explaining medical concepts, and communicating feelings. Semi-structured interviews performed one year later during students’ clinical rotations shows that medical improv has long lasting impacts on specific domains of communication, professional development, and personal wellness and growth.

None

Financial Disclosure: The authors have no financial relationships relevant to this article to disclose.

Funding Source: University of Michigan Center for Research in Teaching and Learning

Potential Conflicts of Interest: The authors have no conflicts of interest relevant to this article to disclose.

Contributors’ Statement:

Dr. Kukora conceptualized the course, co-facilitated the course, conducted quantitative data analysis and contributed to qualitative analysis, drafted and critically revised the manuscript.

Dr. Ravi recruited student participants, co-facilitated the course, conducted the literature review, and critically revised the manuscript.

Ms. Batell co-facilitated the course, conducted the interviews, contributed to analysis, and critically revised the manuscript.

Dr Zikmund-Fisher provided guidance and mentorship in designing the project and analysis, and critically revised the manuscript.

Dr. Thompson transcribed the recorded interviews, contributed to analysis, and critically revised the manuscript

Dr. Mullan collaborated on qualitative analyses, contributed to the literature review, and critically revised the manuscript.

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Table 1. Demographic Information (n=23)

	Number of Students Identifying	%
Gender
Female	14	61%
Male	9	39%
Race
White	11	48%
Asian	8	35%
Black/African	2	9%
Hispanic/Latinx	2	9%
Reported Career Interests	Number of Students Reporting Interest	%
Hospital vs Outpatient Practice
Hospital Practice	6	26%
Outpatient Practice	1	4%
Both	13	57%
Unsure	3	13%
Primary vs. Subspecialty Care
Primary Care	4	17%
Subspecialty Care	9	39%
Both	3	13%
Unsure	7	30%
Specialty/Subspecialty (students could select more than one and write in)
Internal Medicine	14	61%
Surgery	8	35%
Obstetrics/Gynecology	6	26%
Pediatrics	5	22%
Neurology	5	22%
Family Medicine	4	17%
Emergency Medicine	2	9%
Psychiatry	1	4%
Other (Critical Care, Neonatology, Cardiology, Gastroenterology, Infectious Disease, Oncology, Rheumatology, Anesthesiology, Urology, Ophthalmology, Plastics, Orthopedic Surgery, Radiation Oncology, Geriatrics, Otolaryngology).	8	35%

Table 2. Pre- and Post- Course Survey responses (n=23)

	Mann Whitney U Test	Average Rating		Percent Selecting “Very Like Me” or “Exactly Like Me”
	p-value	Pre-Course	Post-Course	Pre-Course	Post-Course
I can “think on my feet” – thinking quickly in the moment when a professional situation requires this of me.	.29	3.04	3.26	26.1%	47.8%
I can give quick verbal responses in the moment when a professional situation requires this of me.	.08	2.87	3.39	30.4%	47.8%
I can make quick decisions in the moment when a professional situation requires this of me.	.13	3.04	3.26	26.1%	34.8%
I can quickly take action in the moment when a professional situation requires this of me.	.90	3.26	3.43	39.1%	56.5%
I can successfully manage multiple verbal and cognitive tasks when a professional situation requires this of me.	*.003*	2.78	3.52	13.0%	52.2%
I can be an excellent listener in my professional role.	.91	4.00	4.00	78.3%	73.9%
I can be an excellent observer in my professional role.	.38	4.00	4.20	78.3%	82.6%
I usually listen to what other people say without interrupting.	.97	3.65	3.70	56.5%	52.2%
I rarely start planning my response while the other person is still talking.	.08	2.17	2.70	17.4%	26.1%
I make a conscious effort to match my body language to the message I want to convey.	.58	3.26	3.48	52.2%	52.2%
I excel at reading the body language of others.	*.04*	2.96	3.52	30.4%	60.9%
I feel confident that I know when to speak and when to be quiet during conversations.	.12	3.13	3.56	43.5%	56.5%
I am very comfortable with silence.	.22	3.09	3.65	47.8%	43.5%
I think I have whatever “stage presence” is necessary to excel in my professional life.	*<.001*	2.26	3.30	39.1%	39.1%
I think I understand where other people are coming from - I can see their point of view.	.88	3.65	3.74	65.2%	60.9%
I can clearly communicate my true feelings when that’s appropriate in my professional role.	.06	2.87	3.34	21.7%	47.8%
I am comfortable communicating my true feelings when that’s appropriate in my professional role.	*.03*	2.65	3.26	17.4%	52.2%
I feel like I have to be perfect all the time.	.65	3.04	2.87	34.8%	39.1%
I feel ashamed when I’m giving my best effort and I make a mistake.	.47	3.13	3.39	43.5%	47.8%
I often feel paralyzed by a fear of making mistakes.	.97	2.52	2.52	21.7%	26.1%
I am anxious or fearful in many social situations.	.50	2.30	2.04	17.4%	8.7%
I break into a sweat, experience shortness of breath, get butterflies in my stomach, or experience other physical symptoms when I feel uncomfortable in social situations.	.36	2.30	1.95	21.7%	8.7%
I feel that I would be comfortable when...
… explaining a medical concept I know to a patient.	*.01*	3.04	3.66	30.4%	60.9%
… eliciting a patient’s perspective on a medical issue.	*.048*	3.35	3.83	56.5%	78.3%
… discussing a medical concept I know with a peer.	.14	3.56	3.91	56.5%	82.6%
... discussing a medical concept I know with a person in a position of authority over me (e.g. professor, preceptor, research advisor, boss).	*<.001*	2.43	3.52	13.0%	65.2%
… discussing a medical concept I know with a person who is an expert and likely knows more than me on the topic.	*.003*	2.39	3.30	8.7%	52.2%
… public speaking when I’m communicating a concept I know to a professional audience.	*.008*	2.65	3.39	17.4%	60.9%
Scale: 1-Not like me at all; 2-A little like me; 3-Somewhat like me; 4-Very like me; 5-Exactly like me

Table 3. Themes, Subthemes, and Exemplary Quotes from Medical Student Interviews after Clinical Rotations.

A. Communications Skills Students Use Regularly

Building Rapport with Patients

“I think things have been going well are establishing rapport. That’s become a little easier, in terms of setting things up in the beginning of the interview, and kind of building on that in terms of building a trusting relationship to direct the interview from there.” –Student 9

Building Trust in the Team

“Communicating to the healthcare team is all about, can they trust you, can they talk to you? Does it seem like you know what you’re talking about?...No one really expects you to know anything, but they do expect you to be able to interact with the team. I’d say that’s the most important part of clinical year.” –Student 6

Responding When Not Having Answers

“Just, like, being able to say, ‘You know what, I don’t know. Can I get back to you?’ or something like that. Because we’re kind of always taught, “You should have answers to things.’ So learning that shift was pretty difficult.” –Student 5

Reading Body Language

“When I was on surgery it’s very much you need—you almost had to be extra good reading the room and reading non-language based communicated things…To be able to read people’s body language and read the atmosphere and knowing when to ask a question and when it was a good time to just not talk because it was a very stressful time during procedure….I think that was—I had to be more careful during surgery and more cognizant of those types of things.” –Student 11

B. Communication Skills Students Find Challenging

Responding to Emotion

“This patient had MS and it was progressing…she just started crying and was just so upset and so I felt like I had to ask and do a suicide screening. And she admitted she had been suicidal, but she wasn’t going to act on it. It was just a really intense moment. And I think for me I was trying to figure out … how do I make her feel better? She has a chronic, incurable disease and there’s really, at the end of the day, there’s nothing we can do for her…So trying to find a way to empathize with her, make her feel a little bit better in the moment.” –Student 4

Avoiding Jargon

“I’ve tried to be very intentional in my medical training of not using medical jargon with patients…what’s the point of communicating with someone if they don’t understand what they’re saying?..I find that it’s harder to do that the further you get along in your training, because that’s the speak you speak in your training with providers and it’s more rapid-fire to do that…the easier it is to get into doctor speak, or medical speak, not just doctor speak, but medical speak, in ways that you don’t even realize you’re doing.” –Student 1

Giving Serious News

“Because I had this good relationship with the family, I wanted to see if I could tell him the bad news….but I was only able to get out two sentences before I just panicked and froze… I think more practice probably would've made it better. It was also my first conversation where I was telling somebody that they were gonna die…it really shook my confidence in that kind of conversation.” –Student 8

Managing Conflict

“I felt like I was kind of like this mediator. There was some animosity between the mom and the attending… They weren’t arguing, but they weren't communicating very clearly with each other. And they both saw me as someone they could talk to comfortably. And so then it just, I don't know, it was awkward. I tried to be that person that made sure that the doctor-patient relationship was strong.” –Student 10

Table 4. Reported Skills Improved by Medical Improv with Exemplary Quotes

Flexibility

“Just being able to have a conversation with somebody without being rigid to my list…. That's probably the biggest thing I learned. I always go in with a list of questions because I'm so nervous talking to people. I can't think of my next question when I'm in the middle of a conversation. So I write down all my questions before I go in. But now I feel like I can just sit down and relax enough that I can let the conversation go. And even if the question is not worded exactly like the question on my paper, I’m OK with it.” – Student 2

Yes, and Approach

“I will say that the one good skill that I think in a few cases helped me…is thinking more of the kind of a ’yes, and’ mentality and kind of the idea of not, not using language that will put down or, kind of, put a halt to what the patient is saying...I think it's definitely helped me with a few patients when maybe my ideas are not truly aligned with where they're at. So if [patients] don't want to do specific Treatment A that I'm offering because they want to do whatever alternative treatment…For some of those I will take a... ‘Yes, I think those are great.‘ I will say the value I see in them. ‘Tell me more about that. This is why I am offering this.’ I'm not saying, ‘No this isn't going to work. This is what you should be doing.’ – Student 7

Accepting Mistakes

“There were so many curveballs in that whole situation. And even though… I didn’t handle it as perfectly as I wanted to, I didn't like - I didn't run away. I was still there. I was still present in the moment. I was still able to come back from those periods of perceived wrongdoing or miscommunication on my part and still have a really wonderful relationship with that family. And I think the experience in the improv course really helped me that. Because regardless of what kind of fool you made of yourself in the class, you still had to come back. You still had to pick yourself up and do it again the next exercise...You're going to make mistakes…maybe you can learn from this mistake…I think that that helped me.” – Student 8

Listening

“I think being aware of, like, the dynamic of a conversation and, like, who’s doing the talking and who’s doing the listening. And always making sure people are getting equal opportunities to do both.” – Student 11

Confidence in Unknown Situations

“I had an increased awareness for how I go about conversations that are less comfortable or just more unknown. I think that that was helpful in my clinical time, so far as a med student, to have slightly better awareness of my own thoughts and feelings.” – Student 3

Table 5. Feedback on the Course Exemplary Quotes

Positive Impact on Professional Development

“I'm a better medical student because of the course, and I will be a better health care provider because of the course…I think just both medical students and providers, their primary function is to deliver health care to patients. And if you can better talk to patients and help them to relax in a way that they can tell you what they need to tell you, then that makes you a better provider.” – Student 2

“It’s more learning basic skills that you can apply to a variety of situations. I can’t name a single clinical situation that improv directly applies to, but in my head, learning when to speak and when to just listen. And learning when it’s your opportunity to shine versus somebody else’s opportunity. Learning how to be flexible. Learning how to be comfortable with silence. Learning to always have a sense of humor and, like, keep that kind of lightness in the conversation. I think those are all very essential pieces to my communication toolkit.” – Student 11

Positive Impact on Personal Growth and Wellness

“In general, in impact in terms of my wellness. I mean I think that was a fun semester and it's a fun of course to do. It's a good break from school. I think I interacted with some of my friends, some of my peers, in a way that I wouldn't have, otherwise. And I made some new friendships. I think that's one impact.” – Student 7

“It's nice to have, like, something reinforce the personal value I have in silliness and having fun and finding joy in things. I think having that reinforced in an academic setting was really nice because so much of what we learn and what we do is so serious and so grave and sometimes really sad. So much of medical school is figuring out, at least for me, like ’How do I balance my personal identity with my professional identity and have those two things come together?’” – Student 10

Importance of Timing of Training

‘I think some of the discussions we had after -- you know when we were like, ‘Let’s apply this to clinical medicine’ were always interesting, but I think, given where we were, were a little artificial. I think it would be interesting if we went back and did it again now, how those discussions would be different. Because at the time we were like, “’Yeah, I can totally see how this exercise that we did would apply to what we will be doing,’ but we hadn’t done it yet. But now that we’ve all had that experience it would be interesting to be like, ’This is totally how this could make sense in what we’ve done this past year.’ –Student 3

Value in interprofessional participation

“I also think it would be valuable, not just as medical students, but also nursing… I’m a big proponent of IPE – the interprofessional education…I think the more you can work alongside other trainees in that safe space while you’re still at the same level before the kind of forced hierarchy of healthcare is upon you.” – Student 1

Barriers to additional sessions

“There’s no good time and we were all on different schedules. Things get easier now, in electives and Sub-Is. They’re a little bit more flexible…. The hard part is just knowing if you’re going to be able to. So, you can often get stuck. There’s no good answer.” – Student 6

Barriers to engagement

“I mean, it’s kind of one of those things where you put in is what you get out. So if someone came into it, kind of close-minded and didn’t want to be there, then I don’t think there would be any benefit to that. I guess it depends to who and what their thoughts are going in.” – Student 9

No competing interests reported.

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Medical Improvisation: Impact of Training on Medical Students’ Experience with Communication on Clinical Rotations - A Single-Center Mixed-Methods Study

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