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Academic Medicine:
doi: 10.1097/ACM.0b013e31822cf858
Art and Medical Education

Perspective: Serious Play: Teaching Medical Skills With Improvisational Theater Techniques

Watson, Katie JD

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Author Information

Ms. Watson is assistant professor of medical humanities and bioethics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Correspondence should be addressed to Ms. Watson, Medical Humanities & Bioethics Program, Feinberg School of Medicine, Northwestern University, 750 N Lake Shore Drive #625, Chicago, IL 60611; telephone: (312) 503-1675; e-mail: k-watson@northwestern.edu.

First published online August 24, 2011

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Abstract

The physician–patient encounter may be structured, but it is never scripted; every physician–patient interaction is to some degree improvised. Both physicians and improvisers must prepare for unpredictability, and the surprising and unrecognized overlap between improvisational theater and medical training and medical practice led the author to develop a seminar that tailors improvisational skills to physician needs, teaching communication, professionalism, and other medical skills through an approach she calls “medical improv.” The author observes that there is no example of this teaching strategy as a recurring part of a medical school curriculum reported in the literature, and she describes the contributions medical improv can make to physician skills. The author reports on medical students' positive response to the medical improv seminar she has taught at Northwestern University Feinberg School of Medicine since 2002: 95% of students anonymously evaluating the seminar from 2002 to 2010 agreed with the statement, “Studying improv could make me a better doctor,” and 100% agreed with the statement, “I would recommend this class to other medical students.” The author proposes a medical improv teaching model that other medical schools and hospitals could adapt and adopt.

It is 1:00 am, and a father anxiously waits for his son to come home. The teen is an hour past curfew, but he strides in with his head held high.

“Hey Dad,” he says as he grabs a drink out of the refrigerator.

“I've been so worried about you!” the father exclaims, still seated.

“You worry too much!” the teen chirps, patting his father on the back. The father hangs his head in his hands.

“You should let me know who you're out with because I—”

“What'd you do tonight?” The teen focuses on making a sandwich as he interrupts and changes the subject.

This parent–child exchange highlights the difference between role (authority conferred by title) and status (power in relation to another), but this low-status parent and high-status child do not stay that way for long. They are actually medical students in a medical improvisational class at Northwestern University Feinberg School of Medicine (NUFSM). Their next task is to switch status and reprise their roles, improvising a second scene about a low-status teen coming home late to a high-status parent. Afterward, the players will discuss which status was easier for them to play (gaining insight into their own “default position”), the class will discuss what verbal and nonverbal strategies they saw their classmates use to successfully communicate status, and new pairs will be given new scenarios to experiment with other strategies. After everyone has worked through these nonmedical scenarios, the group will brainstorm moments in medical practice that might be served by actively choosing behavior communicating low or high status. This exercise in distinguishing between role and status through improvised performance is one of many exercises I lead in my “Playing Doctor” seminar at NUFSM.

In 2001, I was a lawyer who had just begun teaching bioethics at NUFSM, but on weekends I did improvisational theater, and the only thing more nerve-racking than performing without a script was seeing my new boss in the audience. But Kathryn Montgomery, the director of our medical humanities and bioethics program at the time, was more than just a theater fan; she also was writing a book about clinical judgment called How Doctors Think.1 She and I began discussing the thought processes and skills that allow improvisers to create characters, dialogue, and plot on the spot, and our discussions revealed the overlap between improvisational theater and medicine. The physician–patient encounter may be structured, but it is never scripted; every physician–patient interaction is to some degree improvised. This insight led me to develop a seminar that tailored improv skills to physician needs, a focused application I now call “medical improv.”

Since 2002, I have taught my medical improv seminar 14 times to a total of 116 medical students as part of NUFSM's humanities selective requirement. Student response to this unique method has been very positive: On anonymous course evaluations collected between 2002 and 2010, 83 of 87 (95%) NUFSM medical improv students agreed that “studying improv could make me a better doctor,” and all 87 (100%) agreed with the statement, “I would recommend this class to other medical students.”

Playing Doctor seems to be the only improv course offered as a recurring part of a medical school curriculum. A review of the literature reveals that at University of California, San Francisco, School of Medicine, medical students taught their peers one improv course as an elective,2 and in 2005 the University of Arizona College of Pharmacy added 12 hours of improv to an existing patient communication course for first-year pharmacy students.3 Both sets of authors report success.

In this article, I discuss how medical improv courses might help students and physicians develop skills, and I report student responses to the implementation of these ideas in 12 sessions of my medical improv seminar. I use personal observations and student feedback from anonymous course evaluation forms to illustrate the promising role of medical improv in developing essential communication and professionalism skills in physician trainees. Table 1 shows students' numeric responses of agreement with 18 statements about the course. Students were also invited to provide narrative responses to eight questions about the medical improv course, and representative statements are quoted throughout this article. Although this is not intended to be a formal report of the data, the students' words underscore the unique way medical improv could help meet educational goals and improve students' and clinicians' confidence and performance in clinical situations.

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The Connection Between Improvising and Doctoring

Physicians and improvisers are driven by the same paradox: the need to prepare for unpredictability. Improvisational theater teaches its practitioners to accept uncertainty and ambiguity as the conditions in which you must perform, rather than reflexively trying to impose order on something that has not yet unfolded. As one first-year student reported in the medical improv course evaluation, “I really learned how to immerse myself in the moment and not freak out if I didn't know what was going to happen next” (2006). Physicians and improvisers both must develop the mental agility to think creatively and recognize patterns in rapidly changing circumstances, all while maintaining professional composure under great stress. In Blink, journalist Malcolm Gladwell4 highlights improvisational theater as a technique that trains people to make “very sophisticated decisions on the spur of the moment” “under the fast-moving, high-stress conditions of rapid cognition.” As a first-year student remarked, “We have to be able to react and adapt quickly when interacting with patients. This seminar really teaches that” (2010).

“Improv” is not the same as “comedy.” Comedy is focused on humor, whereas improvisational theater is focused on honesty and spontaneity. However, part of what makes improv so enjoyable is that people behaving spontaneously often make us laugh. That's what makes medical improv “serious play”—the method is fun, but the content is serious. Improv is both an art form and a skill set, performance and practice. Some experience improv as a transformative practice, because working to listen, observe, and respond in the moment deepens human capacity in many arenas.

The art form originated in Chicago in the 1920s as therapeutic theater games that were used to help inner-city and immigrant children “adjust to the society in which they lived,” and in the 1930s, it was further developed in the Recreational Project of the Works Progress Administration.5 In 1959, Chicago's famed Second City was founded using improvisation to inspire scenes that would ultimately become written sketches. Later, those who believed improvisation was an art form in its own right developed long-form improv (in which a single suggestion inspires a spontaneous, 25- to 55-minute performance featuring recurring characters and plotlines), and in the 1990s the television show “Whose Line Is It Anyway?” popularized short-form improv (in which structured games challenge performers to find quick punchlines in response to audience suggestions). Regardless of which type of improv they pursue, the key to every improviser's success is the principle of “yes–and”: learning to affirm whatever your scene partner creates (“yes”) and to contribute creations of your own (“and”).

Contemporary medical education is focused on skills and competencies, and medical improv is particularly relevant to two of those: communications and professionalism.

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Medical improv's contribution to communication skills

Successful medical training requires student communication skills that are rarely taught but often required, a category I think of as “medical education communications.” For example, the trainee–faculty interaction known as pimping puts a trainee's knowledge on public display as the trainee answers questions posed by a person in power in front of a group in a situation where “often more can be learned from incorrect answers than from correct ones.”6 Students recognize that success is related to “being able to think quickly, ‘on your feet,’ or ‘on the spot’” and that “shy people get left behind.”7 As one fourth-year student explained in a study by Wear et al7 of students' reactions to pimping,

A lot of times you would have known the answer if it'd been one-on-one or if you'd been taking a test, but the fact that the whole group is there and he's asking you the question and everyone's listening and everyone's watching, it's like you really can't think straight or think well.

A defining element of medical improv is “thinking well” in front of an audience. One second-year student framed it this way: “We were forced to put ourselves in ‘on the spot’ situations and think on our feet.… I definitely … learned something completely new to me” (2006). As another second-year student explained,

A common fear (that is necessary to overcome) in medicine is the fear of thinking on your feet, being put on the spot, being wrong or judged for speaking up. This is something we practiced in this seminar (2006).

In 2009, I met a third-year student whose fear of speaking in front of groups was jeopardizing her medical career. She had not taken the Playing Doctor selective, but the student promotions committee suggested she contact me because the student was perceived as unprepared in her clinical rotations. The student told me she prepared, but she became so anxious when asked questions that she could not convey the information she knew. After I worked with her individually and she took a four-hour improv workshop I co-taught in the community, the student reported improvement in both her anxiety levels and her performance. The student successfully completed her studies, and at graduation she told me the improvisational work was a significant factor in her ability to do so. Discussions about piloting a medical improv workshop tailored specifically for students whose medical training is impeded by performance anxiety are under way at NUFSM.

Medical improv could address other obstacles to successful medical education communication as well. Some medical students are comfortable speaking up but are poor listeners because their minds are racing to compose the next thing they will say. A first-year student wrote that one surprising thing about the class experience was “how much I came to learn that I need to be a better listener and be more in the moment as opposed to being only in my head” (2004). Other students just struggle with basic shyness. As this first-year student described it, the favorite aspect of medical improv was “[b]eing free and feeling like I was out of my ‘shell’” (2006).

A second-year student referenced the burden of perfection many trainees feel: “I truly felt that I could be myself … I also felt open to making mistakes for the first time in med school” (2004). Some students never risk a wrong answer because they don't see the difference between mistakes from poor preparation and the mistakes they make testing the limits of their stage-appropriate knowledge in front of their professors. The first type of mistake should be avoided, but the second type should be embraced as a rich educational opportunity that helps prevent mistakes in actual practice. Medical improv teaches students to focus on their “internal auditor” (awareness of what's happening) instead of their “internal editor” (judgment of what's happening), and it reframes “not knowing the answer” as something that can be exciting rather than frightening. After succeeding in verbal performance with no advance preparation, students gain confidence in their ability to speak up about subject matter they have actually studied. As one second-year student put it, “It's all about taking chances. This class boosts your self-confidence in so many ways” (2003).

Traditional doctor–patient communication skills8 could also be enhanced by medical improv training. When a physician sees a new patient, he or she must quickly assess and connect with a new “scene partner.” When the patient is known to the physician, these familiar characters create a new “scene” in which neither knows exactly what the other will say or do. Medical improv helps build sophisticated skills in active listening, clear information delivery, and collaborative narrative building. A first-year student stated that medical improv “[b]rings a new meaning to the importance of communication and listening, observation skills, and importance of body language” (2006).

Some students report medical improv expands the range of communications skills currently taught. As this first-year student noted: “I felt the seminar was useful in teaching me how to read and react to people, like an extension to COM [Communication Skills]” (2010). It is also possible that medical improv reaches different types of learners by teaching traditional communications skills in different ways. As one second-year student wryly stated, one disappointing thing about medical improv was “that we have to learn about how to interact in a stupid way first year when we all should have just been doing this the whole time” (2004).

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Medical improv's contribution to professionalism skills

Medical improv could also contribute to professional development. NUFSM uses a document called the physicianship evaluation form to record lapses or excellence in medical student professionalism, and the exercises I teach explicitly address many of the 18 professionalism behaviors identified on the form, such as acceptance and incorporation of feedback, recognition of limitations and willingness to seek help, adaptability to change, maintaining professional composure in stressful situations, and establishing rapport. NUFSM's definition of professionalism is consistent with the Accreditation Council for Graduate Medical Education's focus on professional qualities like responsiveness, accountability, commitment, and sensitivity.9

The professionalism skill of “accepting and incorporating feedback” provides an illustrative example. Successful physicians make rapid adjustments to patients' verbal and nonverbal cues, and successful improvisers do the same in response to subtle cues from teammates and audiences. Medical students are regularly critiqued by faculty, and improv students receive both postexercise notes and “side coaching”—instructor comments they must immediately accept and incorporate during their performance. In 2010, a first-year medical improv student said he had been feeling defensive and overwhelmed during his physical exam instructor's constant redirection as he struggled through physical exams in class. However, after only two sessions of medical improv, he said he noticed himself feeling more receptive to his physical exam instructor's ongoing corrections. He said experiencing improv side coaching had taught him a new way to “take a note.” Without any discussion with or change in his physical exam instructor, this student reported an internal change in his reaction to feedback and, therefore, a potential change in his learning capacity. He said now he experienced his physical exam instructor's feedback as supportive and instructive rather than discouraging and judgmental. In medical improv, students are constantly in motion—putting new concepts into action, experimenting with new skills, adjusting to failures, and incorporating feedback. The flow from concept to skill to integrated practice is immediate and constant.

Professionalism also encompasses the ability to collaborate with colleagues,10 and medical improv focuses on teamwork behaviors that create productive and trusting partnerships and groups. Three students made representative comments when asked the most important (or favorite) thing they learned in medical improv—a second-year student wrote, “Being in an environment that promoted working in a team and being vulnerable, instead of always competing” (2004); a first-year student wrote, “I can rely on other people, but I also need to be always supportive” (2004); and another first-year student wrote, “How important teamwork is in creating new ideas” (2003).

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Additional benefits of medical improv

An immediate benefit of the “serious play” approach to teaching medical skills is student response—students invest medical improv exercises and discussions with a degree of enthusiasm and joy I rarely see in other medical school classes. As a first-year student put it,

By the end of each session I wanted to keep going … even on the Wednesday before our exam … [and] there's not much that would keep [me] away from the books, especially two days before the exam (2009).

Another first-year student simply said, “I think the laughs helped the learning process” (2004). A second-year student suggested another potential long-term benefit of framing learning as “play” instead of “work,” which is contributing to the development of physicians who are lifelong learners: “[L]earning more about myself and challenging myself in new ways has encouraged me to continue doing that in the future” (2003).

Medical improv students also report experiencing benefits like stress relief, self-esteem building, and group bonding. These are not explicit goals of the seminar, but they are welcome side effects. Several years ago, I ran into a third-year student who had taken medical improv a year or two earlier. When I asked how his rotations were going, he said they were tough, but it helped that he and his improv classmates were bringing their clinical questions and problems to each other. They weren't on the same rotations, he said, but they sought each other out for help because they “weren't afraid to look stupid in front of each other” and knew they could count on each other for nonjudgmental support.

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Playing Doctor: A Medical Improv Seminar in Practice

NUFSM medical students are required to take a medical humanities seminar during both their first and second years.11 Students rank their preferences from a list of 18 to 20 seminars taught in small-group settings for 10 classroom hours (five weekly two-hour sessions). I developed Playing Doctor as an NUFSM humanities selective in 2002. Between 2002 and 2011, I taught this seminar 14 times to a total of 116 first-year and second-year medical students.

As the field of medical humanities expands, it becomes important to identify the intentions of courses in order to measure outcomes. There seem to be three ways of using the arts and humanities in medical education. The first is practice-oriented medical humanities courses, which put students in the role of artist through experiential work that teaches them to produce creative works. The goal of this art-making is not to produce high-quality art, it is to use arts methods to build concrete skills needed for medical practice. The most common use of this approach may be teaching writing to develop attention and expression skills.12 Other examples include teaching human figure sculpture to develop anatomy and physical exam skills, and teaching graphic novel drawing to improve observational and interpretive abilities.13 The second way to use arts and humanities in medical education is the scholarly approach, which puts students in the role of scholar through analytic work that teaches them to interpret and critique existing works of art. These theory-based classes may be more common in medical curricula, and their goal is to develop content knowledge and intellectual attitudes that inform medical practice or (like the practice-oriented classes) to build concrete skills needed for medical practice. The most common use of this approach may be studying stories, essays, or films to develop analytic skills. Another example is teaching visual art analysis to increase diagnostic and pattern recognition skills.14–16 The third way to use arts and humanities in medical education is the humanism approach, which often employs art-making or art analysis as a therapeutic tool. The humanism approach puts students in the role of patient through humanities courses that encourage them to look inward. The goal is to increase their sensitivity to themselves and others.17

These three ways of using the humanities in medical education are not mutually exclusive, and the goals of each are laudable. Playing Doctor was designed as a practice-oriented medical humanities seminar. However, because I suspected it could have unintended (though welcome) elements of the humanism approach, in course evaluations I asked students about both types of outcomes—skills and internal attitudes.

Anonymous course evaluations for Playing Doctor asked students to respond to prompts on a five-point scale (1 = strongly disagree, 5 = strongly agree). Student response to the course was consistently positive across years and between first-year and second-year students in self-assessment of skill acquisition, attitude improvement, and enjoyment of the course.

Playing Doctor course evaluations establish that students believe medical improv could improve their medical skills. There have not yet been outcome studies demonstrating that these medical students are correct in their self-assessment, but Boesen et al3 report that pharmacy students' scores on standardized patient exams improved after 12 hours of improv training was added to their existing communications course.

Playing Doctor course evaluations establish that medical students enjoy medical improv. It isn't clear whether a medical improv course that was required of all students would garner equally favorable responses. Boesen et al3 write that the majority of pharmacy students who took the required communications course reported positive experiences with the 12-hour improv component, although a small percentage struggled and were uncomfortable with the exercises.

However, the instructors noted that even students who struggled with the exercises had significant improvement in their SPE [standardized patient examination] scores, performing just as well as the students who were more comfortable with the exercises.

Finally, NUFSM students who took Playing Doctor had ranked medical improv as one of their three top choices when picking a seminar to satisfy their medical humanities requirement, and that may indicate a self-selection bias. Perhaps these students began with an above-average comfort with communication and teamwork. Every year, several students tell me they chose medical improv for the opposite reason—a fear of public speaking—but these students also have a self-selection bias of deciding to actively work on those skills.

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Challenges to implementation

The success of Playing Doctor at NUFSM suggests that other schools might benefit from adopting comparable courses. One challenge to doing so is availability of qualified faculty. I am trained in long-form improv, I have performed for over 10 years, and I am adjunct faculty of the Second City Training Center as an improv teacher, so my experience with the art form is greater than that of most faculty. Additionally, it is possible that my institutional status as a medical school faculty member who teaches ethics and law may have contributed to students' acceptance of the method.

Of course, other schools may already have medical faculty with improv training that simply never came up in their job interviews, so a first step in implementation would be identifying these teachers. Because instructor skill is key to the effectiveness of the course, institutions without qualified medical faculty could successfully replicate this work through interdisciplinary partnerships between medical faculty and experienced improv instructors who could collaborate on course design. In the classroom, the improv instructor could lead exercises and the medical professor could lead discussions about medical applications of each exercise's skill focus.

Another challenge to implementation is student resistance to humanities courses in general. Shapiro et al18 report that “many” medical students refer to humanities teaching as “pointless, boring, worthless, or just plain stupid.” However, I have not experienced student resistance to medical improv. As one first-year student put it:

For something that seems so far removed from medicine as improv does, I was amazed at how useful it really is. Every communication skill necessary for being a successful physician comes into play when you act out improv, from how to handle difficult and awkward situations, to dealing with different types of people, to being accepting of your surroundings and colleagues (2009).

Another first-year student stated:

It was one of the most interesting things I have ever done. This class should be mandatory. I learned so much about myself and dramatically improved my speech and ability to improvise (2010).

Perhaps because medical improv is skill focused, the potential utility of this type of humanities education is more readily apparent to students. Or, perhaps comments like these should be attributed to a self-selection bias because NUFSM students who choose Playing Doctor have many options for satisfying their medical humanities requirement.

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Recommendations

The medical improv seminar Playing Doctor seems to have provided students with great benefit in proportion to their 10-hour investment. Medical improv training could be successfully replicated in several contexts.

First, medical improv seminars could be offered in any medical school setting with the goal of enhancing student skills like creative thinking, rapid response, interpersonal communication, professionalism, and coping with ambiguity and stressful circumstances. Another aim of medical improvisation could be to provide benefits like group bonding and stress relief.

Second, medical improv components could be added to traditional communication curricula. It could expand the range of skills taught, ensure that a communications class reaches different types of learners by teaching similar skills in different ways, and reinforce communication skills with students who respond to both methods.

Third, medical improv workshops could be offered as a targeted intervention for students, residents, or physicians whose group presentations or individual communications are impeded by significant anxiety or shyness.

Fourth, medical improv seminars could be designed and taught to students or health care professionals with a focus on promoting humanism values like empathy for others and respect for multiple viewpoints.19

Finally, medical improv workshops could be offered to practicing physicians with the goal of enhancing communication with patients, collaboration within medical teams or staff committees, individual creative thinking for diagnosis, research, and problem solving, and individual confidence in professional public speaking.

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“Yes–and” Medical Improv Could Provide Valuable Tools for Effective Practice

Medical improv may be an effective way to teach skills required in medical practice. The listening, observation, and emotional presence that improv teaches are powerful tools for providers seeking deep connections with patients. Improv training could enhance the collaborative skills that physicians working in clinical or research teams require. Improv teaches confidence, spontaneity, and openness in a way that might bolster presentation skills. And the playfulness of improv could help professionals connect with their own creativity, unlocking the kind of fluid idea generation that precedes diagnostics, research, and innovative teaching. Future study should evaluate whether students who take medical improv demonstrate increased skills after the course, and whether physicians who took the course as students demonstrate increased skills in practice settings.

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Acknowledgments:

The author thanks Megan Crowley-Matoka, PhD, Debjani Mukherjee, PhD, Kathryn Montgomery, PhD, and Joel Katz, MD, for their helpful comments on the entire manuscript, Mark Kuczewski, PhD, Catherine Belling, PhD, and Cheryl Wilkes, MD, for contributing their expertise to particular paragraphs, and Ellen LeVee, PhD, and Bryan Morrison for their assistance reviewing the student evaluations.

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Funding/Support:

None.

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Other disclosures:

None.

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Ethical approval:

This work was reviewed by the Northwestern University office for the protection of research subjects and deemed not to require institutional review board approval.

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References

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18 Shapiro J, Coulehan J, Wear D, Montello M. Medical humanities and their discontents: Definitions, critiques, and implications. Acad Med. 2009;84:192–198. http://journals.lww.com/academicmedicine/Fulltext/2009/02000/Medical_Humanities_and_Their_Discontents_.19.aspx. Accessed July 5, 2011.

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© 2011 Association of American Medical Colleges

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