title: 'Thinking on my feet': an improvisation course to enhance students' confidence and responsiveness in the medical interview.
abstract: BACKGROUND
  Effective patient-centred communication requires physicians to respond 'in the moment' to comments and questions. It is a valuable skill to be able to react to unexpected patient utterances with empathy and support, and these surprises may be most common in general practice where patients are encouraged to speak to their doctor about anything. We developed an elective for medical students to learn and practise improvisational skills that would optimise their communications with patients during medical encounters.
  
  
  METHODS
  Nineteen second-year medical students during two consecutive years (n =38) participated in a four-session elective that introduced and allowed them to practise the principles and skills of improvisation, and reflect on the role of those skills in their communication with patients. Specific skills that were practised and emphasised included listening, affirmation, vocal tone modulation, nonverbal communication, agreement, collaboration, acceptance and validation. In addition to previously developed 'Improv' exercises, students created their own improvisation exercises targeted at specific communication skills.
  
  
  RESULTS
  Twenty-seven (71%) of all participating students completed the post-curriculum assessment survey. Twenty-two (81%) rated their enjoyment as 'tremendous'. The desire to experience something new and different from the standard medical curriculum served as the motivation for many of the students (67%) to sign up for the course. Most students (23/27; 85%) thought that the concepts that were addressed were either 'very much' or 'tremendously' relevant to the care of patients.
  
  
  CONCLUSIONS
  We have found that an improvisational workshop geared towards enhancing medical student communication skills has the potential to impart valuable skills that are essential to providing empathic, supportive patient-centred care. Communication skills training programmes have become a cornerstone in medical student and postgraduate medical education over the past 20 years. Both national accreditation and expert panel consensus guidelines have stressed the importance and framed the structure for best communication practices. Exemplary curricula for teaching medical trainees in core communication strategies to use with patients have been published; many emphasise patient-centred and/or relationshipcentred strategies. Simulated patient technologies with video review can allow learners to practise their skills through both self-assessment and feedback from others. However, despite these newer learning resources, frameworks and behavioural checklists, learners naïve to clinical patient encounters must still learn how to function and adapt within the interpersonal communicative space that is created by the learner and patient. At its core, this is an iterative, spontaneous process created by the dyad and yielding, from moment to moment, to unique and unanticipated outcomes. Thus, repetitive practice will improve confidence but may miss the mark in learning the essential skills of intuitive and improvised interpersonal responsiveness. One could argue that existing approaches in teaching medical learners communication skills may promote rigid and stereotyped responses. Haidet proposes that there are significant parallels between the patient-physician dialogue (when a physician attempts to learn details about a patient and their illness) and improvisational jazz. 11 He contends that effective clinicians who are committed to relationship-centred practice depart from overarching principles of biomedical inquiry when necessary to respond spontaneously and without script to the particular circumstances of each encounter. It is believed that successful doctor-patient relationships are founded upon trusting and open communication, as well as genuine respect that can be shown by a willingness to listen or respond to the issues raised by patients. 12 The nature of the comprehensive care in family medicine makes it likely that GPs will regularly be surprised by concerns raised by patients such that they must be adept at improvising. Because of the gap that currently exists in interview skills training programmes, we hypothesised that the field of improvisational theatre would effectively supplement the traditional curriculum. Improvisation relies on listening, confidence and responding instinctively and spontaneously. 13,14 In this paper, we describe our efforts to develop a brief curriculum for medical students providing training in the art of theatre improvisation, with the goal of enhancing students' confidence and performance in clinical encounters. We hoped that this innovative curricular experience would establish a venue where secondyear medical students could learn and practise improvisational skills that might prove helpful in their communications with patients during medical encounters.
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Shochet
authors.forename: Julie
authors.initials: J
authors.lastname: King
authors.forename: Rachel
authors.initials: R
authors.lastname: Levine
authors.forename: Sarah
authors.initials: S
authors.lastname: Clever
authors.forename: Scott
authors.initials: S
authors.lastname: Wright
mesh_terms: D015142:Baltimore; D003142:Communication; D004504:Education, Medical, Undergraduate / Q000379:methods* / Q000592:standards; D006801:Humans; D008487:Medical History Taking / Q000379:methods*; D018802:Patient-Centered Care / Q000379:methods* / Q000592:standards; D010817:Physician-Patient Relations; D015397:Program Evaluation / Q000379:methods; D012381:Role Playing; D020377:Self Efficacy; D013337:Students, Medical / Q000523:psychology*