Improvisation in the Time of a Pandemic: Field Notes on Resilience

Health care is an inherently complex and unpredictable system, and the COVID-19 pandemic has brought radical uncertainty worldwide. Medical schools, residency programs, and trainees alike were required to improvise in order to navigate this pandemic. Improvisation entails competence in spontaneous adaptation during evolving situations. By definition, improvisational performance is spontaneous, yet it is also a learnable skill.

The benefits of improvisation training are increasingly being recognized and used in medical education, especially to improve communication, empathy, and teamwork.^5,6  Our experiences and early evidence suggest that it can contribute to resilience as well. The adaptation of applied improvisation in the medical field has been termed “medical improv,” defined as the “principles and training techniques of improvisational theater to improve cognition, communication, and teamwork in the field of medicine.”⁷  Improvisation uses powerful tools, including attentive listening, observation, emotional presence, empathy, and collaboration.⁸  Medical improv does not train participants to be actors, but to effectively react to evolving situations in clinical contexts. It is not about being witty or funny but rather about full presence and open engagement.

The elements that tie well-being, resilience, and burnout are intricate, multifaceted, and complex. While external factors (eg, workload, autonomy, community, fairness) play a critical role in resilience, internal factors (ie, individual) deserve scrutiny as well. Wood et al discovered 4 potentially protective factors for residents against burnout: grit, social support, psychological flexibility, and resiliency.⁹  Resilience is one's ability to endure adversity, challenges, and disruptions with quick recovery. Experts have underscored “flexible adaptability” as the core tenet of resilience,¹⁰  which can be approached as a mindset of dynamic traits that can be intervened upon and improved.¹¹ 

A complete medical education proactively equips trainees with protective tools that can help them recover and rebound in the face of challenges. We complied an inventory of essential improvisation skills that have helped us buffer the ill effects of pandemic-related stress and foster resilience (Figure).

Improvisation promotes uncertainty tolerance via exposure. Each successive moment in improvisation opens many possibilities; as such, an improv encounter provides direct and consistent experience with uncertainty. This exposure leads to learned habituation, whereby the initial fear response atrophies as nonthreatening associations are formed over time.¹²  Inability to cope with uncertainty poses risks for clinicians, including undue distress, which may increase resource utilization, poor communication skills, and poor attitudes toward the underserved.¹³ 

Tolerance of uncertainty is an essential skill for professional and personal well-being and for resilience.¹⁴  Medical improv training provides an ease and comfort in the ability to adapt and react in uncertain situations, contributing to increased resilience.^15,16  The ability to say “Yes, and…,” to accept what is, even if you don't understand where it's all going, and add to it, is a fundamental improv principle. The ongoing pandemic has been a meditation in uncertainty tolerance—approaching and engaging it with an open mind has been key to resiliency. Improv has taught us to be comfortable in this discomfort.

Divergent thinking implies the potential to consider myriad creative solutions to an issue at hand. It contrasts with convergent thinking, the ability to arrive at a single accurate solution. Divergent thinking processes occur in a spontaneous and nonlinear manner, generating multiple ideas in many permutations and combinations. Evidence suggests that improv training increases divergent thinking,^15,17  which is essential for an optimistic, positive outlook. Improv training gives learners increased confidence in their knowledge, skills, and experience when taking risks, even if their attempts lead to failure. Individuals with low harm avoidance (ie, those with a positive outlook) are decisive and less anxious.¹⁸  During the COVID-19 pandemic we have been faced with many low points when enduring dread, and distress felt insurmountable. Maintaining optimism was crucial for resiliency.

A core ethic of improv is the focus on the “ensemble,” rather than an individual performer.⁸  Improv performers are in a tacit, collective agreement to share responsibility for a scene's outcome, commit to their team's success, and lend unwavering support to their partners. Medical improv teaches essential and powerful skills to function in groups and promote a culture of trust. Studies show that mutually supportive relationships and coherent team structures have protective effects against burnout for residents.^19,20 

Self-awareness, the metacognitive capacity, has also been noted to reduce burnout and improve resilience.²¹  Improvisation training builds awareness through a process of reflection. Improv exercises target specific communication or skills domains, followed by a debrief, feedback, and reflection. Participants are encouraged to reflect on these exercises, which can help cultivate a reflective mindset in their professional roles. This consistent practice of reflection lays the groundwork for performance improvement by consolidation of skills and inculcation of proficient behaviors.^4,22 

Mindfulness entails presence, which is critical for a meaningful connection.²³ Presence involves “learning to step back, pause, suspend expectations, and receive and connect with someone's story.”²⁴  A metanalysis of mindfulness practice found it to be effective in reducing burnout in physicians.²⁵  Improvisation training helps cultivate the skills of presence by practicing having your teammates' backs and being able to respond to the dynamics of what is happening in the moment. On the frontlines, amidst loss and despair, sometimes the gift of presence was the best we could offer. This presence had a centering, and often disarming, effect. These moments, in their ache and sadness, often gave way to unexpected joy, profoundly adding to our resilience.

Medical improv training has been reported as transformative.²⁶  An improviser's mindset is a liberating headspace that has helped us reframe the COVID-19 crisis into opportunities to grow, tolerate uncertainty, engage in divergent thinking, and practice mindfulness and self-compassion. Our experience and increasing evidence suggest that resilience can be cultivated through improv training. The Association of American Medical Colleges is leading a broad initiative to better integrate the arts, including improv, into medical education.²⁷  Additionally, the Accreditation Council for Graduate Medical Education Clinical Learning Environment Review initiative has a special focus on trainee well-being.²⁸  Drawing on an established core of effective medical improv exercises ranging in length from 5 to 20 minutes, residency training programs can select those that fit their needs for an energizing way to bolster well-being and resilience.^5–7,29,30  For faculty training, “Medical Improv Train-the-Trainer” is an annual 5-day course offered at Northwestern University for medical educators to learn exercises they can bring back to their programs.³¹  “Applied Improv” for health care professionals from the Alan Alda Center for Communicating Science is another option and is now being taught in various medical institutions worldwide.³²  In our experience, even a single improv class/workshop has the potential to foster a mindset of flexible adaptability and can carry forward into clinical encounters.^29,30  The Box and Table summarize practical strategies and exercises when starting medical improv.

Creating time and space for any new training in residency can be challenging. Creative solutions may include adding improv training as part of intern orientation, dedicated wellness days, or residency retreats. With the goal of fostering the mindset of flexible adaptability, we recommend incorporating improv trainings in GME to provide tools to residents and to prepare for future stressors.

Improv training is imbued with the spirit of curiosity, discovery, and humor. It is often described as an instructive dive into laughter and positivity. Preparing residents and fellows to navigate stressors including pandemics and natural disasters, both before and after they occur, is a much-needed skill that may be enhanced by improv training and is essential for longevity in their careers.

The authors would like to thank Katie Watson, JD, and Belinda Fu, MD, for the gift of “medical improv” to the medical community. Our heartfelt thanks to Alan Alda for inspiring and dedicating efforts to applied improv.