Improvisational and Standup Comedy, Graphic Medicine, and Theatre of the Oppressed to Teach Advancing Health Equity

Abstract

Ninety-minute virtual workshops that used improvisational comedy, standup comedy, graphic medicine, and Theatre of the Oppressed were implemented in 2020 within a required health equity course at the University of Chicago Pritzker School of Medicine to train 90 first-year medical students in advancing health equity. Learning objectives were to (1) deepen understanding of diverse human experiences by developing relationship skills, such as empathy, active listening, engagement, and observation; (2) recognize how diverse patients perceive students and how students perceive them to gain insight into one’s identity and how intersectional systems of oppression can stigmatize and marginalize different identities; and (3) engage in free, frank, fearless, and safe conversations about structural racism, colonialism, White and other social privileges, and systemic factors that lead to health inequities. With a 61% (109/180 [90 students × 2 workshops per student]) survey response rate, 72% of respondents thought workshops were very good or excellent, and 83% agreed or strongly agreed they would recommend workshops to others. Key recommendations are to (1) incorporate experiential storytelling and discussion; (2) define clear learning goals for each workshop, map exercises to these goals, and explain their relevance to students; and (3) create a safe, courageous, brave space for exploration and discussion.

For health equity, transformation happens as students share their perspectives of curriculum content from their intersectional identities, experiences, and varied privileges; are challenged by others’ perspectives; and attempt to understand how others can experience the same content differently. The arts create a powerful form of sharing beyond routine conversations or discussions, which is critical for honest dialogue on difficult topics, such as racism, homophobia, and White privilege and other social privileges. Educators should enable students to have the space, time, and courage to share their true perspectives and engage in authentic discussions that may be uncomfortable but transformative.

Teaching trainees how to advance health equity is difficult. ^1,2 Education should improve trainees’ human connection with diverse populations; address multilevel drivers of health inequities, including intrapersonal, interpersonal, and structural racism ^2,3; and recognize complex intersectional relationships across factors such as race, class, and gender identity. ^4,5 Educators need to create a safe, courageous, brave space for difficult and honest discussions on emotionally charged topics, such as racism, social privilege, and systems of oppression. ⁶ They must be prepared to enable all trainees (e.g., racial/ethnic minorities, sexual and gender minorities, rural students, students with guilt about privilege, and students resistant to equity arguments) to participate and grow. These educational challenges are formidable and require innovative approaches.

Lectures about implicit bias, ⁷ cultural humility, ⁸ and structural racism ⁹ have been used to educate individuals about health equity. However, passive teaching methods have significant limitations, whereas equity courses that incorporate active, experiential, and reflective modes of learning offer an engaging alternative. ^10,11 Despite incorporating many active learning techniques, our first-year medical students have consistently asked for more discussion time and more intensive exploration of issues in their required course Health Equity, Advocacy, and Anti-Racism at the University of Chicago Pritzker School of Medicine. ¹⁰

The arts are a largely untapped tool to enhance learning about health equity. Although the humanities are increasingly used to teach general patient-centered approaches to clinical care, ¹² the literature is limited on how the arts might specifically teach trainees how to advance health equity. Different art forms vary in the extent to which they have been used to teach health equity. For example, Theatre of the Oppressed is a social change theater developed by Augusto Boal based on the critical consciousness theories of Paolo Freire and his book Pedagogy of the Oppressed. ^13,14 It aims to transform inequities by having the audience become “spect-actors” who change the reality of an oppressive scene by replacing actors in the middle of the scene and improvising new endings (Appendix 1). Theatre of the Oppressed has successfully taught medical students to engage senses and emotions, embrace ethical behavior, and identify and resolve conflict. It has provided a forum to “bring out social problems in public,” “examine the root causes behind lived experience,” “provide context for understanding and for exploring alternatives,” and “convert thoughts to action.” ¹⁵ More generally, different art forms have been used in health education to teach communication, humanism, and patient-centered care rather than health equity. For example, improvisational theater training tailored for health care students has been demonstrated to improve learner confidence, verbal and nonverbal communication, active listening, teamwork, professionalism, and ability to deal with uncertainty.¹² Although general humanities-based approaches to care are helpful, they do not sufficiently explore several issues that are critical to effective health equity training, such as explicit and implicit bias, ⁷ racism, ^1,3 privilege, ¹⁶ intersectionality, ^4,5,17 and structural systems of oppression. ^18,19

In fall 2020, the director (M.B.V.) of the required University of Chicago health equity course, in collaboration with faculty and collaborators interested in the health humanities, allocated 3 hours of class time to improvisational comedy, standup comedy, graphic medicine, and Theatre of the Oppressed virtual workshops to train students about health equity. In this Invited Commentary, we share invaluable practical lessons learned from this pilot program to guide arts and health equity training.

The University of Chicago Pritzker School of Medicine Arts and Health Equity Pilot Program

Our planning and teaching group of 13 people included clinicians with experience in the use of improvisational comedy (M.H.C., N.M.O., J.M.R.), standup comedy (M.H.C.), graphic medicine (B.C.C.), and Theatre of the Oppressed for medical training (D.C.M.), a scientist with expertise in using improvisation to improve scientists’ communication (J.A.D.), a theater owner with professional improvisation experience, a professional international standup comedian, and a program administrator with expertise in education. Seven members were experienced in teaching health equity and facilitating challenging discussions around race and systems of oppression (M.H.C, B.C.C., D.C.M., M.E.P., M.B.V.). Four teachers were African American, 2 were Asian American, 1 was Latina, 1 was Muslim British Palestinian American, 1 was a White British citizen, and 4 were White Americans. We conducted 3 group planning calls with details formulated separately by the art workshop teams. We planned 90-minute workshops that were virtual because of the COVID-19 pandemic. Ninety first-year students were randomly assigned to 2 of 4 art forms for 3 hours of class time.

The overall workshop learning objectives were to (1) deepen understanding of diverse human experiences by developing relationship skills, such as empathy, active listening, engagement, and observation; (2) recognize how diverse patients perceive you and how you perceive them to gain deeper insight into one’s own identity and how intersectional systems of oppression can stigmatize and marginalize different identities; and (3) engage in free, frank, fearless, and safe conversations about structural racism, colonialism, White privilege and other social privileges, and the systemic factors that lead to health inequities. Each art form developed exercises that contributed to the learning objectives. All exercises were basic and suitable for a beginner audience. We evaluated workshops with quantitative and qualitative survey questions ²⁰ and interviewed 17 students randomly chosen to represent different racial and ethnic groups. With a 61% (109/180 [90 students × 2 workshops per student]) survey response rate, 72% of the respondents thought their workshop modules were very good or excellent, and 83% agreed or strongly agreed that they would recommend the workshop modules to others. An evaluation of the standup workshop has been previously published, ²⁰ and comprehensive data for the other workshops will be reported in future research articles. The recommendations below are based on discussions among ourselves and our initial impressions of the data.

Recommendations

Incorporate experiential storytelling and discussion

Delivering curriculum content followed by discussion with experiential storytelling is important. Every student will hear something different because each student experiences the same content differently. For health equity, transformation of student understanding does not happen in the delivery of the content. Transformation happens as students share their perspectives of the content from their intersectional identities, experiences, and varied forms of privilege ²¹ and are challenged by the perspectives shared by others and attempt to understand how someone else can experience the same content so differently. ²⁰ The key to the arts is that they create a powerful form of sharing beyond routine conversations or discussions. The arts give students cover to say things they might not otherwise share, critical for authentic dialogue around difficult topics, such as racism, homophobia, and White privilege and other social privileges.

Discussion that incorporates storytelling has other benefits. Clinicians should learn the authentic stories of their patients, including marginalized patients, who may have very different life experiences from clinicians’ experiences. ⁴ The clinician needs to listen and build a relationship with the patient while identifying and managing biases that the clinician has of the patient and that the patient has of the clinician. ^22–24 In health equity education and patient care, narratives should be constructed that help clinicians better understand their patients. ²⁵

Starting with stories about inequities tends to be a more effective way to engage learners and audiences than leading with statistics. ¹ In addition, our experience providing diversity, equity, and inclusion training at the University of Chicago Medicine has taught us that sharing personal stories among peers frequently has a powerful effect on transforming attitudes and relationships among group members. ¹⁸ Storytelling has also been a tool for social change and advocacy. ²⁶ Thus, storytelling can improve care of individual patients, enhance discussion of structural drivers of inequities, and meaningfully increase self-insight and relationships with others.

Define clear learning goals for each art form’s workshop, map the exercises to these goals, and explain their relevance to students

A key challenge in developing the health equity workshops was determining what the most appropriate equity-specific teaching points should be for each workshop. Each art form has different strengths. In our curriculum planning, we matched each form with the learning objectives that highlighted that art form’s strengths. For example, our introductory improvisation workshops were best suited for building empathy and teaching active listening, paying attention to verbal and nonverbal cues, and the collaborative “Yes, and” principle of engaging patients from where they are. ²⁷ For trainees with no previous background in improvisation, our improvisation workshop focused on improving communication and listening as a critical first step in teaching about health equity rather than discussing structural racism.

We thought the most important and feasible objective for a beginner workshop using standup comedy principles was recognizing how diverse patients perceive you and how you perceive them—what a standup comedian would call reading yourself and reading the room. ²⁰ Comic-making exercises in the graphic medicine workshop focused on how stories are constructed and directly deal with issues of representation and identity. ^21,28 Theatre of the Oppressed can address any of the 3 objectives, with a special emphasis on the last objective of exploring systems of oppression. For each art form, we provide example exercises in Appendix 1, including instructions to trainees, debriefing discussion questions, and teaching points.

Some students easily saw the connections among exercises, clinical medicine, and health equity, whereas others requested concrete linkage of exercise to goals and clinical relevance. Educators should make these linkages explicit. Our pilot program used 4 art forms for which our faculty had expertise. Different art forms can be effective tools for improving trainees’ attitudes and skills to advance health equity. Schools should choose art forms for which they have expertise and interest and clearly define the appropriate learning objectives and exercises for those arts. Of note, the umbrella health equity course had already introduced the concepts of biases, inequities, racism, privilege, civil discourse, and safe space; thus, students were better prepared to engage and discuss during the arts workshops.

Create a safe, courageous, brave space for exploration and discussion

Learners have different learning needs regarding health equity and varying experiences, skill sets, and readiness to change and grow. For example, African American, American Indian, Asian American, Latinx, and White students may have different experiences of health equity. ¹⁶ Students have a range of buy-in and skepticism about health inequities. Some sociopolitically conservative students may not speak up because of fear of being ostracized. Similarly, students of color frequently assess the safety of the environment before speaking.

There is no need to alter health equity curriculum content to different audiences when it is delivered with inclusive pedagogy. ^1,29,30 However, a mechanism is needed for students to have the space, time, and courage to share their own honest perspectives and to challenge the predilection to not rock the boat and instead engage in authentic discussions that may be uncomfortable but transformative. The real learning will happen in that moment and later when the words of their fellow students return to them when they are with a patient, in a conversation with a patient’s family members, or in another highly emotive or meaningful situation.

We recommend training teachers in both the basic art form and facilitation of discussions on equity and/or pairing a teacher with experience in the art form with a teacher skilled at facilitating health equity discussions. Teachers’ skills engaging trainees, facilitating discussions, and managing conflicts around racism and other challenging equity topics are far more important than their arts skills in these introductory exercises.

Conclusion

We found that improvisational and standup comedy, graphic medicine, and Theatre of the Oppressed virtual workshops in a health equity course are promising techniques for teaching first-year medical students how to advance health equity. Professional associations, such as the American Medical Association, American Hospital Association, and Association of American Medical Colleges, are increasingly decrying racism and inequities. ^31–33 Many individual health care organizations are committing to addressing health disparities. ^18,34 A great challenge in teaching health care professionals about advancing health equity is having free, frank, and fearless discussions about complex and emotionally charged topics, such as racism, social privilege, and systems of oppression. ¹ Honest self-examination takes courage; frequently, the discoveries and self-insights are troubling. ²² We believe that the vital components of the 4 art forms in our beginner workshops are experiential storytelling and discussion. Sharing personal experiences in safe, courageous, brave spaces packs striking cognitive and emotional power. Further research should explore the best methods, including with longitudinal and in-person training, to enable this impactful sharing of experiences among diverse trainees with heterogeneous world views. Such research and demonstration projects should be priorities as we address health inequities and racism in a polarized country that struggles to communicate constructively within itself. ²

Acknowledgments:

The authors wish to thank Mengqi Zhu, MS, for the descriptive data analysis.