Because I come from a long line of successful teachers, and was a teacher myself before entering medical school, it was a natural transition for me to move from training into medical education when I finished my psychiatric training at the Medical University of South Carolina (MUSC). I have always enjoyed the energy I get from teaching, especially in the clinical setting, and find that teaching motivates me to become the best clinician and educator that I can be. Though I have devoted countless hours to my roles at MUSC, I must admit I am leading a double life…

Just as I am a practitioner and teacher of psychiatry, I have to divulge that I am also a practitioner and teacher of another art…Improvisation. I have been an improviser longer than the span of my medical career and have been a primary company member with Theatre 99, in Charleston, SC, for 15 years. When those at my institution first discovered my double life, many questioned how such “different” occupations could possibly blend together? Over the years, the more I explored and attempted to master both, the more they not only blended, but synergized each other. In fact, I have found my improvisational training to be invaluable to me as a teacher.

When I am teaching improvisation, I begin my lesson by informing my students that there are five key principles that guide improvisational play:

  • You must be “in the moment”

  • Failure is required

  • You must know how to play the game

  • You must always operate on two levels

  • You must know the “magic word”

I then always remind my students that each and every one of us are experts in improvisation. After all, LIFE is improvised. When we are forced to make decisions in life, our brains take all of the information and resources available to it in that moment, categorize it, analyze it, and then use it in an attempt to create the best possible outcome. That is also what we do in improvisation…but on a stage. Knowing that we all possess this innate ability, it is my belief that, by using these five principles, we can become more effective teachers

Being “in the Moment”

As a teacher I constantly have to remind myself that there is no more powerful teaching moment than now. No experience in the past is ever going to mean more than it already has, and there is nothing in the future that effects the power of THIS moment. So, when you are teaching, “pay attention to the now.” One of the biggest educational foibles I continue to make is to fall into a pattern of treating rounds as only a clinical endeavor. Getting caught up in the existence of the mountain of tasks that I have to complete and trying to make rounds as “efficient” (see also: fast) as possible.

Adult Learning Theory tells us that it is the delivery of information in the moment of need that facilitates great learning [1]. I try to remind myself that each moment on a clinical service may be the important moment that changes a student’s perspective that keeps me ever-present during clinical rounds. This principle also reminds educators not to “save up” teachable moments for times when we may have “more time” because by then, the optimal time for our trainees to learn will have already passed. We must remember that it is important to never rationalize away the power that each individual teaching “moment” possesses.

Failure Is Required

I have found that many educators are more afraid of giving wrong information than they are excited about giving good training. In improvisation, we teach that a show as a whole is built of scenes, and all the scenes must be used to create it. There is no such thing as a “wrong” scene or an “unsuccessful” scene, even if in that moment the scene appears to be a failure. These “failures” are only steps to a greater success in the near future.

On rounds, I try to emphasize this principle by letting trainees know that there are wrong answers but no wrong “process.” I have given wrong answers on many occasions during rounds, but I always try to remind my trainees that I am not perfect, and I try to tune into my own intuition and be honest with my trainees about my level of certainty in the answers I give. I try to use these moments of uncertainty to teach the students that the process of finding out the correct answers (diagnosis, medication, formulation) is the most important task in psychiatry.

Many educators struggle with how to accomplish teaching “process” over answer, and I believe that I have come up with a way to do this that makes teaching, for the most part, effortless (if you can swallow your pride). Decide out loud. That’s it. Challenge yourself not to sensor your thought process when making clinical decisions. Openly monolog, fight with yourself, go through your “pro’s” and “con’s” audibly with your audience present. Seeing how you make your decisions will undoubtedly bolster their confidence and competence in making their own clinical choices.

Playing the Game

Many people think that improvisation is completely made up. Improvisation is seen by many as a cauldron of chaos that produces funny from thin air. Nothing could be further from the truth. While most theatrical elements are made up, improvisation can only be accomplished by following a distinct set of rules, agreed upon by the players. The rules, however, are not there to constrain us but instead are in place to free us up inside the game to take risks. Knowing that all the players have agreed to the same rules allows us to develop trust and to provide the opportunity to show our trustworthiness.

I have found with educators that this is the principle of improvisation that is often the hardest in implement in their daily life. Honesty and transparency are the foundation of any great training program. Our students should be trained in life, not sheltered from it. The rules that apply to them (seeking supervision when needed, admitting and atoning for their missteps, demanding professionalism in patient and inter-professional encounters) must also apply to us. As a teacher, we must be honest about our shortcomings as a clinician and educator and be willing to ask for help and supervision for ourselves when needed. We must always use the rules of the game to our benefit to continue to learn and improve. The moment we believe we are outside or above the rules of the game, the minute we begin losing the trust of those playing (or working) with us.

Thinking on Two Levels

This principle is the real “skill” of improvisational theater. It is the ability to be able to stay in the moment interacting with your fellow players, while constantly banking information from the scenes in order to effectively utilize that information at a later time. Inserting information, characters, ideas, and themes from a previous scene into a future scene in improvisation is known as “re-incorporation.” These re-incorporations are the moments that connect the work to the audience and make them feel as if they are a part of something special.

Adult learning theory explains that adults learn by assimilating and adapting information from our current surroundings and past experiences to define and explain our world around us [1]. This is no different than the re-incorporations generated in improvisation. Our job as educators is to create these re-incorporations for our trainees, facilitating the connection of clinical experience to their own memory and emotion. My father used to call this the “oh, so it’s like” phenomenon. He always said that when he was coaching a player if in the middle of his session the player said “oh, so it’s like” followed by a personal example, that he knew the player had the concept and he could move on.

Know the Magic Word

It is no secret that in improvisation, the word “yes” is important. The magic of improvisation flourishes when all the players are in conceptual agreement of who they are, where they are, and what they are doing [2]. This is “yes” in improvisation, this agreement. However, “yes” is not the magic word. “Yes” is the password. “Yes” is the affirmation.

The magic word takes things one step further. The magic word in improvisation is “and.” The magic word adds, builds, and connects. “And” is an outstretched palm. “And” is the cooperation.

In order to be a great improviser, you have to pay attention, expect to fail, know the rules, think out loud, and be willing to affirm and cooperate. It did not take me long after moving into a role as a clinician-educator here at MUSC to learn that being a teaching physician required the same exact skill set. We all have an improviser inside of us, and letting him/her out may be the best thing to happen to you and your trainees.