Feature

Using Improv Training to Teach Palliative Care Skills

Larry Beresford

A small group at the palliative care program of Children’s Hospital of Los Angeles (CHLA) is using techniques of improvisational theater to enhance the clinical work of the palliative care team as well as to teach primary palliative care communication skills and concepts to broader clinical audiences.^1,2

Improv is one example of using arts and humanities to transmit the person-centered approach, holistic listening, and effective communication at the heart of palliative care. Others include art museum teaching, art and music therapy, narrative medicine, and storytelling. These have been used with medical students, residents, and fellows in hospice and palliative medicine (HPM); as team- and skill-building exercises for palliative care teams; and for broader clinician groups to learn the basics of primary palliative care.

Improv seems to be a particularly fertile medium for conveying medical communication skills—how to listen and engage with patients and families confronting the difficult decisions of serious or life-threatening illness, said pediatric palliative social worker and onetime New York stage actor Rachel Rusch, MSW MA. Using the tenets of improvisational theater can help prepare clinicians to listen carefully and respond authentically to these conversations with their patients and families.

“My background was as an actor and performance artist before I got my master’s degrees in social work and child development and became a palliative care social worker,” Rusch explained. “Improv has so much to teach us: this is palliative care—being in a vulnerable space with others. How do we listen? How do we create the space for collaboration with an open heart?”

“I think there’s something about improv—which at its root is about togetherness and listening without judgment. Those things at their core can help with the difficult conversations of palliative care,” Rusch said. It also can help clinicians learn to trust their training and themselves when they enter these encounters.

One of her CHLA colleagues had mentioned an interest in taking an improv class, which Rusch encouraged and helped her to find. That colleague, Gitanjli (Tanya) Arora, MD, a palliative care physician at CHLA, took the class. “I’d come back to work the next morning after class and say, ‘Everything we learn in improv is what we’re doing in a patient’s room,’” she said.

Not About Being Funny

Improv is not about trying to be funny or perfect or the smartest person in the room, Dr. Arora explained. “It’s trying to partner together, doing your piece with the patient and family and your colleague—and somehow together it all works. Improv training is a low-stakes way of experimenting with what you might do or say in certain situations. When we enter patients’ rooms with difficult news, those are high-stakes situations.”

The guiding principles of improv, which is a well-defined form of performance created collaboratively without script or rehearsal and used to build an improvised scene with one or more other participants, are taught in countless improv classes coast to coast. The group at CHLA has adapted its principles, such as the notion of “Yes, and…,” which means whatever gets thrown at you in the course of the improvision is a gift—something you should go with and build on in the moment.

Another principle is to be 100% responsible for 50% of the interaction, meaning you are entirely engaged in giving your all to the scene while leaving just as much room for the other person to give their all. Also, trust yourself—listen to your inner voice and follow your intuition.

Rusch and several colleagues presented a standing room–only workshop on improv at the Academy’s 2019 Annual Assembly in Orlando, FL. “Many participants said this workshop helped them to remember why they chose to work in palliative care,” she reported. Since then, despite the interruptions of the pandemic, they have connected with other like-minded palliative professionals around the country and have been invited to speak at a variety of local and national conferences and lectures about improv and to lead improv exercises.

At CHLA, a new initiative proposes to combine this improv training with narrative medicine, an established technique of working with literary pieces such as poems or short prose and asking the students to reflect on the feelings they evoke and then do their own brief writing exercises following a prompt. Chris Adrian, MD, attending physician at CHLA, has used narrative medicine training to teach primary palliative care skills to clinicians at CHLA. He, Rusch, and Dr. Arora are researching the impact of combining improv and narrative medicine in a single 3- to 4-hour session.

Narrative medicine, as Dr. Adrian practices it, aims to connect people with their deepest values, which emerge from their writing. “We say, ‘Pay attention to what the writing does to you. Can we look together at how and why it’s doing that?’” he explained. “It felt to us like improv was an opportunity to immediately put these reflections into practice through an improv exercise. First, we connect participants to themselves with the narrative medicine exercise. Then, from that grounded place, we connect them to each other through improv.”

Arts and Self-Care

At the University of Alabama at Birmingham (UAB), arts techniques are integral to the training and experience of the HPM fellows—with an emphasis on self-care and self-compassion. “The intensity of this compressed, 1-year fellowship is hard on the fellows,” said Michael Barnett, MD, who, until recently, was the fellowship’s program director and is now core leader for education in UAB’s division of gerontology, geriatrics, and palliative care.

“When we recruit new fellows,” Dr. Barnett explained, “we talk about the curriculum we employ. We say this is not an afterthought—it’s foundational to our ability to care, to who we are as clinicians and as humans. It’s not about just giving a burnout inventory test.”

The commitment to self-care needs to be practiced proactively. “It needs to have protected time. Many of us love art and music and storytelling. So why wouldn’t we use the arts to think about the human experience and the human suffering our patients’ experience?” Dr. Barnett said. “We believe that there isn’t an arbitrary divide between self-care and good patient/family care. Having these conversations and taking care of ourselves and each other translates to better care at the bedside and a sustainable practice in palliative care.”

There are three main thrusts to UAB’s arts orientation for its palliative care fellows. One is to make a guided visit to the local Birmingham Museum of Art. A “silent patient exercise” includes an immersive viewing of a chosen work of art, followed by self-reflection and discussion of what the participants see in the painting, including the kind of human suffering they observe, explained Chao-Hui Sylvia Huang, PhD, assistant professor at UAB and founder of its Psycho-Oncology Counseling Residency Program. She also works with the HPM fellows.

It can broaden their understanding of human suffering—but also of healing, Dr. Huang said. “The message is: don’t be a silent patient. When you are struggling or need time off, ask for it.” Some works of art explicitly portray illness, such as a family deathbed scene. But the art doesn’t have to be that overt to spark relevant responses.

A second arts exposure takes place at a beautiful private garden removed from the UAB campus, with a picnic and conversation with a UAB music therapist who discusses how music is integrated into the medical center and how it can be used to increase self-awareness. “We talk about different musical instruments and their particular sounds, different styles of music, and music therapy concepts. At UAB, music therapy is used with patients from neonates to the elderly,” Dr. Huang explained.

A third encounter is done in collaboration with the UAB Arts in Medicine program, which, since 2013, has integrated the arts and artists-in-residence into the broader healthcare environment at UAB—for patients, families, and staff. One of the artists-in-residence, who is also a poet, teaches the HPM fellows about using creative writing for self-reflection, with a writing exercise followed by debriefing. According to Dr. Huang, the experience is designed to be engaging, encouraging participants to just be human, to not try to make a literary statement but let their thoughts fly.

UAB follows up with its fellows after they graduate. It has documented reductions in burnout and emotional exhaustion among participants in the arts encounters. “But a year later—even allowing for the impact of the pandemic—we see an increase in burnout and other symptoms since they have started their “real world” practices. They no longer have the protected time [for self-care],” Dr. Barnett said.

“Giving yourself permission to be whole, letting this be part of your life and your practice, is essential. If we don’t do these things intentionally, we are going to continue observing the burnout pattern for the whole field. We can spend our time creating healthy clinicians, but what happens when we send them out to unhealthy organizations or systems that don’t honor people in this way? It may require us to rethink our strategy.”

Dr. Barnett was asked whether the same principles apply to the permanent palliative care faculty and clinicians at UAB. Do they practice the same self-care techniques that are taught to the fellows? Do they participate in the immersions in art, music, and creative writing designed for the fellows? Four years ago, it was reported in this publication that the collective imperatives of self-care weren’t as high a priority for permanent faculty.³ But Dr. Barnett said they recently have started to join some of the sessions with the fellows.

“Emerging from COVID[-19], not just the physician faculty but the whole interprofessional team, all of us are coming together, doing poetry, creative arts, painting, drawing. Feedback from our very busy faculty has been incredibly positive,” he said. “Last week, we introduced a joint art project of pieces that were created by our staff, which now hang in our palliative care unit.”

Honing Observational Skills

Laura Morrison, MD, director of hospice and palliative medicine education at Yale School of Medicine in New Haven, CT, also uses art museum visits and other arts-oriented programs with HPM fellows. “Nine years ago, when we started our fellowship, we wanted to emphasize resiliency, self-care, and wellness for fellows across the training year,” she explained. That included art museum teaching, which can involve a number of different exercises around building observational skills and finding meaning.

“In one strategy, we look closely together at a piece of art, asking ‘what do you see?’ People are guided to share observations initially without judgment or inference. The group is repeatedly asked ‘what more do we see?’ The opportunity is to look more deeply, and more deeply again, rather than quickly concluding what may be going on—a lesson that can translate to daily clinical work,” she said. “In reflecting on the exercise, fellows often draw on parallels and meaning from their clinical experiences and reflect on how expanding it is to hear peer perspectives. Themes like joy, fulfillment, death, and rejuvenation often arise.”

This is also a chance to get out of the hospital to a more tranquil space and to talk specifically about resiliency and wellness, with structured time for reflection in the museum. Fellows have time to sketch, draw, and write in a journal. During the COVID-19 pandemic, the art visits pivoted to virtual tours, but in-person visits have since resumed. Dr. Morrison and a group of AAHPM colleagues active in art museum teaching presented these techniques at Academy meetings in 2018 and 2019.⁴

“Visiting our local art museum was part of my initial vision for incorporating the humanities,” Dr. Morrison said. “I also started a session in the hospital’s healing garden—with its architect speaking to our fellows and teams about what creates a healing space.” The fellowship program draws upon other local resources, including time with an art therapist and hospital-wide art projects.

A Listening Mindset

At the Cleveland Clinic in Cleveland, OH, the Center for Excellence in Healthcare Communication has made a significant investment in teaching communication skills to over 10,000 clinicians since 2010. Katie Neuendorf, MD, the current hospice and palliative medicine fellowship director and former director of the Center, trained a significant number of those clinicians. “Our task was to create something that would resonate with physicians—not just communicating but showing patients we care through the language we use,” Dr. Neuendorf explained.

Dr. Neuendorf has also received training from professional improv actors and worked with a PhD psychologist in developing exercises based in improv to support the communication skills curriculum. “When I think about improv theater, you have a sense of the characters and the scene, but you don’t know what they are going to say next, and they don’t know what you’re going to say after that. That depicts every medical encounter I’ve ever been in. You need to listen deeply,” she said.

“One of the things we try to teach is how these skills can help clinicians respond to what’s happening in front of them, rather than being beholden to a step-by-step process. I feel that the improv approach helps people stay nimble. I hope it makes them better clinicians.”

Narrative medicine also offers fascinating ways to get at key palliative care concepts, according to Dr. Neuendorf. “Everything we do in medicine is in response to a story,” added Dr. Neuendorf’s colleague Laura Shoemaker, DO MS FAAHPM, chair of the department of palliative and supportive care at Cleveland Clinic. “How do we identify, appreciate, internalize the details of that story?” Dr. Shoemaker leads narrative medicine sessions of 1 to 2 hours with fellows, introducing them to its principles and concepts while engaging with selected texts and then responding to them.

“We write timed reflective writing exercises, followed by sharing,” she said. These techniques are inspired by Rita Charon, MD PhD, executive director of the Program in Narrative Medicine at Columbia University in New York City, who believes that understanding patients’ stories helps clinicians face otherwise vexing problems in medical practice.⁵ Dr. Shoemaker uses texts like “The Aquarium,” a personal essay by Aleksandar Hemon about his young daughter’s death; Fortitude, a play by Kurt Vonnegut, Jr; and “His Stillness,” a poem by Sharon Olds.

“These are skills we can use in our medical practice. It helps the clinician be a better story interpreter, so we can be more responsive to our patients’ concerns,” Dr. Shoemaker explained. “It also helps decrease our assumptions and bias, if we are willing to let the patient tell the story and listen without interruption.”

For Rusch, Dr. Arora, and Dr. Adrian, working with these arts approaches is a chance to consider issues like bias and implicit bias, preconceptions, and the need for cultural humility. In this moment for America’s healthcare system, providers have a mission to work toward breaking down inequities and trying to impact the healthcare system’s dysfunction. “Palliative care as a field has a specialty in communication, and in valuing the perspectives and lived experience of the person in front of us,” Rusch said.

“Arts can uplift us, challenge us, and remind us of our shared humanity,” Rusch explained. “There’s something about utilization of arts in our world, hopefully, to be a space of expansion and reflection on ourselves. People can have a greater awareness of their own humanity and can partner with the humanity of others. If we can create more spaces to appreciate and learn about the diversity of lived experience, it adds another inclusive layer to our work.”

References

1. Arora G, Chua I, Rusch R. Yes, and…lessons borrowed from improvisational theater to teach primary palliative care skills (TH334). Abstract. J Pain Symptom Manage. 2019;57(2):380-381.
2. Arora G, Chua I, Rusch R. Harnessing the power of improv training in uncertain times. Center to Advance Palliative Care Blog. https://www.capc.org/blog/harnessing-the-power-of-improv-during-uncertain-times/. Published June 13, 2022. Accessed November 2022.
3. Beresford L. Resiliency on the job is vital for palliative care teams—and for their organizations. American Academy of Hospice and Palliative Medicine Quarterly. Spring 2018;19(1):12-15.
4. Morrison L, Zarrabi AJ, Hauser J, et al. Afternoon at the museum: connection and meaning at the Frist Art Museum (P07). Abstract. J Pain Symptom Manage. 2022;63(5):779.
5. Charon R. At the membranes of care: stories in narrative medicine. Acad Med. 2012;87(3):342-347.

Larry Beresford is a medical journalist in Oakland, CA, with a strong interest in hospice and palliative care.

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