Society for Medical Decision Making

Session Summary

Technological advances in intensive care medicine and supportive technologies have led to more complex decisions around goals-of-care for patients with serious illness. Guidelines from professional societies recommend that when facing decisions in which more than one option would be ethically appropriate, outcomes are uncertain, and patients may have differing views about their acceptability based on their values, shared decision-making is appropriate (SDM). SDM is a collaborative approach in which clinicians and patients/families approach decisions jointly, discussing pertinent medical information and options as well as patient/family values to determine a course of action. Despite its demonstrated benefits and policy statements supporting its use, numerous barriers to SDM have been identified as inhibiting implementation in clinical practice. In particular, lack of training and clinician discomfort in engaging in these conversations contributes to challenges in its utilization. This has serious implications for patient care. Failure to engage parents may lead to serious consequences, including preference misdiagnosis and medical decisions that do not aligned with parents’ values. Innovative strategies to improve clinicians’ communication skills and confidence/comfort in having these difficult conversations is greatly needed.

Medical improv is a technique that has recently been developed to address the challenges of teaching advanced communication skills for difficult conversations to medical providers and trainees. In Medical Improv, theatrical improv exercises are adapted to align with health care in 3 ways: 1) standard improv exercises are followed by a debriefing that highlights their applicability to the health care context; 2) standard improv exercises modified to simulate the health care context; and 3) novel improv exercises target specific medical communication goals.  The “Walk like a…” exercise, for example, encourages participants to walk around the room and consider how their walk might change if they were another person, based on characteristics or experiences of that person.  Following the exercise, the group is led through a debriefing to think about physical embodiment of emotion and perspective-taking.  Similarly, in the “Cut to the Chase” exercise, what is originally a 2-minute story is passed down between participants in half of the time of the previous telling until it is reduced to 10 seconds. Debrief of this exercise includes discussion of fidelity of the brief version to the original story, as well as identifying the importance of clear language and appropriate level of detail in conveying the most important information.

To address the gaps in healthcare professional training on communication for shared decision-making, we have designed a workshop using medical improv to introduce participants to the ways they may use this type of communication, with a focus on clear explanations of medical information, active listening and eliciting values, identifying and acknowledging emotions, and cultivating and expressing empathy in communicating with patients and families.  We will use standard and adapted improv exercises that are geared to be active and engaging. Small and large group discussions with a mixture of interprofessional providers will encourage participation, as well as individual and group reflection.  The exercises will be accompanied by a facilitated debriefing to encourage reflection on how the lessons learned can be applied to a variety of outpatient and inpatient pediatric encounters. The debriefing will focus on 1) the identification of subtle factors influencing how these conversations unfold, 2) how to utilize knowledge of these factors in tailoring conversations to patients’ and families’ needs, and 3) how to practically apply these skills in patient care.

Learning Objectives

Describe the elements of physician-patient and family communication that are challenging for medical professionals engaging in shared decision-making. Identify ways in which improvisational exercises can prepare health professionals to communicate with patients, including in contexts where complex decisions must be made. Identify techniques to enhance the impact of each of the following variables in interpersonal patient/family communications: body language, vocal tone, language/phraseology, status dynamics, goal clarity/prioritization, and values expression/interpretation. Demonstrate interpersonal communication skills such as empathy, patient engagement, flexibility, and active listening.

Pre-Course Preparation

No particular pre-course preparation is required, although we will assume participants have an understanding of the basic principles of shared decision-making

Time Allocation & Topic Outline

Our understanding of the short course format is a half-day, including 180 minutes of active teaching time and 30 minutes break time. We have designed our agenda around this, but offer that it could easily be adapted shorter or longer as needed.

Welcome and “Yes? Yes! Circle” intro activity (10 min)
       - Debrief about attuning  to verbal and nonverbal cues, being present, and active listening

Introduction to medical improv (5 min)

“Yes, and” exercise (15 min)
       - Debrief about active listening, building on ideas, and validating others’ perspectives

“Walk like a...” exercise (15 min)
       - Debrief about body language, embodiment of emotion, empathy, and perspective-taking

“Conducted story” exercise (15 min)
       - Debrief about listening to foster collaboration, value of multiple perspectives and adaptability

Break (15 min)

“Status party” exercise (20 min)
       - Debrief about status dynamics in relationships (particularly in medicine) and how this can affect difficult conversations and decision-making

“Time traveler” exercise (20 min)
       - Debrief about cueing off of patients’ needs, meeting people where they’re at, and using appropriate tone, terminology, and levels of detail

“Cut to the chase” exercise (20 min)
       - Debrief about clear language, level of detail, and thoughtful conversation structure and pacing

Break (15 min)

“New choice” exercise (15 min)
       - Debrief about staying flexible and adaptable to new information

“Movie star interview” exercise (15 min)
       - Debrief about empathy, feelings and values elicitation, and perspective-taking

“2 minute rant” exercise (20 min)
       - Debrief about empathy, identifying underlying values and belief systems, and conflict resolution

Wrap-up and takeaways (10 min)

Faculty Background & Qualifications

Brittany Batell, MPH MSW CHES: Brittany is a Plain Language Specialist and Project Manager in the Office of Patient Experience at Michigan Medicine. Her work centers around education and health literacy, and ensuring that all patients are able to find and access the information they need, understand the information, and use the information to adopt behaviors and/or make decisions to support their care or the care of their loved ones. She has been a medical improv practitioner for about 8 years. At her institution, she recently developed and launched a series of medical improv skills labs for healthcare professionals to boost their critical interpersonal skills for positive patient-provider interactions, including listening, courtesy and respect, and clear communication. 

Stephanie Kukora, MD FAAP: Stephanie is a neonatologist and bioethicist at Children’s Mercy Kansas City, where she serves as core faculty in Certificate Program in Pediatric Bioethics. Her research interests include parent/clinician communication and shared decision-making in antenatal consultation, as well as tracheostomy and other goals-of-care decisions. She conducts global health work in neonatology with partners at St. Paul’s Hospital Millennium Medical College in Addis Ababa, and collaborates on capacity building in clinical pediatric bioethics with her Ethiopian colleagues. She also does work on education of medical trainees with advanced communication skills using improv theater exercises.

COI

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