Exploring the Value of Improvisational Theater in Medical Education for Advancing the Doctor–Patient Relationship and Health Equity

Abstract

Purpose

Health care inequities persist, and it is difficult to teach health professions students effectively about implicit bias, structural inequities, and caring for patients from underrepresented or minoritized backgrounds. Improvisational theater (improv), where performers create everything in a spontaneous and unplanned manner, may help teach health professions trainees about advancing health equity. Core improv skills, discussion, and self-reflection can help improve communication, build trustworthy relationships with patients, and address bias, racism, oppressive systems, and structural inequities.

Method

Authors integrated a 90-minute virtual improv workshop using basic exercises into a required course for first-year medical students at University of Chicago in 2020. Sixty randomly chosen students took the workshop and 37 (62%) responded to Likert-scale and open-ended questions about strengths, impact, and areas for improvement. Eleven students participated in structured interviews about their workshop experience.

Results

Twenty-eight (76%) of 37 students rated the workshop as very good or excellent, and 31 (84%) would recommend it to others. Over 80% of students perceived their listening and observation skills improved, and that the workshop would help them take better care of non-majority- identifying patients. Six (16%) students experienced stress during the workshop but 36 (97%) felt safe. Eleven (30%) students agreed there were meaningful discussions about systemic inequities. Qualitative interview analysis showed that students thought the workshop helped develop interpersonal skills (communication, relationship building, empathy); helped personal growth (insights into perception of self and others, ability to adapt to unexpected situations); and felt safe. Students noted the workshop helped them to be in the moment with patients and respond to the unexpected in ways more structured, traditional communication curricula have not. The authors developed a conceptual model relating improv skills and equity teaching methods to advancing health equity.

Conclusions

Improv theater exercises can complement traditional communication curricula to advance health equity.

Health professionals must connect with patients from all backgrounds—including races, socioeconomic status, and gender identities—while navigating a landscape of inequity, structural racism, and gender stereotypes. The ongoing COVID-19 pandemic and recent police brutality against people of color have brought increased national attention to health inequities,¹ and health education governing organizations including the Liaison Committee on Medical Education have called for health equity education for medical trainees.² While many medical schools strive to teach trainees how to advance health equity, effective equity training remains challenging.^3,4 Ideally, health care professionals would establish trust with patients through skills such as active listening, empathy, and shared decision making.^5–7 They would understand how implicit bias and structural racism affect encounters with patients from minoritized or marginalized backgrounds and the care they receive.^8–10

Not only the content but also the process of teaching about health equity is difficult. Discussions about racism, power, and privilege are emotionally charged,¹¹ and trainees are in different stages of readiness regarding their willingness to acknowledge and address these issues.¹² In addition, creating safe, brave spaces where all trainees can discuss and learn is a challenge.¹³ Trainees include people of color and members of sexual and gender minority groups who regularly experience microaggressions and the effects of structural racism and bigotry.¹⁴ Trainees also include socio-politically conservative students who may be afraid to speak up for fear of being branded as racist or bigoted. Curricula need to meet the needs of all these trainees.¹⁵ All too often clinicians, patients, and trainees feel like they are speaking different languages or not discussing difficult issues that are submerged yet salient.

Improvisational theater (improv), an unscripted theatrical art form where the performers create everything in the moment, has potential as a tool to teach about advancing health equity.¹⁶ From its inception, improv theater has been used to address social inequity. The practice of improv started in the 1920s by Neva Boyd, a social worker at the Hull House in Chicago, as a means of teaching adjustment skills to inner-city and immigrant children.¹⁷ Theatrical games were used to teach children self-expression and self-realization. This would later develop into a form of comedy and entertainment.

Patient-centered, empathic communication and trusting clinician–patient relationships are essential for addressing health inequities.⁵ The evidence-based humanistic framework, Presence 5, which highlights preparation, active listening, agreement, connecting to the patient’s story, and exploring emotional cues, fosters strong clinical and interpersonal connections and has been used to teach about racial justice and health equity.^18–21 Similarly during an improv sketch, performers must actively listen, form relationships, agree quickly, and place themselves in the minds of other characters. The principles of improv theater have previously been applied to medical training as a tool to develop communication skills, empathy, dealing with uncertainty, and collaborative patient care.^17,22,23 Improv gets at the core of how people communicate, and this theatrical practice may be a fun and effective way of advancing health equity.

Effective patient-centered communication requires a mix of iterative and scripted communication styles. While early in medical training the scripted approach may be more dominant, over time successful clinicians employ a more iterative-based approach to communicate effectively with patients, including those experiencing health disparities. While clinicians are required to adjust their communication framework to the individual needs of each patient, current curricula often rely on structured questioning techniques and memorizing key phrases.^24,25 Early learners can struggle when the patient “goes off script” and they must adapt their communication skills. Improv provides a more fluid model of communication based on adapting to the needs of the patient and meeting them where they are, as opposed to forcing the patient into a preconceived script.^23,24 A central tenet of improv is the concept of “Yes, and…” in which the actor must accept the suggestion of their scene partner and build on it. Similarly, clinicians are called to accept the patient for who they are at a given moment and to build on this starting point to establish a trusting partnership. Improv’s strong focus on listening and starting where their scene partner is helps build a safe space for the performers or audience and patients or clinicians to have tough discussions.

Prior medical improv curricula have, to our knowledge, had a general patient-centered approach but have not explicitly addressed racism, structural inequities, privilege, and power.²³ Therefore, we piloted a 90-minute virtual improv workshop with first-year medical students designed to advance health equity. Our primary goals were to develop trainees’ listening skills, communication flexibility, and relationship building, and to connect these skills back to health equity. We also aimed to explore the potential for improv to engage students in discussions around differing perspectives, health equity, privilege, and structural inequities, as a means for reflection and personal growth. Our goals are consistent with the mission of the University of Chicago’s Bucksbaum Institute for Clinical Excellence to enhance communication and decision making, strengthen doctor–patient relationships, and reduce health care disparities.

Method

In September 2020, 90 first-year students in their second month of school at University of Chicago Pritzker School of Medicine participated in a virtual health humanities workshop that was embedded in the required Health Equity, Advocacy, and Anti-Racism (HEAAR) course.^4,15 As part of this course, students had previously received professionalism and safe space training. Each student was randomly assigned to participate in 2 out of 4 possible health humanities sessions: improv, stand-up comedy,²⁶ graphic medicine, and Theatre of the Oppressed.¹⁵ Sixty students participated in the 90-minute improv sessions, which were held via Zoom, a video conferencing platform. These students were randomly assigned to 1 of 6 small groups that were led by a physician (J.M.R.), a paired scientist (J.A.D.) and physician, and a professional improviser/theater owner. Each instructor team taught the workshop twice, and thus on average there were 10 students per workshop. All teachers had experience teaching improv in either a medical or general context.

The instructors and investigators considered the overall goals of the humanities workshops to be improving students’ ability to care for patients from marginalized or non-majority-identifying backgrounds, exploring interpersonal bias and discrimination, and understanding systemic and structural inequities. Considering the context—a 90-minute 1-time workshop; students who did not know each other well; required workshop rather than students who electively chose an improv workshop; different teachers with varied amounts of experience teaching improv, medical students, and health equity—we decided to focus on simple general improv exercises aimed to improve active listening and patient engagement.

To promote consistency among the small groups, the instructors developed a facilitator guide. Figure 1 and Supplemental Digital Appendix 1, at http://links.lww.com/ACADMED/B389, contain examples of games and discussion questions available to the facilitators to highlight key skills in achieving the learning objectives; we have previously published more detailed instructions for the Group Mirroring and Yes Circle games.¹⁵ At the start of the session, each instructor reviewed professionalism expectations to establish a safe, comfortable learning environment. Instructors debriefed the participants for 5–10 minutes at the end of each session, aiming to connect these exercises to caring for patients from underrepresented or marginalized identities.

Figure 1.

Basic general improvisational theater exercises and key skills, from a virtual improv workshop for first-year medical students, University of Chicago, 2020. Group mirroring requires participants to pay careful attention to even the slightest sound and action of others, practicing close observation and attention to non-verbal cues. Yes circle, played in multiple versions, demonstrates to participants the effects of enacting the “Yes, and…” principle, including the need to pay close attention to other participants and the futility of planning their contribution. One-word story further enacts “Yes, and…” and encourages participants to share ownership of the output (i.e., the story) amongst the team and to trust one another. Colors/patterns correspond to the pillars of health equity (see Figure 2): Medium gray grid, effective communication; dark gray dots, trustworthy relationships. See Supplemental Digital Appendix 1, at http://links.lww.com/ACADMED/B389 for discussion questions.

Instructors asked students to complete an online survey with Likert scale and open-ended questions (see Supplemental Digital Appendix 2, at http://links.lww.com/ACADMED/B389)) that was built on Watson’s improv survey and a prior survey we had used in an improv workshop for ethics fellows.¹⁷ Participating students were asked to complete the survey immediately following the session, with 3 email reminders. Survey questions evaluated the workshop, including a global evaluation; whether it was stressful, safe, and enabled the student to take risks; whether it helped the student bond with classmates; and whether it included meaningful discussions about systemic inequities. The questions also assessed the workshop’s impact on communications skills, including listening and observing, and whether students perceived it would help them better care for patients with lived experiences different from their own. Open-ended questions inquired about the workshop’s strengths, impact, and areas for improvement.

After the workshops, a subset of the entire class of 90 students was asked to participate in structured one-on-one interviews by a doctoral student not known by the students. See Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/B389 for the interview schema. We aimed to interview 5 Asian American students, 10 Black or Latinx students, and 5 White students to provide a range of perspectives across race and ethnicity. We invited students to participate from a list of students randomly ordered within race/ethnicity category until we reached the enrollment goal, the list had been exhausted, or the enrollment period ended. We conducted 17 interviews (with 4 Asian American, 6 Black, 2 Latinx, and 5 White students), of whom 11 students (4 Asian American, 4 Black, 2 Latinx, 1 White) had done the improv workshop and are the focus of this analysis. All interviews were recorded and transcribed. Four of the investigators (J.M.R, N.M.O, J.A.D., M.H.C.) developed an initial codebook by reviewing the same 3 transcripts, and the codebook was iteratively updated as the other transcripts were reviewed, reaching theme saturation. Each transcript was coded by at least 2 reviewers and disagreements were discussed until consensus was reached. The same 4 investigators coded transcripts. The team also analyzed the open-ended answers to the survey that was administered to all students.

This study was approved by the University of Chicago Institutional Review Board.

Results

Quantitative survey results

Thirty-seven (62%) of the 60 workshop participants completed the self-assessment survey. Of these, 17 (45%) were female and 1 (3%) was non-binary. Thirteen (34%) were White, 3 (9%) Black, 3 (9%) Latinx, and 15 (41%) Asian American. Twenty-eight (76%) students rated the workshop as very good or excellent, and 31 (84%) would recommend this workshop to other students. Most students agreed or strongly agreed that the workshop helped them to develop listening (30, 81%) and observation (31, 84%) skills and to bond with peers (33, 89%). Six (16%) students felt stressed during the workshop, while 36 (97%) felt safe. Eleven (30%) students agreed or strongly agreed there were meaningful discussions about systemic inequities during this session. Additional data are reported in Supplemental Digital Appendix 3, at http://links.lww.com/ACADMED/B389.

Major themes from qualitative interviews and open-ended survey responses

We identified 6 major themes in the interviews and surveys (Table 1 and Supplemental Digital Appendix 4, at http://links.lww.com/ACADMED/B389). For the quotes, participants are designated by a randomly assigned number and by A, Asian American; B, Black; L, Latinx; or W, White.

Table 1.

Improv and Advancing Health Equity: Themes and Quotes From Qualitative Interviews and Surveys After a Virtual Improv Workshop for First-Year Medical Students, University of Chicago, 2020

Theme	Attributes	Illustrative quote
Interpersonal skills	• Listening • Empathy • Communication • Relationship building • Interdisciplinary communication	• It made me understand that there are a lot of different ways to actively listen to people, not only by hearing what they are saying but by interpreting their body language. Similarly, I learned how my own words and body language could be portrayed by others. Finally, it taught me the importance of affirmation for a patients’ thoughts/experiences/feelings by practicing the “Yes, and…” method. (Survey W32) • Translating that to medicine in the sense of being able to listen to someone’s story and kind of, you know, almost like harmonize with them and build that together is an important skill. (Interview A2)
Personal growth	• Self-perspective • Perspective of others • Adaptability • Professional identity	• It was a creative way of practicing active listening and observation. It was a very low- stakes way of practicing how to hear and accept what others bring into a situation, and how to work with what you are presented with as opposed to countering or negating what someone brings into a situation. (Survey A59) • Really helped me consider the social privilege afforded the doctor within the patient- doctor relationship. (Survey W44) • I mean, I think in some ways they were shaped by my lived experiences as someone who grew up in neighborhoods where they didn’t necessarily have things like improv and standup shows readily available, and so it wasn’t a norm. It was my first time doing that. So I think if anything it would be the unfamiliarity of it all was shaped by my identity as a person from a lower socio-economic status. (Interview B8)
Safe space	• Fun • Trust • Learning environment • Inclusive	• Was a lovely experience! Thinking about improv in a way that could actually help our future practice as physicians was unique and new to me. I really enjoyed it. (Survey W30)
Limits of traditional communication curriculum	• Checklist approach • Scripted • Not being in the moment	• It’s not the best way for me to learn how to approach a patient because we get these PowerPoints … with bullet points on things I need to hit… I used to think I needed the perfect transition sentence, the perfect responses, but having more workshops like the classes that we did really opened my eyes to just a different way of approaching things. (Interview A3) • Putting myself in the shoes of the lived experiences of other people there’s like an imaginative quality to the classes that we did, and imagination is kind of at the root of empathy ‥ .I do think that empathy is not something that you can learn through a medical curriculum, at least the way the current standards are nationally. (Interview A3)
Value of improv workshop	• Peer bonding • Collaboration • Value of the arts and humanities in medical education • Connection to patient care	• We recognized that no matter what experiences or backgrounds people bring to the table, it is crucial to listen, observe with respect, and respond in a way that is accepting and open-minded. (Survey W30) • I think for improv it helped me see the importance of everyone’s voice. … I feel … I will be the type of physician where I know my patient’s voice is important. But it also helped me see the rest of my team, the rest of the family members in a patient’s life, those are all just as important, so understanding that those voices mean a lot to the patient, mean a lot to me in my decision-making as well. So it’s like patient, their family, their life, and then my team—nutritionists, pharmacists, chaplains, whatever, it may be, nurse practitioners. So understanding that the voices are equal. (Interview B5)
Feedback to improve the improv workshop	• Not applicable	• There was not a lot of talk about structural inequities, so maybe we could add one or two more activities on this. (Survey L39)

Interpersonal skills.

The students felt the improv workshop helped improve interpersonal and communication skills including listening, empathy, iterative communication, interdisciplinary communication, and relationship building.

A big thing … was the importance in improv of listening because you can’t respond to something if you’re not hearing what the other person is saying, and if you’ve already planned your response then you’re not actually fully participating in the conversation or in the activity. (Interview B4)

Definitely the improv workshop made me think more about working with patients and families … I feel like so often when we’re talking to people, we’re thinking about what we’re going to say next versus really listening to them and reacting off of that and kind of like mirroring and all those social cues. Yeah, it’s so easy to get stuck in a script and not be able to go with the flow. (Interview L3)

Personal growth.

Students highlighted personal growth, including how they perceived themselves and others, adaptability, and developing their professional identity.

The module made me more attuned to ways that my behaviors might affect others and how to pay more attention to the behaviors of others. (Survey A27)

Students also referenced how improv teaches a joint, collaborative process and that clinical shared decision making should value both clinician and patient preferences and values.

As far as improv … you’re not dominating the entire thing, you understand that whatever comes out at the end is not necessarily going to be your maybe ideal scenario, it’s going to be the one that was balanced by the preferences and values of probably you and your patient. (Interview L2)

Safe, brave space.

Most students felt this workshop was a safe, fun, and inclusive learning environment. Students noted how improv could improve trust, which is critical for patient care.

It’s really about cultivating kind of this emotional landscape where you can inspire trust, where people can feel free to be silly and have fun. And so, cultivating those emotions is what is more important in improv and ultimately more important in the patient encounter. (Interview A3)

Limitations of traditional clinician–patient communication curricula.

Students reported how improv filled gaps in the traditional communication curriculum. Students felt the improv approach to patient communication was less scripted, which helped them be in the moment with patients.

I didn’t really ingrain how to be a good listener from listening to our clinical skills lectures. It didn’t really hit me until I did the improv workshop … how to do it in practice. If someone says be a good listener, listen to your patient, they don’t say overcome your desire to say something cool. They don’t really get at what are the actual steps you take, and you don’t get to see the results of it if you improve. (Interview A3)

Value of improv workshop.

Many students discussed how the improv workshop helped them bond with their peers, especially during the COVID-19 pandemic when classes were virtual and students were largely working from home.

We hadn’t interacted much because of COVID. We had been primarily online. So it was a nice way to break down barriers and be a little more informal around each other, and a little more candid. (Interview L3)

Feedback to improve the improv workshop.

Multiple students stressed the need for more time or additional sessions. Also, first-year preclinical students asked for a more deliberate discussion about the clinical applications.

I think it would have been useful to connect it more to medicine at the end. I think it was a fun activity, but a lot of the extrapolating for how we relate this to our practice has to happen independently. (Interview B4)

Many students did not perceive this workshop as addressing systemic inequities. One student did not see how improv could be used in a serious manner to explore the complex systems issues that create disparities.

It’s honestly challenging for me right now to think about other than adaptability how we’re supposed to use improv to handle disparities without sacrificing the complexity of the system that has created all of these disparities and wanting to make sure we’re still holding that at the level of seriousness that it deserves. (Interview B4)

Discussion

Within the required HEAAR course, we found that randomly chosen first-year medical students who took a 90-minute virtual workshop using basic general improv exercises agreed that it could help them take better care of patients with lived experiences different than their own. In particular, students perceived the workshop as helpful in improving their communication and relationship building skills. The workshop included general discussion questions that asked how the workshop exercises related to patient care. Neither the exercises nor discussion questions were geared toward exploring systemic inequities. It is perhaps therefore unsurprising that most students reported that the workshop did not generate meaningful discussions about systemic inequities.

Conceptual model

Based upon our experience teaching and evaluating this improv workshop and teaching about health equity, we have developed a conceptual model for how improv skills and equity teaching methods can advance health equity (Figure 2). To advance health equity and improve the quality of care and outcomes for patients from minoritized or underrepresented backgrounds, 3 pillars of health equity are crucial to teach health professions students¹²: effective patient–clinician communication,⁵ trustworthy patient–clinician relationships,²⁷ and addressing bias, racism, systems of oppression, and structural inequities.¹¹ We identify 3 categories of improv skills and equity teaching methods that buttress the 3 pillars. The first 2 categories are based on our preparation of this pilot workshop and the evaluation results: “Yes, and…,” active listening, and non-verbal cues; and empathy, collaboration, and trust. The third category is based on our discussions about how future improv workshops could more effectively address bias and systems of oppression: improv scenarios raising issues of status, power, bias, and culture, combined with discussion, personal storytelling, and self-reflection within safe, brave spaces.¹⁵

Figure 2.

Conceptual model: Improv skills and equity teaching methods to advance health equity, from a virtual improv workshop for first-year medical students, University of Chicago, 2020. Colors/Patterns correspond to the pillars of health equity: Medium gray grid, effective communication; dark gray dots, trustworthy relationships; light gray upward diagonal lines, address bias and systems of oppression.

Our pilot focused on the first 2 pillars, patient–clinician communication and trustworthy relationships. Improv focuses on many key skills for building an iterative communication style such as active listening, observation, and non-verbal cues.¹⁶ Many of these skills are also essential elements for building the empathy needed to develop trusted clinician–patient relationships. While not used in our pilot, some improv exercises require participants to take on a character and feel the emotions the character is experiencing. These theatrical exercises can be a very powerful tool for developing empathy and understanding the lived experiences of others. They can also help learners reflect on self-identity and how others perceive their image. Based on our other improv performance and teaching experiences, we believe that equity-focused improv exercises around status, power, bias, and culture combined with well-chosen discussion questions, opportunities for experiential storytelling, and self-reflection would be promising for teaching around racism, systems of oppression, and structural inequities—the third pillar of our conceptual model (Figure 3 and Supplemental Digital Appendix 5, at http://links.lww.com/ACADMED/B389).) Clinicians must acknowledge their own identities and any bias, privilege, or power they bring to the patient relationship.²⁶ Some improv exercises place participants in different status categories, and thus ensuing scenes frequently raise issues of power, privilege, oppression, and structural inequities and how these can manifest in interpersonal interactions. Two of us (J.A.R., M.H.C.) previously led an improv workshop in which we successfully used the Foreign Movie Translation game, an exercise that could spur discussion about caring for patients with limited English proficiency (Figure 3). One of us (M.P.S.) has successfully incorporated self-reflection exercises in improv workshops and instructed learners to practice improv skills in new contexts such as the home, increasing the likelihood that trainees will learn these skills and employ them in patient care.

Figure 3.

Intermediate equity-specific improvisational theater exercises and skills, from a virtual improv workshop for first-year medical students, University of Chicago, 2020. See Supplemental Digital Appendix 4, at http://links.lww.com/ACADMED/B389, for discussion and self-reflection questions. Colors/patterns correspond to the pillars of health equity (see Figure 2): Medium gray grid, effective communication; dark gray dots, trustworthy relationships; light gray upward diagonal lines, address bias and systems of oppression.

A particular challenge for traditional communication curricula in medical schools is teaching learners how to adapt in the moment to what patients say, do, and emote, that is, the complexity of actual patient encounters.²⁸ Improv workshops are particularly strong at providing skills in adaptability. A jazz-based curriculum with a strong focus on musical improv showed improvement in learners’ ability to adapt within a standardized patient encounter.²⁴ In multiple studies of theatrical improv, learners report improvement in flexibility, comfort with uncertainty, and ability to adjust to unexpected situations.²³ The patients experiencing the largest health disparities often require clinicians to be flexible to understand and meet their needs. A communication curriculum that includes substantial improv training could be an important building block. Learning acquired from active, experiential curricula has a higher likelihood of being translated and applied into new situations such as the hospital or clinic compared with lessons from passive teaching techniques.

Our workshop did not joke about inequities and in our instructions about the improv exercises we specifically noted that these improv exercises were not about being funny. However, a student in the qualitative interviews had the opinion that improv could not teach about systems issues leading to disparities, and thought that discussions needed to have a serious tone. We believe that more advanced improv exercises (Figure 3) could spur productive, serious discussions about systemic drivers of inequities. In addition, comedy has long been used as a tool to enact social change.²⁹ Through laughter, comedians can break down social barriers and bring people together through shared experiences to discuss taboo topics.³⁰ Approaching serious topics in a lighthearted way can lower resistance to audience persuasion and stimulate discussion. Clinicians can leverage these skills to similarly connect with patients, colleagues, and leaders from different backgrounds to move health equity forward. We believe that principles of improv comedy can be harnessed productively to teach about advancing health equity in safe, brave, respectful ways,¹⁵ as we have seen for a separate workshop taken by the medical students that used principles of standup comedy and was highly rated.²⁶

Limitations

This pilot study is exploratory and has limitations. First, this was a single 90-minute virtual workshop at a single institution. Time was an important limitation for number of exercises, skills covered, repetitions per student, and the amount of discussion. Some students suggested that longitudinal workshops throughout their medical school experience would be helpful. Second, we had difficulty recruiting the full number of Asian American, Black, and Latinx trainees for the qualitative interviews, and by chance only 1 of the 5 interviewed White students had been randomly assigned the improv workshop. However, the open-ended survey responses included a broad range of students. One student actively declined being interviewed and the remaining non-participants did not respond to the email invitations. The graduate student who recruited and interviewed the participants noted that students reported feeling significant stress due to the COVID-19 pandemic, police brutality against people of color and the racial justice movement, the 2020 election, the attack on the United States Capitol on January 6, 2021, and being in medical school.¹ Participating in the qualitative interviews felt like “too much,” in the words of one student who was approached for recruitment. Other students noted the many asks made of Black, Indigenous, and people of color students over the past year regarding diversity, equity, and inclusion, and anti-racism efforts. It is critical for health professions schools and training programs to support these students and other marginalized trainees, and for advancing health equity to be everyone’s responsibility.¹⁴

Future directions

Future improvisational theater workshops to teach about health equity could use more advanced status and power exercises. Those exercises could more directly encourage discussions about structural racism and White and other social privileges. Longitudinal curricula across the 4 years of medical school could tailor exercises for stage of training and further develop and reinforce important concepts. For example, we have found that residents, fellows, and practicing clinicians more easily see the application and value of improv exercises to patient care compared with first-year medical students.

In addition, robust evaluation techniques using a variety of mixed quantitative and qualitative methods and experimental designs would be helpful to test outcomes along the spectrum of the Kirkpatrick model of training evaluation levels including reaction, learning, behavior, and results.³¹ A key challenge for medical education and medical education research is that clinical medicine, including providing equitable care to all patients,³² is a complex system that requires adaptable behavior and multilevel approaches.^20,21,28 Traditional competency-based medical education evaluation techniques have limitations for capturing this complexity.^28,33 Moreover, evaluations of curricula designed to teach about health equity, structural racism, and social privilege should capture particularly complex processes and outcomes. Tema Okun and colleagues explain elements of White supremacy culture present in grant and journal review processes that can dominate and negate the voices of marginalized populations, including the concepts of one right way, paternalism, and objectivity.³⁴ Springs and colleagues performed a scoping review of research in arts in health and recommended that rigorous evaluation methods should be tailored for the adaptive and nonlinear nature of the arts and the complex topics the arts have been used to teach, including racism, social justice, and climate change.^35,36 Learner and patient feedback would be important sources of information for assessing the value of improv theater curricula for improving the care of patients from non-majority-identifying backgrounds and addressing racism and other systems of oppression.

Conclusions

In conclusion, our pilot study found that first-year medical students perceived that improvisational theater exercises could help them take better care of patients with different lived experiences from their own through improving skills in listening, observation, relationship-building, and adaptability. Improv exercises could complement a traditional health professional communication and relationship-building curriculum that tends to be more structured. We also believe that equity-specific improv exercises, discussion questions, and self-reflection opportunities have significant potential for teaching about racism, systems of oppression, and structural inequities, and are important areas for future study.