Serious Play: Teaching Improvisational Compassion

When I was a younger man, I traded stand-up comedy for improv, the think-on-your-feet performance art with no net, no script, and no second take. Just you, your scene partners, and whatever reality you build together in real time. I loved it.

Soon, I saw the value of improv training far beyond the stage. I once co-led an improv program for couples struggling to communicate compassionately, and watched them start listening, building on each other's words, and rediscovering the creative collaboration that relationships require.

That phrase, "creative collaboration," is the one I want you to hold onto. Because it turns out to be the key to something healthcare education has been struggling to teach for decades.

#### Compassion Is a Creative Act

There is a quiet assumption running through most healthcare curricula that compassion is a disposition. Something students either have or they do not. We screen for it in admissions interviews. We evaluate it on clinical performance instruments. We write it into mission statements and competency frameworks. But we rarely teach it the way we teach joint mobilization, pharmacology, or differential diagnosis, as a skill that requires structured practice, progressive challenge, and deliberate training.

Monica Worline and Jane Dutton changed how I think about this. In their book Awakening Compassion at Work, drawing on two decades of research through the CompassionLab at the University of Michigan and Stanford's Center for Compassion and Altruism Research and Education, they describe compassion as a four-part process: noticing suffering, interpreting it with empathy, feeling concern, and then acting. That final step, what they call a "compassion move," is where everything either comes together or falls apart.

Because here is what Worline and Dutton make clear: compassion moves cannot be scripted. There is no flowchart that tells you what to say when your patient starts crying during the eval. No protocol covers the moment a colleague confides that she is thinking about leaving the profession. No checklist prepares you for the family member who asks you, in a voice that is barely holding together, whether their father will ever walk again.

Worline and Dutton describe compassion at work as "largely improvisational." Compassion moves are creative acts, built in real time, in response to what another human being has just offered you. They require openness to what is actually happening in the moment rather than what you planned for, and they require the creativity to construct a response that has never existed before, because this particular person's suffering, in this particular moment, has never existed before.

This is the insight that connects everything: compassion is not just an emotion or a disposition. It is an improvisational performance. And if that is true, then we need to train it the way improvisational performance has always been trained.

#### Why Healthcare Education Needs Improv

Katie Watson, a professor at Northwestern University's Feinberg School of Medicine, coined the term "medical improv" in her landmark 2011 Academic Medicine article. Her central insight is one that every practicing clinician recognizes: "The physician-patient encounter may be structured, but it is never scripted." Every clinical interaction, across every health profession, is to some degree improvised.

Think about what this means for healthcare education. We spend years teaching students to master content, procedures, and protocols. We prepare them for the scripted parts of practice. But the moments that define whether a clinician connects with a patient, earns trust from a family, holds together under emotional pressure, or sustains their own wellbeing across a career are the unscripted moments. And for those moments, most curricula offer little more than a lecture on communication skills and a hope that students will figure it out in clinic.

The APTA's Clinical Performance Instrument evaluates physical therapy students on Communication, Professional Behavior, Cultural Competence, and Clinical Reasoning, and the APTA's Core Values for the Physical Therapist and Physical Therapist Assistant define compassion as "the desire to identify with or sense something of another's experience; a precursor of caring" (American Physical Therapy Association, 2019). Nursing, medicine, occupational therapy, and speech-language pathology all have parallel competency frameworks that expect graduates to demonstrate empathy, adaptive communication, interprofessional collaboration, and compassionate presence. These are not cognitive skills you can assess with a multiple-choice exam. They are improvisational skills that require practice in the space between knowing what to do and being able to do it, in real time, with a real human being who is suffering.

Improv training is purpose-built for exactly that space.

#### Compassion Requires Creativity. Creativity Requires Openness.

I want to press on this point because I think it is where the argument for improv in healthcare education becomes not just reasonable but necessary.

Compassion moves, as Worline and Dutton describe them, are creative responses to unique expressions of suffering. They range from grand gestures to micro-moments. Sometimes a compassion move is reorganizing an entire team's workflow so a colleague can be with a dying parent. Sometimes it is a three-second pause, a hand on a shoulder, and the words "I see you." The move that is right for this person, in this moment, under these circumstances, has to be invented on the spot.

That invention requires two things that healthcare education often inadvertently suppresses: creativity and openness.

Creativity, because compassion moves are not retrieved from a database of correct responses. They are generated. The clinician has to synthesize what they are observing, what they know about this person, what the situation allows, and what their own emotional state will support, and then construct something new. This is not pattern recognition. It is pattern creation.

Openness, because compassion moves require you to accept a reality you did not plan for. The patient is not following the expected trajectory. The colleague is not holding it together the way you assumed they would. The family dynamic is more complicated than the chart suggested. Openness means letting go of the scene you rehearsed in your head and stepping into the scene that is actually happening.

Healthcare education, by its nature, emphasizes mastery and correctness. Students learn to find the right answer, perform the right technique, follow the right protocol. This is essential for clinical safety. But it can also train students to become rigid, to experience uncertainty as threat rather than as the natural condition of human interaction, and to avoid the kind of creative risk-taking that compassion demands.

Improv training is the direct antidote. It builds comfort with uncertainty, rewards creative risk, develops the capacity to generate novel responses in real time, and does all of this in a structured, supportive, low-stakes environment where failure is not just permitted but expected.

#### What the Research Tells Us

The research is clear on two critical points. First, compassion is not a fixed personality trait. It is a trainable skill. Reviews of compassion-based programs, including Cognitively-Based Compassion Training (CBCT), find that compassion can be cultivated through structured practice, with moderate effects on suffering and life satisfaction (Kirby, 2017). Self-Compassion for Healthcare Communities (SCHC), an adaptation of the Mindful Self-Compassion program developed by Kristin Neff and Chris Germer, significantly increased self-compassion and wellbeing among healthcare professionals and, in a second study, reduced secondary traumatic stress and burnout, which this site calls occupational distress (Neff et al., 2020).

Second, early evidence suggests improv training in health professions education produces measurable improvements. In one study of 165 healthcare professions students, a single one- or two-hour improv session produced substantial increases in students' state empathy toward one another (Schwartz et al., 2024). An evaluation of the UC San Diego Sanford Compassionate Communication Academy Fellowship, a 60-hour arts and humanities fellowship for clinicians that uses improvisation and theater exercises among other methods, identified five themes behind improved compassionate communication: empathic listening, pacing, checking for understanding, improved teaching and mentoring, and mechanisms for transformation (Bintliff et al., 2025).

The neuroscience adds another layer. Compassion training helps you keep your eyes focused on someone who is suffering rather than looking away, while simultaneously reducing activation in brain areas associated with negative affect (Weng et al., 2018). In other words, training in compassion does not just help you witness suffering. It helps you stay present with it without being consumed by it.

This is the same skill that improv develops. You learn to stay in the scene, to resist the urge to bail out, to trust the process even when you do not know where it is going.

Watson's own data from Northwestern showed that 95% of medical students who evaluated her improv seminar agreed that studying improv could make them a better doctor, and 100% would recommend the class to other medical students (Watson, 2011). Gao and colleagues' 2019 scoping review in Medical Teacher found consistent positive outcomes across empathy and communication, active listening, teamwork, confidence and risk-taking, and resilience. The Health Professional Training Improv program in France (De Wever et al., 2023, Frontiers in Medicine) brought together nursing, midwifery, medical, and speech therapy students for a transdisciplinary 16-hour applied improv program. Their conclusion was direct: "Just as gestures and procedures can be taught, so can empathy and communication skills."

In speech therapy education, De Wever and colleagues (2023, Medical Education) used exercises where students enacted "the worst way to" handle a patient scenario, debriefed, and then re-enacted "the best way to." The key pedagogical advantage was that students were encouraged to fail and then improve, rather than needing to perform correctly on the first attempt. In training environments where the pressure to be right the first time drives anxiety, creating structured space where failure is expected is itself a form of resilience training.

#### Distress Does Not Start on the Job. Training Environments Set the Pattern.

This is the finding that should reframe every conversation about curriculum design. Training programs are systems, and the conditions they create shape the coping patterns students carry into practice. (It is part of why I stopped using the word burnout.)

A 10-year longitudinal study found that anxiety and academic achievement during the second and fourth years of medical school predicted distinct career outcome profiles four years after graduation, including vulnerability to burnout, career satisfaction, and professional competence (Walkiewicz et al., 2012). The patterns students develop during professional education follow them into practice.

In physical therapy specifically, Luna et al. (2024) found that DPT graduates whose entire professional education took place during the COVID-19 pandemic entered the workforce with significantly higher emotional exhaustion scores than graduates trained before the pandemic, suggesting that the conditions students train under can travel with them into practice. Meanwhile, Taylor et al. (2024) found a strong inverse relationship between emotional intelligence and burnout in an interprofessional sample that included DPT students, and students with prior emotional intelligence learning showed higher emotional intelligence.

Taken together, these findings reinforce a central premise of my research agenda: integrating compassion and emotional intelligence practices into student development prepares future clinicians not just to pass licensure examinations but to actually be well and sustain effective, caring practice across decades.

If the conditions that produce occupational distress begin in training, then prevention must also begin in training, in how programs are designed as well as in what students learn. And if compassion is protective, and compassion is an improvisational skill, then training students in improvisational compassion is not a wellness add-on. It is foundational to preparing clinicians who can survive and thrive in practice.

#### The Grammar of Improvisational Compassion: "Yes, And"

The foundational principle of improv is "Yes, and." Accept what your scene partner offers, and build on it. This principle, which every improv student learns on day one, is also the grammar of compassion moves.

The "Yes" is the noticing and validating. Someone expresses suffering, and you accept that reality. You do not deny it, minimize it, or redirect it. You do not say, "You'll be fine." You do not say, "Let's focus on the treatment plan." You do not say, "At least it's not worse." You accept the reality of what has been offered. That acceptance requires openness, the willingness to receive a reality you did not plan for.

The "And" is the compassionate action. You add something. You bring resources, presence, emotional support, practical help, or simply witness. You build on the expression of suffering with a creative response that moves the moment forward. That addition requires creativity, the capacity to generate something that did not exist before this moment called for it.

When healthcare professionals fail at compassion, they are almost always "blocking" in improv terms. Blocking is the cardinal sin of improvisation: denying what your scene partner has established. In clinical settings, blocking sounds like: "Everyone goes through this." "Have you tried not thinking about it?" "I don't really have time for this right now." Each of those responses denies the reality of the suffering and stops the scene cold. Blocking is what happens when a clinician lacks either the openness to accept the moment or the creativity to respond to it.

Del Close, the legendary improv teacher who co-founded the ImprovOlympic in Chicago and trained generations of performers, left behind Eleven Commandments that shaped modern improvisation. When read through the lens of healthcare, they become a remarkably precise framework for compassionate practice.

"You are all supporting actors." In healthcare, compassion is everyone's role. Worline and Dutton call this "compassion architecture," the organizational design that ensures everyone sees compassion as their responsibility.

"Save your fellow actor, don't worry about the piece." In moments of real human suffering, the person comes before the protocol.

"Your prime responsibility is to support." Your job is not to fix someone's suffering. It is to support them through it. This is the shift from empathic distress to sustainable compassion.

"Work at the top of your brains at all times." Compassion is not soft. It requires cognitive sophistication, reading the room, assessing the suffering, choosing the right move, and executing it with skill. Worline and Dutton are explicit that compassion moves are creative acts requiring intelligence and presence.

"Trust." Trust your colleagues to show up when you share something heavy. Trust yourself to respond well without a script. Trust is the container that makes improvisational compassion possible.

"LISTEN." Close put this last and in capital letters because it is the prerequisite for everything. You cannot make a compassion move if you have not heard the expression of suffering. You cannot build on what your scene partner offers if you were not paying attention. Listening is the "Yes" in "Yes, and."

#### Three Outcomes: Communications, Moves, Cultures

When I advocate for improv training in healthcare education, I am not advocating for a theater elective. I am advocating for a pedagogical approach that develops three interconnected competencies that our current curricula struggle to teach.

Compassionate communications. Every clinical encounter is a conversation that unfolds in real time, and the quality of that conversation depends on active listening, adaptive response, nonverbal awareness, and the ability to match your communication style to the person in front of you. A 22-year-old athlete recovering from an ACL reconstruction needs a different communication approach than an 85-year-old who is frightened about falling. A patient disclosing domestic violence needs something entirely different from a patient who is frustrated about slow progress. Improv trains precisely this adaptive, responsive, improvisational communication. Research on pharmacy students showed that adding improv to a counseling skills course improved standardized patient exam scores, particularly in recognizing initial patient cues. The APTA Academy of Education has specifically presented on improv's capacity to develop and remediate communication skills in physical therapy students that typical didactic methods cannot reach.

Compassionate moves. Beyond communication, improv develops the capacity to act compassionately in the moment, to generate responses to suffering that are contextually appropriate, emotionally attuned, and creatively constructed. This is what Worline and Dutton mean when they describe compassion as improvisational. The clinician who notices a colleague struggling and quietly rearranges the schedule to lighten their load is making a compassion move. The therapist who pauses a treatment session because she reads in her patient's face that something else is happening today is making a compassion move. These cannot be taught through a lecture. They must be practiced through experiential exercises that develop the capacity for creative, open, real-time response.

Compassionate cultures. This is the level at which individual skills scale to organizational transformation. Worline and Dutton's central argument is that compassion competence is an organizational capacity, not just an individual trait. Organizations can design what they call "social architectures" that support the improvisation of compassion. But those architectures require people who have been trained in the improvisational skills that compassion demands. When an entire cohort of students learns to listen deeply, accept reality as it is presented, respond creatively rather than defensively, and support each other through difficulty, they carry those skills into practice. They build teams differently. They mentor differently. They lead differently. They create cultures where compassion is the norm rather than the exception.

#### Where Improv Fits in the Curriculum

The practical beauty of improv training is that it is flexible, low-cost, and integrates naturally into existing curricular structures. It does not require new equipment, specialized facilities, or expensive technology. It requires a room, a facilitator, and willing participants.

Foundational professional development courses. Most healthcare programs include early courses on professionalism, ethics, and communication. These are natural homes for improv exercises that make active listening and compassionate response experiential and embodied rather than theoretical.

Pre-clinical preparation. Before students enter their first clinical experiences, improv exercises prepare them for the unpredictability they are about to encounter. The "worst way to / best way to" format allows students to explore both poor and excellent responses to common scenarios in a safe, low-stakes environment where failure is instructive rather than punitive.

Remediation for affective domain challenges. Students who struggle with communication, professional behavior, or emotional regulation in clinical settings often receive more of the same didactic instruction that was not working in the first place. Improv offers a fundamentally different pedagogical approach: experiential, embodied, social, and immediate.

Interprofessional education. Improv exercises work powerfully in interprofessional settings. Bring students from multiple health professions together for improv-based exercises and you accomplish two goals simultaneously: developing communication skills and building interprofessional relationships through shared vulnerability and play.

Clinical educator development. Clinical instructors and preceptors model professional behavior, communication, and compassion for students every day. Improv-based continuing education not only improves their own skills but gives them tools to teach and model improvisational compassion for the next generation.

Student wellbeing programming. Given the evidence that distress patterns established during training persist into practice, incorporating improv into student wellness programming is not extracurricular. It is preventive, alongside changes to the training conditions themselves. Programs that teach students to manage emotional complexity, build supportive peer relationships, and develop comfort with uncertainty are investing in the long-term sustainability of their graduates' careers.

#### The Improvisational Compassion Argument

Here is the argument, stated as plainly as I can.

Compassion in healthcare is not a fixed trait. It is a trainable skill. The research on compassion training programs such as CBCT and SCHC, and on compassion neuroscience, makes a strong case on this point.

Compassion, when it is practiced well, is fundamentally improvisational. It requires noticing, openness, creativity, and action in real time, without a script. Worline and Dutton's research makes this clear.

Improvisation is also a trainable skill, one with a rich tradition of structured pedagogy going back decades. Early research on medical improv suggests that even brief training can produce measurable improvements in empathy, communication, and resilience among healthcare students.

The conditions that produce occupational distress begin during professional education, not after graduation. The evidence on this is growing. If we want clinicians who can sustain compassionate practice across careers, we need to begin training them during the period when their coping patterns are forming.

Improv training develops exactly the capacities that compassion demands: the openness to accept what is actually happening, the creativity to respond in ways that have never been rehearsed, the listening to hear what is really being said, the trust to act without certainty, and the resilience to stay in the scene when the scene gets hard.

We spend years teaching healthcare students the science of their professions. We owe them equal rigor in teaching the art. The art of being present with a person who is suffering. The art of listening without judgment. The art of generating a compassionate response that has never existed before because this moment has never existed before. The art of staying open when every instinct says to close down, and finding something creative and human to offer when there is no script to follow.

That art has a name. It is improvisation. And it belongs in every healthcare curriculum.

#### References

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