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Ethics Talk: Improvising Health Care

Learning Objectives
1. Identify key ethical values or principles at stake, as described in the program
2. Distinguish among factors of ethical, clinical, legal, social, and cultural significance
3. Articulate how central themes of clinical and ethical relevance in the program can influence health care practice
4. Explain at least one way in which micro-level clinical ethics questions intersect with broader macro-level policy questions in health care
0.5 Credit CME

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The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more

AMA CME Accreditation Information

Credit Designation Statement:  The American Medical Association designates this Enduring Material activity for a maximum of 0.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to: 

  • 0.50 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;
  • 0.50 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 0.50 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and
  • 0.50 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Audio Transcript

Tim Hoff (Host): The relationship between humor and medicine has long been appreciated via the lens of “gallows humor.” You've seen these characters on tv and in movies, it's the cynical medical professional joking about GOMERs and patients who are “circling the drain.” But this is an extremely narrow conception on how to apply humor and laughter in healthcare. It's also one that privileges clinicians as the maker of humor and places patients as the often unwilling or unwitting recipients. Some have argued that clinicians' uses of gallows humor is harmless and that it can even be a therapeutic source of release in high-stress situations. But this line of thinking fails to consider that when patients are the butts of jokes, it expresses something important about the characters of the clinicians making those jokes. It doesn't matter that the patient might never of overheard, what matters is that a clinician made a joke that demonstrates the attitude they think that a patient deserves from them. Gallows humor is not always an appropriate but thankfully there are other and often better ways to use humor in health care.

Improvisation for example is one artform that anybody can learn. Improvisation is helpful in teaching healthcare professionals how to deliver bad news to a patient or family, how to talk about sex with patients, or how to navigate any of the ethically complex, awkward, or high-stakes emotional turf of clinical practice and of life itself that exists between birth and death.

Kelly Leonard: People, uh, they don't like getting bad news, but what's worse is silence because that, in that silence… nature abhors a vacuum. They are going to put all their worse fear all their worse thoughts. The idea of offering quick real-time honest authentic feedback, being compassionate but also truthful, is something inside our feedback work that we bring into this space has been very effective with people.

Hoff: So, here's an example. If you've ever seen a medical student deliver bad news for the first time to an actor in an improv class, you can see that the delivery itself is a clinical skill that students might not be great at right away. Delivering bad news is a skillset and it's one that students can learn by practicing improvisation. Good bad news delivery happens when the delivery itself does minimal harm to the people who need to hear the bad news. Now if you've ever seen a clinician who is unskilled at delivering bad news deliver bad news to a real patient, you can see why learning how to improvise – especially before you're thrown into a situation that requires it – is a critical clinical and communication skill. Improvisation isn't always funny, but it doesn't have to be funny to be useful in healthcare.

Welcome to Ethics Talk, the AMA Journal of Ethics podcast on ethics and health and health care. I'm your host Tim Hoff. Our issue this month focuses on humor in health care and on this episode of the podcast we are joined by Kelly Leonard. Mr. Leonard is the Executive Director of Insights and Applied Improvisation at Second City Works, the co-author of the book of Yes, And: How Improvisation Reverses “No, But” Thinking and Improves Creativity and Collaboration--Lessons from The Second City, and he is the host of the Second City Works WGN podcast Getting to Yes, And. Kelly, thanks for joining us.

Leonard: Thanks for having me Tim.

Hoff: Improvisation and healthcare share at least one thing and that is that they're scary. Why is that?

Leonard: Well, you're working without a script, right? You don't know what's going to happen next and you're forced to interact with messy, messy human beings. Part of the high-wire act of improvisation – why people enjoy it is: they know how hard it is, it kind of feels like magic and when it works it's just so truly funny. What we know about comedy is: great comedy is about truth. It's about recognizing behaviors in situations reframed in a different way. Part of the reason comedy is so effective in discussing taboo or uncomfortable things is that it kind of lets us off the hook. It calls out the elephant in the room. This sort of mashup of the improv which is the skills building that we train our people in and then have taken to businesses and hospital units, health care units all over the world leads to a lot of really funny stuff. You see it at The Second City on stage but even in corporate workshops there is a lot of laughter.

Hoff: In Yes, And you offer strategies for making improvisation less scary and those generally are in the form of games. I imagine you use many of these games in your work with the improvisation for care givers program. Can you tell us a little about that program and how it works?

Leonard: I was lucky enough to meet Ai-jen Poo who runs an organization called Caring Across Generations. We got introduced by Adam Grant, the Wharton professor and author. Ai-jen's job is to change the cultural conversation around caregiving in this country. We decided to team up and bring the skills of improvisation to that space. We ended up presenting at Aspen Ideas Festival, Ai-jen, myself, and my wife Anne Libera who is a long-time improv teacher and comedy professor. Someone from the Cleveland Clinic was there; Ruth Bauman and she brought us in and got us a grant. We developed a six-week program that was at first focused on home caregivers, many of whom were dealing with relatives with dementia. The program really dealt a lot with some of the work we've done with the behavioral science community around self-regulation, around providing agency for themselves in these situations. But also to think of in an ensemble mindset, this is something we believe very strongly at Second City. None of us are in this alone. And yet, we tend to burden ourselves as if we are. We like to have people create ensembles – that the person you are caring for are is part of your ensemble, their relatives can be part of that ensemble, other people, doctors, nurses, anyone who is connected can be an ensemble member. That means that we are not just relying on ourselves all the time, that we are okay with asking for help. One of the things that we know from our work with a program that I co-lead called The Second Science Project at the University of Chicago, the work of Nick Epley, the scholar, shows us that people wildly underestimate how interested others are in their personal details. They don't want to share, we don't think people care, but in fact we do and when we share even sort of mundane things about our daily lives, we end up collaborating more effectively. People listen to us more deeply, they see us more. In the care giving space the ability to see your patients and see the people you are caring for and be seen back, I think is a very powerful ingredient in process of providing care.

Hoff: Besides this idea of the ensemble, which lessons from improvisation practice do you think are the most important to professional care givers?

Leonard: Here's a big one … I've had my own experience with relatives in this space. So many mistakes get made, we can't just act as if they don't. In improvisation, we have a couple of phrases, we have one that says “make mistakes work for you” we also have “see all obstacles as gifts.” This also reflects on the work that Amy Edmonson did in Harvard when she did coin the term psychological safety. You want to create an environment where people are sharing their mistakes so that they don't get made again. This idea and it's a big one in improvisation of failing forward – you are going to fail, we all fail. Fail out loud, it's okay. Especially when there are tiny little failures at the top when they are not in a crucial life and death situation because we are going to have to make a lot of rapid decisions in a short period of time and we need everyone to be comfortable acknowledging the mistakes and moving on from them rather quickly. I think that's a huge thing that I saw in my experience with a sick relative was, “there are mistakes. Let's talk about them so they don't happen again.”

Hoff: When we are in the face of making tough decisions in those crucial life or death situations we don't typically think of improvisational comedy, but you and your wife, Anne Libera, have devoted many hours to grounding your uses of improvisation in social science and neuroscience. What should our listeners know about the evidence that the science reveals?

Leonard: Yeah, so, I think we all know that the way the brain works, the “fight or flight” we're constantly sort of fighting. And we actually worked with the neuroscientist Charles Limb to study what happens in the brain when people are improvising. It's very interesting because what happens is – he did this by studying Second City improvisors under an FMRI – and they did scripted work and then they improvised and when they are improvising they move into a different brain state. And the brain state they move into is where they dial down the shame and they build up this, sort of, creativity. The brain shows us that when we are freely improvising we are able to craft our stories with a clarity of communication that's available to us, we increase our ability to collaborate.

I know this from being a theater producer and auditioning thousands and thousands of people to try to get on to Second City and seeing the people who are in fear just fail. We don't do good work out of fear, and we certainly don't do good work out of shame. In working with the behavioral scientists there's all kinds of interesting work that we ended up drawing on for the Improvisational Caregivers program, I think the most powerful one was when we looked at the classic improv concept of “yes, and” which is the title of my book because it's the most sticky concept in improvisation. For those of you who don't know “yes and” principle, quite simply when groups of people are making something out of nothing, you don't get anywhere when people approach that with a “no.” And you actually don't get very far with just a “yes.” We want people to say “yes, and” – to affirm and contribute in order to explore and heighten. We have an exercise, a “yes and” exercise, that we did for all the scholars at the University of Chicago, this is on one of the first lab meetings that we ever held, and they were like we get it. There is actually evidence to back up why “yes and” is a good idea. It's rooted in behavioral economics where we understand that people's default setting is to do nothing or say no. And you're giving what Richard Thaler will call a nudge – the Nobel Prize winning economist – giving you people a nudge to actually take that conversation farther and get to an abundance of ideas.

But they asked the question: they said what happens if you had a true disagreement, a real black and white “we do not agree.” How do you stay inside a conversation? Neither party quite knew, so the scholars went back and looked at the research, and we went back and looked at our, sort of, improv exercises and the literature in improvisation. And when are came back together we actually figured it out. So, we created an exercise called “thank you because.”

The idea here is if two people are in a disagreement and they need to stay inside the conversation, the way they can do that is by listening to what the person says, saying “thank you” which sets off the gratitude part of the brain – it's a very warm thing – and then the “because” which is finding some point of agreement as you are explaining to the person what they just said to you, some point of agreement so that person feels seen and heard. So the gratitude first and the seeing and the hearing. When you do that with each other, when you do that with other, you end up staying inside the conversation. This is something that we deployed in our improvisation for care givers workshops on the very first day, and there was a bunch of medical professionals, and I remember in the debrief afterwards after they done this exercise, the one physician held up his hand and said “I know that's how people are supposed talk, how I'm supposed to talk and I don't do it and I don't know why” and he just literally had tears in his eyes.

After we were debriefing internally with the Caring Across Generations people and ourselves in Aspen, we talked about an hour, and then we left the room that we were in, there were at least six different couples who had taken the workshop they didn't know each other before, they had done that exercise together and they were still inside that conversation. This is a very powerful tool that people can use when … you know especially in the times we live in which are so polarizing and so tribal and we tend to block people and not want listen to them, the idea of really attempting to be grateful authentically grateful for the information, and then make sure the person knows that you understand them and you find some point of agreement.

I will tell you Xuan, a woman who was one of the academics who worked on the study, we did it with thousands of people, and she was just about to write the paper and she goes you know what I want to do one more thing I want to see what happens when one person does “thank you because” and the other doesn't and see if it's still effective. It turns out – I think she's about halfway through so maybe seeing like 500-600 people – It is. The results so far that actually even when just one person does it, they can stay inside that conversation and it's a more effective conversation.

Hoff: … hmmm, so they can encourage the other person to stay even if they might not want to or maybe incline to.

Leonard: There is a social scientist by the name of BJ Fogg who's got a book called “Tiny Habits.” I interviewed him for the podcast, he talked about advising a client who is a divorced parent and they always had conflict when they dropped off the kid. He advised based on his understanding of the literature a very similar thing which is just don't respond to any of negativity, be thankful, use thankful words, smile and basically within six weeks that relationship had been repaired to the sense they would have very nice exchanges with the drop offs. This is something I think we are seeing in behavioral sciences and can be applied to human beings using in the world.

Hoff: Sure. That's amazing, and I think it's clear how some of those skills would be helpful in the healthcare setting and you work with a lot of clinicians in various Second City programs that you host. What are some of those successes with healthcare workers specifically that you have observed?

Leonard: A big one is the difficult conversations because there's many of those in that space. People, they don't like getting bad news, but what's worse is silence because, that in the silence… nature abhors a vacuum. They are going to put all their worse fear all their worse thoughts. The idea of offering quick real-time honest authentic feedback, being compassionate but also truthful, is something inside our feedback work that we bring into our space has been very effective with people. There's also another exercise that my wife and I, our daughter had cancer and so we applied many of these techniques inside her hospital room during her journey. One of them was an exercise my wife created called “Universal Unique.” And I mentioned this earlier that we had evidence from the fact that people don't think others want to know their personal details. This exercise we pair up people. One person shares a universal something, like in one minute tell me how people grocery shop just universally. And they do that. And then we say take a second and think about how you personally grocery shop. And then tell that to the person. The second conversation is always funnier, it also you have these absurd shared truths that you have with people like I always forget my bags and then I'm struggling do I go back and get my bags or do I buy new ones how do I … you know we all have these weird like … and you realize oh my God that actually meant something I actually know something about you. In Nora's hospital room anytime a new nurse came in that we didn't know we would instantly be like this is Nora she also goes by Eleanor, I am Kelly, this is Anne, we have a 100-pound Burmese mountain dog named Benchley who's kind of a jerk to other people, most Burmese are very sweet he's not. Then we're like so who are you, where do you come from? We really built up an ensemble of our care givers because they knew us and they would see Nora. They understood, they truly got it when she was not doing well and when she was doing well. It was just very apparent. I think that has a lot to do because we did this sort of early work, we just took a moment. So much of improvisation is about … like “yes, and” is not something like… you're going to say “no” a lot, like we get that. But maybe try five minutes at top of a brainstorming or five minutes at the beginning of a conversation just to entertain everything. Just to say “yes, and” to everything … . We certainly edit like crazy at Second City when we develop. We're creating … this is how it work professionally is, we “yes and” the creation these new sketches that we create. We probably try 150 sketches and only about 17 or 18 are going to end up in the final show. But the way we get to the really good stuff is miring through a lot of stuff that maybe isn't so great but we also find gems. The idea, it's a simple idea of experimentation. Scientists know this they need to experiment, also as a human you need to experiment. This stuff isn't easy. These conversations aren't easy. It's tough enough for one human, then add two then add three and then add four and then add a whole hospital. It's amazing that we get through the day as well as we do.

Hoff: That certainly sounds true. I love that idea of the universal unique activity. It seems like a secondary benefit of that would be to have the things that are unique but that you are not quite so proud of be validated by somebody else, somebody else can see the things you say, “Oh I know I really should be doing this or that but I just don't” and to have somebody else say it's okay I do that too.

Leonard: Dan Gilbert, who is the Harvard scholar who studies happiness, he has a thing he says which is “if an alien came down to the world and met one person he'd understand 95% about humanity” We share a lot. And especially the foibles and the failures and stuff, yeah I think it's a big relief. Stephen Colbert says when working at Second City “you've got to learn to love the bomb.” That's in part of like yep that's something that we know and really is a tool of resilience which is another thing that is big in the improvisation for care givers program. These hard jobs. The idea that somehow magically you're going to be able to come to work with a good mood in all of these sort of life and death situations is impossible that can't always be the case. If you can train yourself and practice and build up the muscles of resiliency and a lot of that is when you can share laughter about the stuff that's hard. I think that's really important. I know we're living through this global pandemic right now. I would be nowhere if I didn't have the shared laughter of my colleagues even if it's via a Zoom call.

Hoff: Along that line of thinking, what are some of the most important failures, that is failures that you've learned the most from, during these Second City programs?

Leonard: Oh God, there's are a litany of failures.

Hoff: [Laughter] Pick one, yeah.

Leonard: Here's a good one, the Second City has a thing. We have a holiday party every year and we've been doing this … I've been being at Second City for 32 years, and they've been doing it before I was there, so I think it's like a 45-year old tradition. What happens at the holiday party is that the staff – like the bar staff, waiters, waitresses, box office staff – they put on a show for the rest of us – for all the talent, for the producers, the directors, the tech people. Their show what it always comprises of are lampoons of the current Second City material that's on stage and all directed at us, all making fun of us or things that have happened throughout the year. So basically every failure that happens is then displayed back to our faces. In one year, this is a while ago, the waitresses were singing a song they sung in one of the sketches those in the show and they literally walked on the stage in front of our owner Andrew Alexander and sang him that “you can dress up a pair of jeans why don't we have health insurance?”

[Laughter]

Leonard: And Mike Conway who is our general manager at the time is just sinking in his chair he's like this is … I'm going… you're getting me fired. But that's not what happened. The next day Andrew called all the executive team in the office and said, “how do we get them insurance?” And we did. I think this is a good example of setting up ways in which truth can be spoken to power. In organizations you can't just have an open door and you can't just tell someone you can say anything to me. You have to create again nudges, systems, ways that people who don't have power can feel safe in speaking it to you. The Second City holiday revue is that. It is a temperature check on what's working and what's not working and every year we have it. One of the things I noticed in my time at Lurie Children's Hospital, it is a wonderful, wonderful hospital and our care giving team was excellent, the only time things kind of suffered was when the bigshot surgeons got involved. They were usually older white men, and they didn't listen. And that was fairly consistent across the board and something that I've seen studies on as well in the work that we've done. I think it is not … unfortunately, most of the people who need to hear the hard truth the most don't want to hear it. But I do believe that there's generations that are coming up now that I have a lot of faith in who are here for the tough news because they want to live a life of meaning and a life of purpose and that means trying to be the best person. We are not always the best person. We need to get those notes so that we can do better.

Hoff: Some many clinicians are so skilled and so good at what they do and they care very deeply about their patients, but healthcare is fraught with all kinds of problems that extend beyond the interpersonal conflicts that you might think improvisation would be most relevant for. Some of these problems are sort of macro-level issues of pervasive racial ethnic and gender inequity and lack of parity between how healthcare systems handle physical illnesses versus mental illness. How can improvisation help tackle some of those systemic problems?

Leonard: Funny you should ask…

[Laughter]

Leonard: One of the very first programs that we developed at the University of Chicago was based on heuristics and all the, sort of, bias work, unconscious bias. We created an orientation program that's still running there, actually there's three now. Every incoming freshman at the University of Chicago and now the law school goes through this program. The very first one is called “Hearing One Another.” There's stacks and loads of evident that shows that diversity training doesn't work. People walk in in their “fear brain” or their “shame brain” and you cannot learn when you are there. And so, we take a different approach. Our training is not fear or shame based. We're just trying to get people to understand that all of us treat people differently and that can have consequences. Now sometimes that's fine because you don't want to treat a child or a baby the same way as you would an adult or an elderly person. So that shortcut makes a lot of sense. But sometimes it doesn't. It doesn't mean you're a racist, but it does mean that you, like all of us, have bias. One of the first exercises that we do in Hearing One Another program is we gather the group in a circle and the instructor says, “Okay, when I yell out this attribute or speak this attribute I just want you to move to another part of the circle if it's something that you identify with.” She starts saying. “I'm someone who's wearing blue jeans. I'm someone who identifies as a male, I'm someone who identifies as Catholic, I'm someone who owns a gun, I'm someone who identifies as Republican.” Slowly what you start to see is everyone is looking around the room and it's like, “Man, the vegan is a republican?!” or “This person owns a gun and they identify as a liberal?” Walt Whitman was right we contain multitudes. This is something … it becomes … then we can sort of breakdown how bias works how our brains work that way we do take these shortcuts and increasingly in more complex situations we have to learn not to take those shortcuts and then the training sort of goes on from there. I think that there's a starting point for people to really be able to educate themselves and when they can understand that every single, the Dan Gilbert thing, every human being has bias. That includes people who are in minority communities and there's biases within those communities. We all have it. It's the job of all us to tackle it, not just them and not just us, all of us together.

Hoff: Many of our listeners might be interested in learning more about how to use improvisation in their practices or in their teachings, and of course anyone can enroll in the Second City online programs, but before we a wrap up if you could teach our listeners three ways that they can become better improvisors with just skills they already have or skill that might be easy to learn, what would those three ways be?

Leonard: Oh interesting. Here's the first one, we're really bad at listening and we don't always know it. Here's a thing you can do. We have an exercise where you can't begin your sentence in response to when someone speaks to you with anything but the last word that the person said. You listen what someone says you take the last word they said and make that the first part of your response. What you will discover is that we don't listen to the end of sentences normally, we start planning our come back. That is a really good and effective tool. And here's the other thing too, the silence before your response is not going to make the person across from you think that you aren't listening. What they're going to figure out is that you are considering what you just heard which is huge – like, “Oh you are actually listening to me.” That's a great one.

There is an improv exercise that we used as a parenting tool and the exercise is called one “one-word story” where you tell a story one word at a time. Our kids are named Nick and Nora and they would fight in the back seat and so my wife Anne would be driving and say let's do the “one-word story” game. It shifted their attention but the other thing it did is it taught them how to have collaborative conversations. Everyone wants to win a game and you don't win that game if you're not ready to share a lot of boring “the's” and “and's,” you don't always give the juicy adjective, and you learn that when you do the “one-word at a time” game.

The last one is a thing I'll talk about from our experience. Nora didn't make it, she passed away on August 1st, and it was tremendously difficult, as you can imagine. There is an improv phrase that I leaned on both during her illness but also in my grieving process and that's “play the scene you are in not the scene you want to be in.” It is so easy to catastrophize. It's so easy to linger in the past of like, “How could we have caught this, what did we miss?” None of that is helpful. The thing that is most helpful is when I can be in the moment and understand how grateful I am for her life, and grateful for the people who cared for her, and grateful for the family I have now which she'll always be a part of. It's a little bit mindfulness, right? It's a little bit, sounds a little Buddhist. But it really is about staying where I am now, and working with what's in front of me. I think for a lot of us, especially I know this with my friends who suffer from anxiety and depression, they're always worrying about the thing before the thing after it's usually never about the thing happening right away. So much improvisation is about directing us to keep us in that moment. You're on the stage right now. All you have is the person across from you. Their job is to save you and make you look as good as possible until you are off that stage together. Then you are on with someone else and it's the same thing, we are all operating with these rules. That's something that's really important to me in the hardest times and I think it can be useful at all times.

Hoff: Kelly Leonard thank you very for joining us and for a great conversation.

Leonard: Thanks Tim.

Hoff: That's our episode for the month. Thanks to Kelly Leonard for joining us. Learn more about the Second City's online courses at secondcity.com/online-classes. Music for this episode was by the Blue Dot Sessions and fact checking was performed by the journal's researcher, Shaun Rouser. To read our entire issue on humor and healthcare for free, visit our website journalofethics.org. And for our latest news and updates follow us on Twitter @journalofethics. We'll be back next month with an episode on one physician's experience with opioids and a policy statement from the American College of Preventive Medicine. Talk to you then.

Audio Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

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