When I say … improvisation

Two clinical teachers meet over a good eastern dish in Oslo. After initial handshakes and with chopsticks at hand their conversation evolves. 'I remember hearing the Jazz formation "earswideopen" play in a cafe in Amsterdam, my hometown. The performance was great and I was intrigued by the way they communicated with each other during their improvisation. A little nod here, a blink of an eye there. Amazing!' Christiaan dips his dim sung in the soy sauce. 'That is somewhat like capoeira in Brazil,' Marco continues. 'Capoeira combines dance with martial arts. There is no fixed script. The body talks and it listens. Active contribution and response to the other participants results in a unique experience.' So what do we mean when we say improvisation? Let's start by mentioning what we don't mean when we say improvisation. Often improvisation is understood as 'a second best' when one is forced to change or abandon 'Plan A'. In this case, it is seen as an occasional, artless approach that one only uses when an unforeseen element forces a change in plans. In this case, as Plan A would bring the best expected outcome, improvisation outcomes are almost always understood as suboptimal. Since the Latin root to improvisation is 'improvisus', the unforeseen, this thinking about improvisation is understandable.1 Nonetheless, we conceive improvisation as something radically different. We see improvisation as a continuous, artful process of creating that comes about by the joint and active participation of all involved. The unforeseen becomes not an exception, but a given. Or even stronger put, that which is not (directly) seen becomes a crucial element in the process of creating. It is artful because the co-creation of an authentic, spontaneous and efficient solution depends on the wisdom of each participant in the process of improvising. Improvisation is not a response to an accident, it is a thoughtful process of working together and embracing ever present complexity and uncertainty. Since all involved have unseen and thus unacknowledged elements to contribute, the fundamental conviction underlying this process of improvisation is that 'it takes two to tango'. For improvisation is the joyous celebration of life lived; where people meet each other on the same level 'playing field'. In other words, improvisation starts with thoroughly acknowledging that reciprocity is key (read: there is no hierarchy). As a result, improvisation deliberately emphasises the importance of creating a safe environment, an environment that welcomes all participants and their contribution. This implies openness for the other, their views and experiences. For only when all contributors are recognised for being a unique and therefore crucial element in the improvisation can they play their vital part. 'Who could have imagined the similarities between Jazz and Capoeira?' says Christiaan. 'Both are based on improvising over a repertoire of skills and knowledge. Players need to be present to build up on each other.' 'That is the beauty and core of improvisation. In the attuning to another, the unseen is not only welcomed to become visible … it sparks something new,' Marco replies. As the vignette illustrates, improvisation requires a mindful 'presence'—a state of physical and intellectual alertness to explicitly and constantly attune to each other. In this process of attuning, the stage is set to perform together, to charge the air with excitement for something new is about to come to being. Improvisation is a process which celebrates the uniqueness and diversity of every 'dance' performed. At first sight, improvisation might have little to do with medical education and medicine itself, but looking closer, it is actually the very core of both. For in both 'the unseen' is crucial. Be it unseen aspects of the patient and doctor that determine what good care looks like or how it is delivered or unseen elements of the student and teacher that are crucial for the learning process. We propose that having an improvisational mindset creates a context in which knowledge and skills can be developed, incorporated and deployed. The improvisational realm creates a relaxed and open atmosphere and lights an alertness of mind and body nurtured by an authentic sense of curiosity about 'the other', be it the patient or the student. Any contact and interaction between a student and an educator is a unique moment and an improvisation as such. It takes place in a specific context, with specific needs and specific expectations. In order for the interaction to move in the appropriate direction, the right starting point is essential. Just like starting with the agenda of the patient is pivotal in a clinical setting, so the (partly unseen) agenda of the student is pivotal in the educational context. By prioritising the student's agenda, the educator not only gathers vital information but also legitimates perspectives, feelings and understandings, validating the student as a key player in the improvisation. It invites the student to take ownership of their own process of education. Only after addressing the student's agenda can we open space to bring topics that, from an educator's perspective, are also relevant. 'Last week, a young doctor asked for my supervision in a difficult case,' says Christiaan. 'I learned a lot by a mistake I almost made.' 'What was that?' 'I assumed that she would ask about the medication given and the complication that followed. I was lucky enough to first ask her what was going on. It turned out that she was feeling angry because her inputs were not taken seriously by the multiprofessional team and guilty because of the complication. She was martyring herself because she did not speak up.' 'Your curiosity and questioning her do you credit!' This openness to prioritise the other, a key element in improvisation, is critical for both the clinical and educational encounter to succeed. In the clinical encounter, the question 'What do I need to know about you as a person to give you the best care possible?' is called the patient dignity question (PDQ).2 The PDQ acknowledges and welcomes the unseen, often impactful elements present in the clinical encounter, while underscoring the relational aspect of improvisation by inviting the patient to contribute to the process. If phrased to fit the educational context, it can have the same effect. The correspondent question 'What do I need to know about you as a person to support your personal and professional development in the best possible way?' invites students to pay attention to personal elements that remain unmentioned and therefore out of sight. It also challenges students to question potential unconscious convictions and opens a space to reflect on unspoken elements of the medical culture. This 'tango' depends on the educator adopting a mindset charged with curiosity to the extent that the educator may, when the improvisation calls for it, become 'the student'. The student, as a result, becomes 'the teacher'.3 This shift in perspective contributes to creating a democratic space of mutual discovery, which may increase students' engagement. With all participants engaged, the improvisation will intensify and establish a context of connection in which the educational process can flourish. If improvisation is indeed a learnable skill and a sign of expertise in itself, how do we acquire this mindset and skill? We propose that the use of the arts can play an important role in the nurturing of this skill. Arts help us to see differently, to use our imagination to experience that which is not directly visible. The authors suggest that the contribution of art in education is not rational and 'thought through' as such. Arts such as drama, music and drawing, creates a connection that besides being cognitive is also emotional and capable of creating meanings beyond words.4 This connection creates safe spaces for meaningful conversations that would not happen otherwise. Conversations touching upon topics such as the purpose of becoming a doctor, how to find balance in life, how to regulate (and learn from) emotions and develop empathy. This qualified connection facilitated by arts can help both students and educators feel more comfortable with the process of improvisation. Working with arts may give them the experience and reassurance that they can become competent to work with each other and contribute to the educational process. In the end, art's biggest contribution is to make improvisation tangible by providing a possibility to make it 'lived through'. Fitting to the concept of improvisation the contribution of arts to medical education should be explored together with artists in different art settings. This process of exploration can be a source of learning and inspiration on how different worlds attune to each other. After all, reciprocity is key. As our dinner came to a close, the stream of thoughts was still flowing … 'We should make this improvised conversation into an article.' 'Count me in, Marco!' Open to one more reading suggestion, Christiaan? 'Always room for reading.' 'By way of closing … In "The aesthetics of the Oppressed" Augusto Boal says "To improvise is to live! Life is an eternal improvisation, or it is no life at all!"'.5 Both authors like to thank the Centre of Sustainable Health Care Education for their hospitality in hosting the meal and 'improvisation' and thereby making this thought on improvisation tangible. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.