How Improv Comedy Can Benefit Healthcare Compliance and Coding

“The scene can’t begin until we start paying attention to each other.” -- David Pasquesi

If you think improv comedy and healthcare compliance and coding require opposite skillsets, you might be surprised by our latest podcast episode...

We invited Dr. Mike Smith, a multi-talented physician and improv aficionado, to join us for our latest episode of Compliance Conversations. Dr. Smith is currently an Attending Physician at the University of Nebraska Medical Center and a Consultant for Healthcare Improv.

Tune in to “Can Improv Comedy Improve Your Compliance Program?” to find out:

• • How the emphasis on connection in improv strengthens healthcare communication
  • The importance of finding balance when you are off balance
  • Why the concept of “yes -- and” can be lifechanging inside and outside of work

Comedy isn’t just about getting laughs – it's about creating deeper connections, staying on your toes, and finding stronger ways to communicate. If you ask us, it seems like those skills may have a broader appeal than just improv.

Episode Transcript

CJ Wolf: Welcome everybody to another episode of Compliance Conversations. I'm CJ Wolf with Healthicity. And today we have, I think, a very interesting topic about improv and what, everyone's thinking, "How does improv work with coding compliance?" Well, we have Doctor Mike Smith on to share a little bit about this topic, welcome Mike.  

Mike Smith: Yeah, thank you. It's a pleasure to be here.  

CJ: We're really glad to have you and I was just really grateful to communicate with you and be introduced to you by one of our other guests, actually. And because I think this topic is fascinating. But before we get to the topic, Mike, would you mind sharing just a little bit about yourself professionally and what's kind of brought you to doing what you're doing?  

Mike: So, I'm an academic hospitalist at the University of Nebraska Medical Center. I did my residency and a chief resident year at Tulane University in New Orleans. And then my wife and I moved back to Omaha in 2014. I had just torn my ACL around that time and was kind of bummed about it because most of my identity was wrapped up and playing sports, playing in Merrills, being active, and whatnot, and that's hindered me and really affected my identity. My wife and I were both from here, and excited to come back, but at the same point, I was kind of in a transition period and kind of what my life was about. That Christmas, my lovely wife got me improv lessons at a local theater. Prior to that, I had no formal or informal training in anything theater related. And so, I just started going to that once a week and just kind of kept at it, and then it slowly worked its way into all of the different aspects of my life, especially my work as a hospitalist here in Omaha.  

CJ: Yeah. And that's so fascinating to me, and we're going to dive into that a little bit more. Maybe before we kind of start questions, could you just tell us what improv is in the context that we're going to be talking about it? I mean, you're not asking the listeners to become stand-up comedians, right?  

Mike: Right, right! So, I did a workshop once and at the end, someone said, "Can we do an improv anywhere?" And I realized at that time that they had no idea what improv was at the end of my presentation. So that's a very good question because I think a lot of people have a lot of different ideas about what improv is and what it is not.  

So, improv is any performance that's made up on the spot. And so, like short-form improv would be, Whose Line Is It Anyway, as probably the most famous example of that. Long-form improv, most people have heard of people who end up in Saturday Night Live coming from Second City in Chicago or Upright Citizens brigade, there are a handful of very famous theaters. And so that's a much longer production that's made up on the spot, usually from some suggestion that the audience gives, and is never performed again.  

CJ: Yeah, interesting. So, tell us a little bit then about this connection with improv and your job in healthcare. How did that come to be and how is it serving you?  

Mike: So, as I said, it was just a nice way for me to get out of the house one night a week. And I just kind of kept at it. And at a conference, I ran into a mentor of mine and I told him I was doing it and he was like, "Oh yeah, I'm sure that helps you in your role as a hospitalist." And I was like, "Oh, yeah, yeah, definitely," in the back of my head, I had no idea what he was talking about, but I just went with it. And as the classes went on, we'd have breaks in the classes and I'd come back to improv class and I wouldn't remember anything or it would feel like that. And so, I started to think of ways that I could practice the improv skills at my job. And so, I started doing that and over that same period, at the next division meeting, they said the most improved patient satisfaction scores for that period of time, and it was me. I was like, "Oh, would you look at that? Isn't that wonderful? My improv practice at work is serving a good." So, my initial excitement was kind of tampered by the idea that I thought I was good at these skills already, and so I thought I was a good listener. I thought it was connecting with patients and people liked me, so it was kind of eye-opening that maybe there are some blind spots in how I was communicating.  

And so, that was kind of my own revelation about my own performance. And then in 2017, within my immediate family, we had five cancer diagnoses, like month after month after month, and we're a big family and had not had any major health crisis up to that point. So, it's just more interesting that it was concentrated in such a short period of time. However, I saw a lot of very well-intentioned smart hearing members of the healthcare community cause harm to my family in the way that they communicated and this was kind of a greater wake-up call to me, like, "When have I inadvertently caused harm in the way that I communicated or not communicating effectively with patients and their family members.” 

CJ: Right! 

Mike: One particular time I told my family member, "Well, I teach three or four students every couple months, these skills to prevent this," and I realized that that was probably not enough, that the skills of improv could solve a lot of the issues that my family members had, because of the way it helps you focus on how you communicate effectively not just get your message across.  

CJ: Yeah, that's interesting, you know, I've had a dear family member who a few years ago also had terminal cancer and kind of went through that process. If you don't mind if there is something on top of mind, what's an example of something that maybe the healthcare provider, the way they were communicating, you know, wasn't helpful? How could they have done it differently with an improv skill? What would it sound like, or what would it be like from you know, pre-learning these skills and post-implementing the skills if that makes sense?  

Mike: Yeah, absolutely. So, one time my sister-in-law had labs that were bad, but they had been bad, and so the provider that called my sister-in-law said, "Hey, your labs are looking bad." And while that's true, it's not in the context of her overall condition, and it caused her a great amount of stress for the next two weeks about what are the implications of these bad lab results. And then she went to see the doctor and the doctor, rather than acknowledging that this caused stress just kind of swept it under the rug and kept proceeding on with the treatment plan, things that are very important. I'm not saying any of those people are bad or not good doctors or not caring in the least, that's kind of my main thing is, improv skills, the focus becomes connection first, so connecting with the patient and building a reality together, and so at that moment, my sister-in-law cared most about this way of communication and what it how it affected her as opposed to what's the long-term treatment plan and all of those things are important but I think if you keep in mind the goal of connection first, which is an essential part of any time you step on an improv stage, you're forced to do that. Whereas in the world you're not as much forced to do it if you keep that in the front of your mind, it's a lot easier to avoid those miscommunications.  

CJ: I see. So, like if you did have to share that the recent labs, were not as good as you wanted. Is it before you share that idea? You have some, you say something or make some sort of connection with that individual and if so, how do you do that? And then how do you deliver the news of the labs? Is it like saying, "Well, you know, the labs weren't that good, but that's not the main important thing here, the main important thing is your long term," or how does that work?  

Mike: Yeah, that's a great question. And I think there are two separate issues I think the provider that called my sister-in-law, the kind of principle that's practiced on improv stage is low inference language. So, being clear what exactly you mean, and what not leave the response up to the interpretation of your scene partner and so saying what the labs were and what the next steps are. "So, your bilirubin was 2.9 we're going to need to bring you in to see the doctor sooner than before," which may sound the same, but that's less worrisome and less dependent upon the listener than saying, “Your labs were bad.” And the next improv principle would be for the physician, whose main goal is to transmit the long-term treatment plan or the kind of near-term next steps is connecting with the patient first and saying yes to their reality. So, saying "Yes, you're upset that this was communicated in this way. I feel very bad about that. We'll work on how those things are communicated to you and other patients in the future." And then just get on that same page and once you get that connection, build from there. That sense of trust, I think, has to be there for any long-term treatment plan anyway.  

So, I think that there are two different improv principles that you have to practice on the improv stage. You have to use low inference language and you have to say yes to your scene partner's reality. Otherwise, the scene just doesn't work and there are no real-world consequences to a scene not working, but you get the same practice and the joy that comes from that connection makes it worthwhile, and so you understand the importance of it in a deeper way, in my opinion, while practicing it on the improv stage.  

CJ: Yeah, that is so fascinating. That makes a lot of sense to me. So, low inference, you know, the difference between, "Oh, your labs are bad," cause the person hearing that news doesn't know what that means, right? Does it mean I'm dying tomorrow? Does it mean, as you said, your bilirubin was this, and it means we need to do this, that's much more lower, it's a lower inference because the person then you're just telling them the fact as opposed to an interpretation, and then they don't know what bad means.  

Mike: Right! 

CJ: And then, I think you call it your scene partner, right? That's the person you have to make a connection with them. And so that's going to be different for each patient probably, right? The way you make that connection.  

Mike: Yeah, absolutely. And that again is practice and improv. You step out on stage and you may have an idea of what you want to communicate, but you don't know what you're seeing partners communicating at that moment. And so that sense of finding balance when you're off balance is practiced on improv stage that is a necessary skill in my job in the hospital, going from patient to patient to patient who has different expectations, different goals, different understandings and so I have to come in fresh every single time, in every single patient room because that's what I would want for my family member.  

CJ: Yeah, that's so, that's like refreshing when I hear you say that if all of our caregivers, you know, doctors, nurses, whoever could focus on that, I think. And again, as you said, none of these individuals are bad, they have good intentions, you know, it's just trying to apply new skills to improve that interaction.  

Mike: Yeah, exactly. And I think that that's what I mean when I had that realization that I may have caused harm to other people's family members in the way that I communicated, cause I'm sure I was not perfect and I know that I was trying my best and I know that I was caring for them and wanted the best for them. But the improv skills and practice kind of opened the door to me exploring those ideas that I could be doing it better in a fun way. So, improv practice is always fun and laughter filled. And so, it kind of eases these difficult topics into my consciousness.  

CJ: Ah, that is so great. Like, we're going to ask you some more questions. We're going to take a real quick break and then we'll be back to ask you some more questions on this, cause it's a fascinating topic. So, hang in there everybody and we'll be right back.  

Welcome back from the break, everybody. We're here with Doctor Mike Smith and he's teaching us about improv and skills that can be used in everyday life and where he's applying it, he's a physician and he's applying it to the patients that he sees on a regular basis. Mike, let's talk a little bit about how those activities developed over time if there's more to say on that point. 

Mike: The first workshops I did were for the faculty development here and I came up with five workshops about the ways that improv had helped me as a physician. So that was kind of the easiest way for me to apply these ideas. But the people that signed up were from all across campus, including the business office and the librarians, all sorts of non-clinical and clinical people that came together to practice these ideas. And so, then I kind of had to change it to fit the people who weren't necessarily going to apply these ideas to patient care, and it worked really, really well. And the workshops had, as I said, people from all across campus, and that was universally seen as a highlight. Just getting everyone's perspective on how we go about our day and healthcare and how to get the best results in our job, whatever that particular job may be.  

CJ: Yeah, you had to improvise on your improv!  

Mike: Yeah, exactly! Yeah, there was literally the first one I was greeting people as they came in and someone said, "I work in the business office, will this be applicable to me?" And I had to say, "yes!" And so, from that, I'd developed 3 workshops or three more workshops for the library department here because there's a library in there and they said, "This would be good for our whole department." And so, it's funny, the first-year workshops were just advertised as communication workshops and they sold out, they had waitlists and everyone wanted to come.  

CJ: Right!  

Mike: And then the next year that I was like, "Oh, we can tell people that they're improv workshops," and those were kind of a little more difficult to get people to come, just as the idea of improv, I think, does scare people or that connection.  

CJ: It does.  

Mike: I do these each year. So, this is the fifth year that we're doing it, and there are four workshops that I do that are geared towards personal communication, like empathy, listening, wellness, and emotion, and they're paired with one workshop that's geared towards group communication or leadership principles. So, that's adaptability, body language, growth, mindset and trust in the workplace. And you don't need to attend all of them to benefit from one, but the pairing works really well together to kind of seal in the ideas and practice them both when you're talking to one person versus when you're operating in a group. 

CJ: Yeah, that's really interesting, when I hear you talk, and you correct me if I'm wrong, but it rings to me a little bit of being present in the moment and in that unique moment with those unique individuals that you're with. And, is that a part of it? I mean, you mentioned your consciousness and those sorts of things, is kind of being present at the moment a key principle of this?  

Mike: Yeah, absolutely. They're kind of scaled-down versions of that and scaled-up versions of that, I would say like in improv one nice thing is that if you have a bad show, you'll never have that show again, and the same thing is true for a good show, and so that that can scale down to an interaction with a colleague, like I each new interaction is an opportunity to have a more productive interaction. And just because I had a bad interaction with someone, the next person is should expect me to bring the best that I can to them at that moment, and that is very difficult for many people, myself included.  

CJ: That's so interesting. Now, Mike, if we could transition just slightly, so a lot of our listeners might come from the healthcare coding and compliance world, and I'm sure you're pretty familiar with compliance professionals at your institution and kind of coders. And people that are interacting with clinicians, they might not be clinicians themselves. How do you think these skills could be applicable to those types of interactions? Let's say a coder is, I don't know, presenting audit results or a documentation review to a doctor or those types of things, if that makes sense.  

Mike: Yeah. And I think it's very, very applicable. The best coders and compliance people that I've interacted with do an amazing job of recognizing the physicians' reality that they're working in and connecting to that and then building together. And so, the best ones of the coder compliance world recognize the physicians' reality and then the physicians that I know that are the best at documentation, they understand the reality and the kind of frequent changes in the coding and compliance world as well. And so, I think from both ends there are some natural improv skills, in the high performers, in my opinion, but it's a skill if practiced can, I think, lead to much better results with a larger group of people.  

CJ: So, my background, I'm clinical by background MD by schooling, but I left the clinical route, you know, decades ago and I've been doing full-time coding compliance work and I think, and it maybe just helps me for maybe the first 5 or 10 seconds of the encounter. The fact that I have a little bit of understanding of what that MD or that nurse or whoever might be going through from a clinical perspective, you know, knowing what their day is like, that their day is not focused on documentation, right? Their day is focused on taking care of people. And the documentation is like this, sometimes a burden that they have to do. They know it's important, but it's not why they get up in the morning and I think just when I had that little bit of understanding and I'm like now bringing coding results or audit results to the doc that helped me, again I still had to be good at what I was doing. It maybe gave me 5 or 10 seconds of a connection but then if you get that door open, it sounds like maybe what I was doing, but I didn't know I was doing. I was trying to practice these skills and I was trying to maybe I was doing a little improv and I just didn't know what I was doing.  

Mike: Yeah, the big rule from improv is "Yes, and..." where you say yes to your scene partner's reality and then you add something to it and your scene partner does the same, and that way you build a reality together. And so as you said, you coming from medical school training that gave you some time where you were saying yes to their reality, like "Yes, I can understand, or I can see where this is causing hiccups in your life and I understand that, let's figure out a way to gather that works the best within that reality."  

CJ: Right. Yeah, I love that, "Yes, and..." it sounds like I could apply that in so many aspects of my life. I know we're talking about our professional life, but I just think my personal relationships and those sorts of things that just seems like a magical phrase that I think everyone's listening today if they don't come away with anything else, it seems like, "Yes, and..." I love that.  

Mike: Yeah, I completely agree. And I still remember those very first faculty development workshops I did five years ago. After the first one and people came back for the second one, I said, "Did anyone use "Yes, and..." over the course of the past week?" and one person said, "I used it with my son and I was about to yell at him, and then I just said yes to his reality and he still didn't do the thing that I didn't want him to do. And it turned what could have been a confrontational reaction into an interaction that was positive and enjoyable." And so, I think it very much applies to my personal interactions as well as professional with patients professional with colleagues. And so, yeah, I think it's life-changing, but I'm very biased.  

CJ: No, I love that, Mike. So, people listening to this, I know at least me personally listening to it, I'm like, "Okay, how can I learn more? How can I explore these skills and more?" What are some ways for someone who's listening to explore these skills some more, what would they do?  

Mike: So, there are improv classes at just about any theater in the country that I'm always surprised with the improv communities that exist out there and how good they are. It doesn't need to be in a big city like New York, Chicago, or LA. I think that's been part of my ability to explore these, is because Omaha is a very good scene. There are people who take it very seriously and some that want to move on to some of those bigger cities. And also, there are people like me who are just going out, one night a week to go have fun with friends. Exploring what's available locally is great. There are also a ton of options on the Internet. There's something called the Applied Improv Network, and they have all sorts of zoom experiences which, personally, I don't think are as nice as being in person with the connection that develops, but it's a great way to kind of dip your toe in, in my opinion.  

CJ: Yeah, that's great. Now, Mike, I know you do some as well. Can you tell us a little bit more about your workshops are they all like, local and people would have to be in Omaha or do you do any online or zoom type of things or do you have a website or anything that you could share about what you do?  

Mike: Yeah, yeah, I have a website called healthcareimprov.com. And so, there has links to what I write about these topics regularly, on the current thoughts section. And in the Omaha area, I do faculty developments and workshops that are healthcare improv that is just using improv as a way to explore these skills, so you don't necessarily learn too much improv, it's not necessarily that you become an excellent improviser at these workshops, it's just they create the condition to practice certain skills and then I actually also teach level 1 and level 2 classes at the theater where I learned and currently performed the backline theater in Omaha.  

And I've traveled to do workshops in the past and I very much enjoy that and hearing what needs people may have within their group. I recently went to North Carolina and there were a group of third-year internal medicine residents who reflected back that they didn't get a Med school graduation because of COVID, so they graduated in 2020 and everything was canceled and then they had this improv workshop. And it was like the polar opposite, like the isolation and uncertainty of COVID 2020 compared with the improv workshop; connection and laughter, they're kind of on opposite ends of the spectrum for them. And so that's really meaningful for me to hear, and I enjoy that.  

CJ: Oh, that's so great to hear. So, it sounds like you do some traveling. If somebody wanted to reach out to you, is your website the best way? Do you have another means that you prefer?  

Mike: Yeah, the website is great, and then social media, I think most of them are just H care improv on Twitter, Instagram and I think LinkedIn is just me, Michael Smith. But there are lots of different ways to connect and I'm always excited to even just talk about what people are looking at doing and exploring options.  

CJ: Yeah. So, you mentioned, kind of local theaters, are these like things at universities and community colleges, theaters, or just like even just like? You know, like I, we have a theater in town that puts on plays, but I don't know if they do classes. How would somebody go about in their local community, do you think?  

Mike: Yeah, I think I know a lot of community colleges will have classes available in most theaters, will have an improv opportunity available and I think just exploring there isn't necessarily a central resource, but if you Google your city or town and improv, there are usually results because it is a very fun activity and a great way to build community. Just you have a bunch of people saying "Yes, and..." to each other and so.  

CJ: Exactly! 

Mike: It's a very, very positive group.  

CJ: Exactly right! It's like inclusive, I love what you said earlier too about recognizing their reality, you know, we all have perceptions. I know one thing, coders sometimes feel intimidated by going to doctors and sharing, because these doctors have had years and years of school, they're so smart, and now I'm bringing coding and then doctors don't always love it and they feel it's a nuisance and so I think sometimes they feel intimidated, but it sounds like if both parties can practice the "Yes, and...", recognize each other's reality and kind of work together, it could be a win-win instead of a bad experience.  

Mike: Yeah, absolutely. And I don't think it's necessarily guaranteed every time from those situations, I do know some honorary physicians, but a lot of people have similar preconceptions about improv about, "Oh, I'm not nearly creative enough to do that, or I can come up with things on the spot." And that's as you take improv lessons, you learn that's not the goal, the goal is just to say yes to what's there in front of you. And so, if you have the kind of expectation that I need to impress this roomful of doctors that would make anyone feel not able to do it I guess, but if you just say, "I just need to say yes to these people's reality and kind of meet them where they are," that's a lot easier ask than expecting yourself to impress a roomful of people.  

CJ: That's a great way to put it. Mike, we're coming toward the end. I want to give you an opportunity. If you have any last-minute thoughts or comments or anything that you'd like to say to kind of sum up what we've been talking about today.  

Mike: Yeah, just that I think the more people practice, "Yes, and..." the happier they will be and to remember that saying yes to another person's reality is in no way giving up on your own reality. And so, the more we can listen to each other and try to understand people's realities, I think that will make for happier workplaces and happier people in general.  

CJ: Yeah, I love it. I couldn't agree with you more. And I'm so grateful that you were able to share some of your expertise and experience in this area. I think it was the first time I had heard of it and at least put in that context of improv. And so, thank you so much for your time and sharing your experiences.  

Mike: Yeah, it's my pleasure. It it's great and the previous podcast guest is my cousin, so we've been in communication with these ideas for some time, and she's great and so it's nice to connect to this world as well in this venue.  

CJ: And you know the fact that you've connected with somebody who's kind of in that coding and compliance space, I think gives you some unique perspectives too. 

Thanks again and everyone that's listening, thank you for listening to another episode. If you like these episodes, please hit the like button and share it with friends. That's how we get the word out and we'd love for you to share it if you enjoy it. Until our next episode, please be safe and have a great day everyone.