Abstract: The US Medical Licensing Examination requires future doctors to examine actors in simulated, improvisational scenarios to test students’ ability to empathetically collect medical histories, perform basic examinations and diagnose an illness. To better prepare for this clinical testing and improve upon patient complaints related to doctors’ insensitivity, medical schools increasingly turn to university theatre programs to help develop interpersonal aspects of doctor/patient interactions. Based on four years of devising and delivering successful theatre-based programs at two Philadelphia area medical schools, this essay details benefits, challenges and curricular implementation of empathy-building programs that emphasize the embodied nature of theatre and medicine.
Keywords: Empathy-building, Medical Schools, Theatre Pedagogy, Standard-Patient.
The United States Medical Licensing Examination, sponsored by the Federation of State Medical Boards and the National Board of Medical Examiners, requires all future doctors to physically examine paid actors portraying patients in simulated, improvisational scenarios to “[assess] whether [students] can apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory settings.”
A fundamental portion of the examination replicates general practice encounters where medical students collect a fictionalized medical history, perform basic physical examinations, and complete diagnostic interview/observations of a simulated illness. A board of licensed physicians observes and evaluates the procedural and diagnostic aspects of the scenarios but “standard patient” actors often grade would-be physicians on “empathetic response” and “professional demeanor” (http://www.usmle.org/step-3/).
To prepare for this heavily weighted clinical testing and address growing patient complaints related to doctors’ emotional insensitivity, medical schools have increasingly turned to university and professional theatre programs to design curriculum to prepare students for the physical, vocal and emotional aspects of interpersonal doctor/patient interactions. Based on four years of devising and delivering successful theatre-based curricular programs at two medical schools in the Philadelphia area, this essay details the philosophical considerations and curricular creation, delivery and assessment of empathy-building pedagogy that emphasizes the embodied nature of theatre and medical practice.
Imbedding humanities coursework in medical curriculum is becoming more and more commonplace, because, according to Johanna Shapiro and Lynn Hunt, “the inclusion of the humanities in medical school curricula emphasize their ability to help students access the patient’s subjective experience of illness as well as to provide a psychological space for students to reflect on their own professional development.” Or, as another published M.D. notes, “For whatever reason—economics, efficiency, increased demands on physicians for documentation, technology, or the separation of education from patient care—curiosity in physicians is at risk. I believe it is our duty, as those who now teach young physicians, to identify medical students with a gift for curiosity and take infinite pains not to suppress but to encourage that gift.”
Finally, Dr. Kathy A. Stepien explains in her article Educating for Empathy, “The Association of American Medical Colleges states in their Learning Objectives for Medical School Education, ‘physicians must be compassionate and empathetic in caring for patients,” because, “Effective communication and a ‘warm, empathetic’ style have been shown to improve clinical outcomes.” Nevertheless, after reviewing thirteen peer-reviewed articles related to qualitative and quantitative studies on pedagogy designed to teach empathy, she also notes that, “current studies are challenged by varying definitions of empathy, small sample sizes, lack of adequate control groups and inadequacy of existing empathy measurement instruments.”
Although quantifying if/how arts education actually helps teach empathy is challenging, Kate Rossiter counters this concern in Bearing Response-Ability: Theater, Ethics and Medical Education:
Art forms such as theatre elude and truncate straightforward, instrumental, factual analyses. Further they are open to multiple interpretations and impact each learner differently. These qualities make the arts epistemologically disturbing to an educational system that values instrumental skill development and the transfer of objective knowledge. However . . . this slippery, unpredictable quality of art’s impact is precisely what allows the possibility for ethical encounter to occur. That art cannot be solely reduced to its function as a vehicle for knowledge transfer creates fertile ground upon which to build an ethics of inter-relationality [i.e. the author’s definition of empathetic response] that transcends knowledge.
Like Rossiter, many theatre educators intuitively and experientially understand that the direct human interaction of theatre performance provides a strong foundation for students to interpret, simulate, practice, discuss and clinically evaluate how bodies and voices manifest empathy in imaginary circumstances. Therefore, using established theatre-based pedagogy in a studio space, outside of a traditional testing laboratory and/or actual patient interaction, often allows doctors to more easily discuss, practice and interpret empathetic response.
Activity focused theatre pedagogy also offers potential side-benefits of allowing medical students to physically explore their emotional range, discuss how they culturally interpret/read emotional responses and interact with peers in a more direct, non-competitive and personal way.
While evolving studies point to the benefits of infusing theatrical pedagogy into medical training, little research has been published from the perspective of theatre practitioners called upon to provide these services. University theatre programs face both positive and negative implications when choosing to collaborate with medical programs. Primary advantages can include increased agency in the eyes of university administration, potential interdisciplinary discovery, new academic dialogue, enhanced areas of research, fruitful avenues for arts-education application and increased access to ripe funding of STEM based grants.
It can also offer theatre students and/or faculty new career options as specialized performers and/or arts educators. Finally, it can cultivate deeper appreciation of the value of arts education, foster future patronage and build audiences. Ideally, theatre-based medical education can demonstratively impact and improve medical training, which results in better, more responsive and compassionate doctors.
Nevertheless, pitfalls can inhibit productive partnerships between medical and theatre programs. In some cases, serving the rarefied needs of another discipline can divert valuable faculty and departmental resources away from art making, professional actor training, and mainstage production. This shift can inadvertently reinforce a subordinate and undervalued status of theatre pedagogy as an “extra-curricular” activity. Science-minded faculty and students could view the experiential nature of theatre study as a distraction from, rather than a reinforcement of, traditional book-based medical training.
Given the strenuous task of delivering crucial disciplinary content knowledge, justifying the value and time of empathy-focused education could appear low priority for medical students and faculty. Meanwhile, theatre work that requires medical students to physically and vocally engage can suffer if even one reluctant participant undermines the open communication and collaboration needed to make this work happen.
It is also common to face conflicting expectations of the two academic units. Faculty members building these programs generally do not have extensive practical experience in both areas of study. Theatre faculty can lack needed clinical and content knowledge to communicate with authority, while medical faculty can underestimate the time and expertise needed to design and deliver empathy-building curriculum. Logistical concerns regarding the availability of qualified instructors, time, studio space, funding sources, assessment, ongoing communication and program accountability need to be carefully negotiated at the start of any project. Despite these challenges, the potential rewards offer powerful incentives that can benefit both departments.
In 2013, Rowan University in Glassboro, New Jersey, became one of two universities in the US to offer D.O. and M.D. degree-granting programs by acquiring the Rowan School of Osteopathic Medicine (formerly University of Medicine and Dentistry of New Jersey) and simultaneously establishing Cooper Medical School of Rowan University. The massive expansion and accompanying state funding to implement and maintain these satellite programs quickly transformed Rowan from a liberal arts university into a budding Research Institution.
To better fulfill the missions of all three institutions and to utilize common resources, medical faculty soon reached out to the main campus to address the national call to prepare students for doctor/patient interactions. The M.D (Allopathic) granting program at Cooper Medical School in Camden, New Jersey prides itself on forward-thinking work in this area and notes in the core mission:
Being a new school afforded us with the unique opportunities to create a culture centered on teamwork, professionalism and empathy. We’ve had the advantage of being able to develop a curriculum that offers dynamic teaching methods that support learning, including a focus on active learning, simulation and early and frequent exposure to patient care. (http://www.rowan.edu/coopermed/about/)
To address this claim, Cooper Medical requires second and third year students to complete one “Selective” humanities course each year that generally requires twelve contact hours divided in two-hour blocks on six Fridays of an academic semester. The University website describes the goal of this coursework as:
The Selectives in the Medical Humanities are intended to create a well-rounded physician with a background in the arts as well as the sciences and to foster the development of creative, empathic, and intellectually adaptable physicians who are capable of using their right hemisphere as well as their left. The compilation of courses is meant to provide students with various perspectives and thereby facilitate problem-solving and creativity in multiple arenas.
Course options include: “Dance and Medicine,” “Observational Drawing for Future Physicians,” “Opera and Medicine” and “Art of Observation.” Two courses designed and regularly taught by theatre faculty from the Rowan main campus are “Medical Improvisation,” and “Theatre, Role-playing and Medicine.” Intensive discussions between Melanie Stewart (Associate Dean of Performing Arts), Dr. Dyanne P. Westerberg (DO, FAAFP and former Chair of Family and Community Medicine) and Elisabeth Hostetter, PhD (Chair of Theatre and Dance), led to the following overarching goal to, “explore the humanistic side of patient and health care using physical and vocal theatre techniques to interpret patient/character emotion and general motivation.” The role-playing course requires students to:
- Practice interpersonal communication skills needed in peer and patient interactions.
- Emphasize the essential humanity of the medical profession.
- Heighten awareness of non-verbal communication, including gesture and vocal tone/inflection.
- Build awareness of spontaneity and presence as markers of active listening and observation.
- Practice improvisational responses in interpersonal conversation.
- Create a sense of peer ensemble in a non-competitive, non-judgmental space to diffuse stress, anxiety and to build trust among colleagues.
- Prepare for mandated “Standard Patient Scenarios” used to evaluate bedside competency.
Meanwhile the Improvisation class designed by Melanie Stewart with assistance from Gina Sewter encourages students to:
- Understand basic rules and principles of theatre improvisation.
- Improve cognition.
- Develop listening, responding, and observation skills.
- Promote cross-cultural and status sensitivity through theatre improvisation exercises.
- Effectively collaborate and work in teams.
- Develop ability to respond creatively and spontaneously in stressful situations.
- Expand understanding of emotions and communication through theater improvisation.
- Bridge the communication gap in the physician/patient relationship.
Designing specific exercises and progression of course work was also a point of mutual discussion and, for the Role-Playing course, involved:
|Recognizing Doctoring as an embodied practice, being present and available to patients and hospital staff. Contextualizing humanistic challenges of working with patients within the art of live performance.
|Recognize the important of being present, emotionally alert, collaborative, communicative and flexible and physically and vocally express ideas and emotions. Practice working in a collaborative ensemble with peers.
|Students discuss and engage in challenging, well-established theatre exercises that physically and vocally engage all participants to build a cohesive, communicative, open, supportive, and trusting ensemble. Students will actively engage in social interactions that inform/replicate patient/doctor interactions.
Group focus and cohesion exercises. Introduction of relevant literature, overview of goals and expected outcomes, establishing group ensemble.
|Emotion and Verbal/Non-Verbal Communication
|Appreciate emotion and communication implied in printed word, physical gesture and vocal tone.
Realize body movements, facial expression and vocal inflection can affect our relationship with others
|Discussion of body language.
Exercises from Augusto Boal’s “Theatre of the Oppressed”
Assignments: Sculpting physical and emotional relationships, tactics exercises, Building effective problem-solving by practicing a variety of physical/vocal tactics to achieve goals,
|Write/perform an original monologue from patient’s perspective and build scenes around the fictionalized characters.
|Develop and workshop group improvisations and physically performed scenes dealing with doctor/patient/colleague interactions related to weekly issues
Themes include: Cultural Sensitivity, Professional Awareness,
Extended Family Interaction, Conflict Resolution
|Students develop a character suffering from a medical concern and write a monologue from the character’s perspective. Students read/perform each other’s work and develop/rehearse a group scene set in a medical environment based on a selected character’s backstory. All students perform a role in the scenario (medical personal, patient(s), family, administrators, community members.)
|Preparing/Perform Original Standard Patient Care Scenarios and Mastering Doctor/Patient Interactions
|Discuss and perform character and scenario. Demonstrate mastery of simulated doctor/patient interactions
|Based on the themes of the previous weeks, students create and perform complex scenarios that demonstrate their mastery of skills learned during the preceding sessions.
Similarly, the Improvisation class focused on:
The Rules of Theatre Improvisation
|Recognize the importance of being present, emotionally alert and flexible. Practice physically and vocally expressing emotions and working in a collaborative ensemble.
|Students will discuss and engage in challenging, well-established theatre exercises designed to establish good listening and responding skills and build a cohesive, open, supportive and trusting ensemble. Students should leave with a feeling of safety, excitement, discovery and possibility.
|Storytelling and Character Development
|Develop the ability to take on the role of another person by “walking in someone else’s shoes” and deep listening skills.
Students practice body language, facial expression and vocal inflection to affect relationships with others
|Discuss the handout “Curiosity” and review the rules of Improvisation. Perform a series of exercises focused on generating stories and characters to explore different walks of life, diagnostics, stereotype and bias. Test listening skills in a “Genre Scene” exercise.
|Thinking on your feet and juggling multiple goals
|Develop body awareness, improve cognition, spontaneous response, and ability to multitask in stressful situations.
|Discussion of “Blink” and the concept that improv is about making good decisions under “high stress conditions of rapid cognition.”
Learn and perform multi-tasking improv exercises
|Emotion; coping with ambiguity; recognizing “what’s really going on”
|Identify the difference between effective and efficient communication
Recognize and identify emotion in self and others
Promote cross culture/interdisciplinary sensitivity.
Bridge the patient/physician communication gap.
|Students write a paper applying the Rules of Improv to a Clinical Encounter they experienced to be presented and turned in on the final day of class.
In class they will perform exercises portraying and identifying emotions using silence and efficiency in language.
|Students will understand how status plays a role in the medical workplace
Promote cross/cultural/gender understanding
|Students will perform exercises to focus on the role of status in the medical workplace. Through a discussion and roleplaying we discuss patient/doctor encounters and other scenarios from the class.
|Performance and Review
|Students discuss their experience and clinical encounter and perform for the class.
|A discussion about student papers on how “Medical Improvisation” informed their medical school education.
Having delivered the classes five times to self-selected populations between nine and twelve students, we garnered extremely promising results. At the beginning and end of the term, students completed surveys published by medical personal at the Mayo Clinic as an appendix to the article Telling the Patient’s Story: Using Theatre Training to Improve Case Presentation Skills.
In all Cooper Medical classes, 95% or more of the students self-reported that, “Theatre techniques may be effective tools in a medical school course.” Specific comments included, “My selective was extremely positive! I looked forward to going in there every week and learning something different,” “I enjoyed this selective experience. It was something that I have never done before so it really put me out of my comfort zone. However, it was very applicable to medical school. I truly enjoyed every minute of it,” “Wonderful. Interesting and relevant to medical education and dealing with patients,” “This selective provided a look into human action and reaction, which many medical professionals tend to overlook.”
“It was a great experience to improve empathy and increase emotional intelligence.” The only negative feedback related to the scheduling of the classes in relation to mandatory medical testing during the semester.
Lessons that seemed to resonate the most highlighted the embodied and spontaneous practice of responding to peers in improvised scenarios. Other foundational exercises emphasizing collaboration, power and status relationships seemed directly applicable in the doctoring profession. Warming students into the work required building a trusting ensemble of students willing to “open up” and share aspects of their lives rarely talked about in other medical classes. The easiest way to gain student trust was through establishing daily warm-ups and a “question of the day,” coupled with quick response and team building exercises. Students also responded to constant reaffirmation that there are no “wrong answers” in theatre exercises. This diffused the sense of competition, self-judgment and repercussions that often plague students in most medical course work. It effectively rendered the studio a safe place to have challenging discussions about the pressure and stress of dealing with patients and their own journey as future doctors.
Having met with success at the Cooper Campus, the instructors also transferred this curriculum to meet different needs and curriculum at the D.O. (Osteopathic) School of Osteopathic Medicine in Stratford, New Jersey. As part of the existing three-year sequence of “On Doctoring” coursework all students take, Rowan SOM faculty asked for six total contact hours featuring empathy-building theatre techniques spread out in two-hour blocks offered once each year. This adjustment mandated a host of considerations and adaptations.
Since all students at Rowan SOM are required to attend the sessions, the class size is at least twenty students at a time and, since they did not opt or self-select to take this particular curriculum, there is increased need for preparatory context and time to effectively engage uninhibited participation. In addition, we found a need to connect the work directly to the existing course content and the larger framework of the “On Doctoring” class. Given that students often forget the work in the year gap between sessions, there is less opportunity to build needed familiarity and progression of pedagogy. Finally, unlike the stand-alone class at Cooper Medical that requires professors to complete an end-of-term student assessment rubric, there is no faculty assessment or corresponding student accountability at the SOM program.
Nevertheless, the student survey conducted at the end of the most recent second-year SOM workshop in January 2018 suggested that, despite the larger population, mandatory participation and simplified curriculum, twenty-four of the thirty-two students answered “yes” to the question, “I found the Improv classes valuable” and twenty-two responded positively to the item, “I believe I learned skills that will help me in my doctoring experience.” One student commented that the best aspect of the session was, “It’s easy to think as the doctor, this helped us think about how the patient was also feeling with certain situations. . . . And I liked playing different roles to see how I and my fellow peers would react to different situations.”
As we continue to refine the work we do with the medical students to maximize the impact of the course content and structure, we continuously seek ways to properly quantify our results and to adapt to a variety of medical contexts and conditions. Obviously, the very idea of teaching the slippery and highly personal expression of empathy can be contested, but it is evident that theatre exercises can help humans become more aware of how to use bodies, voices and minds to communicate with, and respond to others. Medical students particularly benefit from physically practicing how to interpret and embody empathetic response. While the goal is not to create polished “performers,” medical students will “act” as doctors and can benefit from a common phrase theatre teachers use with budding actors, “the idea is to ‘do/act,’ not just ‘think.’” Medical students can’t just intellectualize medical knowledge; they have to physically “doctor” patients as well.
In introductory remarks, I often remind future doctors that, like actors, patients pay “to see” them because doctoring is an embodied, highly interactive practice. In the words of Bill English, the Artistic Director of the San Francisco Playhouse, who worked with the Dalhousie University Medical program, Halifax Nova Scotia:
Theatre is an empathy gym where we came to practice our powers of compassion . . . we are safe to risk entering into the lives of the characters on the other side of the proscenium. We feel what they feel, fear what they fear, love what they love, and hope for what they hope for . . . And along the way . . . realize that under our skin we are the same.
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 Fitzgerald, Faith. “On Being a Doctor: Curiosity.” Annals of Internal Medicine 130 (1999): 70-2.
 Stepien, Kathy A., and Amy Baernstein. “Educating for Empathy.” J Gen Intern Med 21 (2006): 524-30.
 Rossiter, Kate. “Bearing Response-Ability: Theater, Ethics and Medical Education.” J Med Humanities 33 (2012): 1-14.
 Hammer, Rachel R., Johanna D. Rian, Jermy K. Gregory, et al. “Telling the Patient’s Story; Using Theatre Training to Improve Case Presentation Skill.” J Med Ethics: Medical Humanities 37 (2011): 18-22.
 D’Alessandro, Paul Robert, and Gerri Frager. “Theatre: An Innovative Teaching Tool Integrated into Course Undergraduate Medical Curriculum.” Arts and Health 6 (2014): 191-204.
*Elisabeth Hostetter is a full professor and Chair of the Department of Theatre and Dance at Rowan University in Glassboro, New Jersey. In addition to teaching courses in theatre history and acting, she regularly partners with Rowan University School of Osteopathic Medicine and Cooper Medical School of Rowan University to teach performance-based courses. She received her PhD from the University of Missouri, her MA from UT, Austin, and her BFA in acting from Virginia Commonwealth University.
**Professor and Department Chair, Melanie Stewart is a 20-year veteran of the Department of Theatre and Dance at Rowan University. Throughout her tenure Stewart has actively linked her professional career as a performer, choreographer, director and producer of avant guarde dance theatre to her academic career as a teacher, mentor and now Chair of Theatre and Dance. With her professional company, Melanie Stewart Dance Theatre, she produced the nEW Festival, a dance driven, artist fueled festival at The University of the Arts in Philadelphia. She holds two degrees in Dance, a BA from Webster College and an MFA from Temple University. Her awards include numerous fellowships for in dance, theatre and interdisciplinary work from the PA Council on the Arts and The National Endowment for the Arts.
Copyright © 2018 Elisabeth Hostetter, Melanie Stewart
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