Skip to main content

Lessons from the Stage: A Lesson About Patient Communication Learned in an Improv Class



My husband and I took a beginner’s improv class not long ago. Two of the most fundamental rules they taught about performing improv with a partner were: (1) never say “no”—it kills the storyline that you should be working with your partner to build. And (2) never say “yes, but...”…. because you might as well have just said “no.”

It plays out something like this: You and your partner get a prompt, such as pretending to be cops. Your partner has an idea for where the scene could go next. Little does your partner know that you have a brilliant idea for where you want to take the scene next. Your partner boldly proclaims, “Alright, partner, I just heard from the sheriff and there’s a murder to investigate.” Still holding to your own idea, you reply, “Yes, but before we get there, we first need to fulfill our assignment as undercover go-go dancers.” Yes, but… you just killed your partner’s storyline instead of building on it.

It sounds so simple. An easy two words to avoid. But once we were aware of it, we noticed that we were doing it every few lines, our own hidden tug-of-war over the storyline. Now, this is not to say that one can’t influence the storyline in improv. The primary building block of influence, however, is a different two words: “Yes, and…”

My husband and I started noticing “yes, but”s all over our lives. “Yes, but let’s do the dishes first.” “Yes, but I think this movie will be even funnier.” “Yes, but doing it this way might work better.” Countless hidden “no”s disguised under the cloak of “yes, but.”

One setting that is certainly not protected from the “yes, but” is the hospital. I was recently working with a resident, watching her interview a patient. The patient was an older gentleman with advanced hepatic disease. He had received a liver transplant many years ago, but subsequently relapsed on alcohol after the death of his wife. He had a history of poor engagement with care, and we were told had been quite stoic and closed-off during this hospitalization.

I watched with awe as the resident I was working with pulled a chair up to the bedside and really tried to get to know this gentleman. As the patient spoke about his 16 years with his wife before she died, of the way she brought meaning to his life, the tough exterior finally began to melt. For a moment, just a moment, water began to build in his eyes. The proud supervisor in me was rooting in my head, yes, let’s see if I we can keep him in this place. “That must have been so hard,” the resident began, “…but I’m glad that you were lucky to have sixteen good years together.” It was the “yes, but.” Coming from a place of good intentions, but a “yes, but” nonetheless.

As quickly as the door had opened, it had closed—the deep sorrow over a life without his wife closed behind it. His face was wiped, and we were back to business as expected. What would have happened, I wondered all afternoon, if the resident’s comment had stopped before the “but”: “That must have been so hard…” Had the patient transiently thrown us off of our storyline? Had my resident been attached to a plan of shifting this conversation towards positivity? Regardless of the cause, rather than building on the opening, we had reclaimed control of the reigns. Yes, but…

I began noticing the subtle messages embedded in so much of our wording in medicine. “I too hope your father will get better, but I’m also worried that he may not.” A phrase that I’ve said so many times from a place of kindness, but is there the subtle message: my worries and practicality are here to put a check on the hope you are so strongly clinging to. Changing the “but” to an “and”: “I too hope your father will get better, and I’m also worried that he may not.” A one-word change, possibly imperceptible, but perhaps with the subtle message: there is room for us to carry both—all the hope you may have, along with our worry.

Needless to say, different clinical scenarios will call for different communication strategies, perhaps at times even the use of a “yes, but.” Deciphering what type of communication a patient or family may need is indeed a large part of the art of medicine. But let’s face it, strategies that allow us to take control of the storyline come far more naturally to most clinicians. Controlling, predicting, planning—they are traits that are selected for through the years and hoops of medical training. I can say from firsthand experience that the same temperament that has been serving me through medical training, made the act of relinquishing control in an improv class feel surprisingly unnatural. Amidst our standardized exams and linear templates, perhaps this is just the skill that we need to be training clinicians for: neither taking control nor quietly watching the show, but enough engaged flexibility to build on the story— a partner in the patient’s storyline. Yes, and…

by: Danielle Chammas, MD (@ChammasDani)

Comments

Patrice Villars said…
Beautiful post and wonderful reminder of the many ways we strive to find a partnering balance between "control" and "watching the show". Thanks for another important reminder.
Anonymous said…
Yes and yes

and No may need to still be an option. As in , "No, we cannot offer more chemotherapy, now that you are too weak to care for yourself and in our experience, chemo would only make you weaker"
Thomas Reid said…
Agree completely! When a "worry" statement is needed, perhaps even the "and" is unnecessary. "I hope the chemo works too." (momentary pause to let the sentiment land) "I worry that it may make you even sicker."
George Herzog said…
Terrific post Danielle, thank you!
MaryAnn Misenhimer said…
Thank you, so much, for your awareness and your effective writing. What a gift to me, & others.
Oh, the huge difference changing that one 3-letter word can make: from 'but' to 'and'. Yet another example of the power of language in achieving goals in health - and applies beyond healthcare to everyday life, as I learned with my errant teenager. "Yes you have to get to school, and you have to clean the kitchen first" (ok: not life threatening but nonetheless turning an argument into a conversation/negotiation) Thank you so much for sharing improv experiences.
Anne C Mosenthal said…
What a lovely post....reminding us of the importance of language as a means of caring. perhaps the real job of physicians is to HOLD both hope and worry, especially when the patient cannot or willnot. Thank you for beautiful writing

Popular posts from this blog

The Future of Palliative Care: A Podcast with Diane Meier

There are few names more closely associated with palliative care than Diane Meier.  She is an international leader of palliative care, a MacArthur "genius" awardee, and amongst many other leadership roles, the CEO of the Center to Advance Palliative Care (CAPC).  We were lucky enough to snag Diane for our podcast to talk about everything we always wanted to ask her, including:
What keeps her up at night?Does palliative care need a national strategy and if so why and what would it look like?The history of CAPC and the leadership centersAdvice that she has for graduating fellows who want to continue to move palliative care forward as they start their new careersWhat she imagines palliative care will look like in 10 or 15 years?What is the biggest threat facing palliative care? So take a listen and if you want to dive a little deeper, here are two articles that we discussed during the podcast:
A National Strategy For Palliative Care. Health Affairs 2017Palliative Care Leadership…

Advance Care Planning before Major Surgery: A Podcast with Vicky Tang

This week's podcast is all about the intersection of geriatrics, palliative care, advanced care planning and surgery with our guest Dr. Vicky Tang.  Vicky is an assistant professor and researcher here at UCSF.  We talk about her local and national efforts focused on this intersection, including:
Her JAMA Surgery article that showed 3 out of 4 older adults undergoing high risk surgery had no advance care planning (ACP) documentation. Prehab clinics and how ACP fits into these clinicsThe Geriatric Surgery Verification Quality Improvement Program whose goal is to set the standards for geriatric surgical care including ACP discussions prior to surgeryHow frailty fits in and how to assess it (including this paper from JAGS on the value of the chair raise test) So take a listen and check out some of those links.  For those who want to take a deeper dive into how GeriPal and surgery fit together, check out these other podcasts: Zara Cooper on Trauma Surgery, Geriatrics, and Palliative Car…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …