“Improvisation involves reworking precomposed material and designs in relation to unanticipated ideas conceived, shaped, and transformed under the special condition of performance, thereby adding unique features to every creation” (Berliner, 1994, p. 241).
Continuing with the theme of medical education, Sarah Greene from e-patients discusses the book, Pedagogy of the Oppressed by Paulo Freire as a way to improvise talk in medical training and clinical practices.
Although the book is about teachers and students, she supplements these words with doctors and patients. The book underscores that “real revolution can occur when the playing field is leveled between doctor (teacher) and patient (student), whereby critical thinking is infused in education and where ‘doctors become patients’ and ‘patients become doctors.’ Communication amongst students (i.e., social networking) is equally important in this equation.”
She highlights two sound bites in particular:
–Participatory medicine cannot tolerate an absurd dichotomy in which patients are merely following their doctors’ decisions—a dichotomy reflecting the prescriptions of the dominant elite. Revolution is a unity, and doctors cannot treat patients as their possessions.
–The dialog which is radically necessary for the participatory medicine revolution corresponds to another radical need: that of women and men as beings who cannot be truly human apart from communication, for they are essentially communicative creatures. To impede communication is to reduce humans to the status of things.
Her hope, as well as others, is to have the theme of participation, dialogue, critical thinking and communication become infused in medical education materials. And her concluding call: Let’s communicate! But how can we begin to transform or improvise talk?
Karl Weick, a leading organizational scholar, developed improvisation as a mindset where he uses the vehicle of jazz improvisation as the source for orientating ideas. Specifically, understanding communication as improvisation can be understood as “transforming the melody (discourse) into patterns bearing little or no resemblance to the original model of using models altogether alternative to the melody as basis for inventing new phrases.” Improvisation involves the embellishment of something and in this case the embellishment of dominant (scientific) clinical practices.
Understanding communication as improvisation is like understanding communication as a song. The song can be played exactly as scored or with improvisation, but “one would not expect an improvisational theorist to play only one song over and over anymore than one would expect a jazz musician to play only one song throughout a lifetime” (Weick, 1998, p. 550). In a society where fluidity and discontinuity are central, improvisation must play a role in clinical practices.
If improvising is the goal, what would improvising look like for both patients and providers?
Although uncomfortable of “how-to-do communication” lists, I think it’s important to highlight a way this transformation can unfold. That said, I borrow four interaction skills from Stan Deetz, PhD, a professor of communication. These skills, although basic, are believed to carry much significance in terms of revising the way we talk, think, and act in medical training, the clinic and social media forums.
The first interaction skill is immediacy. This is a sense of being present, paying attention, and listening through the inclusion of emotions. It is not simply waiting for your turn to respond but requesting understanding by being responsive. Immediacy is patient and careful.
The second skill is concreteness. This form of talk includes expressions that avoid abstractions by providing details because abstractions create problems. For example, rather than saying, “patients are irresponsible,” try saying, “I was disappointed last week when my patient did not follow-up after their appointment.”
Ownership is the third skill that explicitly involves assigning and expressing appropriate responsibility for feelings and actions. This form of talk stays away from unowned statements such as “you make me so frustrated” because these statements immediately remove the responsibility from you and places it on someone else. This someone else can be a set of rules, generic shoulds and oughts, or actual people.
Finally, the fourth interaction skill is acknowledgment. This way of talking involves making explicit your understanding of the other person’s message prior to responding. In so doing, each participant is affirmed and valued and meanings are clarified. Acknowledgment usually requires some degree of paraphrasing of the other’s statement or nonverbal messages, but goes beyond this to include questions like, what is the patient really saying? What are the most important thoughts, feelings, or perceptions that the patient is expressing?
These skills may sound like a no brainer. Nonetheless, I encourage you to take one or all four of the skills and start incorporating them into your own clinical encounters. This will be an attempt to begin to improvise or transform talk and therefore, begin to re-think medical training and clinical practices as we’ve come to know them and as we’ve come to imagine them.
With thanks to kevindooley and Daniel Greene for their desert images…
Carey Candrian
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