Can improv improve healthcare?

A review of Alan Alda’s If I Understood You, Would I Have This Look on My Face?

A 2012 study conducted on behalf of Bosch home appliances found that over 40 percent of Americans admitted to having fought with a family member over the correct way to load a dishwasher. This is not one of our prouder national statistics, but according to Alan Alda, it’s one that probably shouldn’t surprise us. As he explains in his new book, “Pretty much everybody misunderstands everybody else. Maybe not all the time, and not totally, but just enough to seriously mess things up.”

This may not be a revelatory insight, but Alda’s wide-ranging exploration of how and why we “mess things up” is as fascinating as it is dispiritingly familiar, and it has implications for all of us, not least anyone connected to the field of health care. Communicating effectively with doctors, as most any patient will tell you, is hard. And as most any doctor will tell you, communicating effectively with patients is equally challenging.

Alda’s message is a hopeful one, though. Communication is hard, but practice can make perfect—or at least better. Learning to do so is more art than science. Alda, an artist, not a scientist, navigates this distinction with authority, but anyone coming to this book out of nostalgia for his work on M*A*S*H will quickly learn that he’s come a long way from his days as Captain Hawkeye Pierce. He describes how, as host of PBS’s Scientific American Frontiers from 1993 to 2005, he interviewed hundreds of scientists, and quickly learned how hard it was for many of them to explain the fascinating work they were doing. These lessons had a life beyond the TV show. Would it be possible, he wondered, to train accomplished scientists who are also accomplished communicators? Could doctors, for example, develop stronger patient interactions through learning about theory of mind, cognitive empathy, and affective resonance?

Not everyone thought these aims worthwhile. Professors at one medical school told him flatly that there was just too much science they had to teach, and that students would pick up communication skills simply by listening to good communicators. (I’ve been listening to fine pianists my whole life, reflects Alda, but still can’t play the piano.) Eventually, his dedication to helping scientists share their work more effectively with the public led him to Stony Brook University, where in 2009 he co-founded the Center for Communicating Science. At the Center, scientists strengthen empathy through improvisational theater games—techniques traditionally used by actors and comedians. Even those who don’t know anything about improv might be familiar with “Yes, and”: the principle of generous acceptance. An Israeli scientist who does improv every Friday night told Alda, “A lot of blocking takes place in science, but ‘Yes, and’ frees science to grow… Instead of talking to the data, you listen to it.”

What does it mean to relate to another? For Alda, it goes beyond trying to make eye contact, getting in someone’s face “like an errant telephone pole.” Rather, to relate is to listen with a willingness to be changed: “Even in life, unless I’m responding with my whole self, unless I’m willing to be changed by you, I’m probably not really listening.”

If the profound relevance of all this to medical and health professionals isn’t already obvious, it comes into even sharper focus when Alda discusses the power of narrative. We’re suckers for stories, which serve as one of the fundamental ways that the mind stores and organizes information. Pharmaceutical companies tend to know this better than many of the doctors who prescribe their drugs. Every drug ad you’ve ever seen tells a story, however ridiculous or overwrought, and because emotions help to solidify memory, the ads stick in the mind. Moreover, the act of telling a story has a powerful effect on the cognition of storyteller and listener, activating response patterns in the brains of both. Expert diagnosis and prescription aren’t much use without patient comprehension and compliance, which is where narrative’s power to instruct and to bond can be useful. Lorna Role, the chair of Neurobiology and Behavioral Science at Stony Brook, goes beyond telling physicians to avoid using jargon with patients. Instead, she encourages them to tell patients the story of their condition and care plan.

The payoff? One meta-analysis of studies on patient reaction to physician communication showed that patients were 19 percent more likely to follow the recommendations of physicians ranked as empathic, interactive, and involving patients in their own care.

Empathy doesn’t come naturally to many of us, but it can be learned, as demonstrated by an original study that Alda himself funded and helped to design. It’s hard to make the details of such a study sound interesting, but Alda tells the story of the research process clearly and naturally. One of the book’s primary services, in fact, might be to provide lay-readers some insight into the methods and limitations of the kinds of studies that most people only learn about from headlines, which are often misleading and nearly always reductive.

(On that note, I should add that the book serves as a handy de facto bibliography of work by scientists for non-specialists. I’ve already added to my wish list mathematics professor Steve Strogatz’s Math for People Who Hate Math, upon which Alda heaps great praise.)

It seemed appropriate, for a book on listening, that I encounter it with my ears, and since this is Alan Alda we’re talking about, listening to the audiobook turned out to be a good decision. “Not being able to communicate,” he laments, “is the Siberia of everyday life, a place that, crazily, we often send ourselves to.” The overwhelming quality of Alda’s voice is hospitable warmth, inviting trust in his advice to return from this self-imposed exile, steering away from what he calls “the cold North Pole” of jargon, lecture mode, and PowerPoints. He’s a wonderful reader of his own words, and models with his own patient tones the kind of attentive, relational engagement he urges listeners to cultivate.

The communication strategies Alda discusses would be foolproof—if one only had to use them with people as calm, reassuring, and gently self-effacing as Alda himself. As he is quick to admit, though, in the improv game of life, people aren’t always going to “Yes, and” you. The kind of relationality he describes demands vulnerability, which can be tough and even dangerous for already vulnerable people. These can include physicians themselves, and he shares a few stories of medical doctors whose emotional availability became crippling to them, and unhelpful to patients. In a chapter called Dark Empathy, he admits, “Sometimes empathy worries me.” Empathy and theory of mind, he stresses, are not the same as sympathy. As he points out, few people access the inner states of others as effectively as bullies, interrogators, and corporations. He recounts his shock at finding that pharmaceutical giant Merck’s sales training included techniques of empathy and trust-building, deliberately designed to overcome doctors’ objections and concerns. Even some of his beloved improv exercises were weaponized in a course called, “Captivating the Customer,” designed for company sales managers.

Chilling, but there’s no denying the power of ethical empathy, and not just for doctors and scientists, but for all of us: “If we remembered that every conversation we have, every bit of advice we give, every letter we write, can be an exchange in which the other person might actually have a better way of looking at it, then we have a chance to be in sync, to be in a dance with a partner, not a wrestling match with an opponent.”

The book’s massive success on the New York Times bestseller list is a tribute to its author’s talent and likeability, but it may also attest a public hunger for practical advice on better understanding one another. “When it clicks, when you’re in sync with someone, even for the briefest moment, it feels like the pleasure of reconciliation. We’re no longer apart . . . . We go from, ‘No, you’re wrong,’ to ‘Maybe you’re right.’ And boom! Dopamine. It’s a good feeling.”

It is a good feeling, and such an elusive one for many of us lately that Alda’s bestselling meditation on the art of communication, as well as some of the science behind it, might just be the ideal book for our hyper-partisan moment.

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Footnotes

Alan Alda. If I Understood You, Would I Have This Look on My Face?: My Adventures in the Art and Science of Relating and Communicating. Random House, 2017.