Lessons from Improv Comedy

Preston: [00:00:00] Never miss a good opportunity to shut up. And that's, like, a fun lesson that I've been bringing back to clinical practice too. I framed it differently before as, like, silence can be, like, a good tool, almost like seeing it through the lens of theater where, like, your patient is your scene partner and, like, you let, like, let them build the scene more.

How to be safe

And welcome back to How to Be Patient. We are flying from the seat of our pants today because we will be improvising much of this episode. I'm joined by our co-host, M- M ... standing for Margaret- Oh ... at that every day I signed in on M instead of Margaret. She's on the riverside chat she's made her name M, which I think it's it's subtle, it's vague, it's mysterious.

I kinda like it. Everything that would be good- A stage name ... for a character. Yeah, exactly. 

Margaret: Exactly. Yes, you guys, you heard it right. We are gonna try for the first time ever to be funny on this podcast. 

Preston: Maybe the second time we've tried being funny, but we will be successful. Re- remember we did those, [00:01:00] weekend update style jokes? 

Margaret: Yeah. Well, our Glaucomflecken didn't give us the approval that we wanted from that. This is a beef in four- season 

Preston: four. And it's tough because I think he really wanted to. Like, you could see it in his eyes. He's like, "I want you to be funny. Please, God, be funny right now."

And then we... It was tough. 

Margaret: Unlike you, I cannot be funny on command, so I may struggle with this today. But we're gonna give it our best shot. 

Preston: And, I think that's a great insight even for the start of this episode, which is that improv is not stand-up. and they... Like, for context everyone, I've been taking improv classes for about, like, the last nine months or so at the recommendation of Dr.

Glaucomflecken, which is, great advice. I think it's been a lot of fun. But they said at the beginning, you know, this isn't about trying to show off the funny. You don't have to, like, do it on command. It's not a stand-up class. It's about collaboration, working together with people. So even if you're not funny on command, it doesn't matter 'cause it's just about the scene.[00:02:00] 

And that's what we'll, that's what we'll find out. Improv, is excavating. Stand-up is, presentation 

Margaret: What does improv is excavation mean? 

Preston: It's like we're both paleontologists, and we're trying to discover a dinosaur, and I'm, br- I'm uncovering this part over here, and I'm like, "Look what I found."

And you're like, "Oh, look, look what I found. Looks like a claw." Ooh, 

Margaret: okay. 

Preston: And I'm like, "I see a tail." I mean, it's, a claw tail kinda creature. And then you're like, "Wait, I found wings." Yeah. Now I have to incorporate wings into my perception of whatever this dinosaur is. 

Margaret: That's, 

improv. Oh, that's cool.

That's a cool metaphor. 

Preston: Yeah. 

Margaret: And how, are you... I feel like I'm about to preempt you, but you wanted to do the... You wanted to do it for your own sake when you started. but also, I know you've been making some videos and that this episode is about improv and medicine or psychiatry. So what inspired this episode for you?

Preston: Well, I, think recently I've noticed that my use of my medical training in improv was how it started, which was [00:03:00] I thought my skills as a therapist would make me a good improviser, which they do. But then my skills that I learned in improvisation started translating more into my therapy with my patients- my clinical interactions. And I was thinking, "Wow, this is so interesting how much faster and more comfortable I am with these exchanges now." 

Margaret: Yeah. 

Preston: So I thought it would be kind of fun to have a whole episode kind of diving into the reflections and the nuance of those lessons. and this isn't new.

There already are, like, post-grad courses or for a lot of people at the end of their MS4, they take improv classes. preclinical students take improv, sometimes in correlation with their OSCEs. So it's been something that's been studied, like using improv and education as a way to help train, clinicians.

There's also some kind of work that people are doing for actually, like, TBI and, like, cognitive rehab with improv, almost like a souped-up version of speech therapy. So there are a lot of, like, really fun ways that [00:04:00] improv is being used in medicine already, but I just kinda wanted to... This is through the lens of my personal experience, so I'm not gonna come on here as an expert in improv and tell you all the evidence and all the ways that things are helpful, but this is a, a fun, unique opportunity to say, "You know, Preston's been doing this, and, this is what he learned."

Margaret: I was watching Kung Fu Panda, and you've been doing improv. Exactly. I must bring them, to the podcast. Together. I will say, I do feel like some of the funniest parts of med school were, like, not improv. But I actually... Now that you say that, I think there was, like, a class, like, led by a local improv person in med school before OSCEs.

And then just some of the things that would come up when you would act out, like, this patient simulation. Some of the things- I feel like so many friendships in med school are based on, like, bonding over doing those and one of you saying the, like, stupidest, stupid thing you've ever said. Exactly.

Preston: Exactly. And it's like, it's even something as, as dumb as, like, you, mis- like, mispronounce something. You completely use the wrong [00:05:00] word. I think, I like, misused, like, epescopa- epescopalian To, refer to an ep- Episcopalian ... yeah, Episcopalian to refer to a pescatarian. 

Margaret: Oh. 

Preston: and then we was really talking about diets.

And that one stuck with me for a while. Like, that was pretty funny. or like, I'm a, punny person, and the improv class that I work with, they hate puns. They don't hate them, but, like, they're groaners. So w- so at my last show I did a pun. This is on the Patreon. I- I put this clip there, but I did this pun, and they cut the scene and then made me go do...

Like, they were like, "And now Preston will deliver a 45-second apology to the audience as to why- ... he did this pun." And then I, and I wasn't expecting that. It w- improvised obviously, so I go out in front of, you know, this humble crowd of 30 people and, I got to plead for forgiveness for using a pun with the spotlight on me.

[00:06:00] like, stuff like that is fun, and it sticks with you, and they're happy memories. And actually the, like, some people from the class got together and they wanted to form an improv troupe. And so- Oh, 

Margaret: cool ... 

Preston: I got the invite 'cause I'm a popular- Exclusive ... fun guy. So like once a week I've been, like, practicing with them.

Margaret: Famously, that is how popular, fun guys- Yeah ... refer to themselves in the second 

Preston: person. Yeah. And humble. Popular, fun, humble guys. 

Margaret: Humble- 

Preston: They... 

Margaret: Yeah ... handsome, smart, intelligent, prize-winning- 

Preston: Mm-hmm ... 

Margaret: unstoppable, tremendous. Never been 

Preston: seen. Took the words right out of my mouth. Never been done. Not all of them.

There's more words that could describe me, but those are most of them. 

Margaret: There are many more words that could describe you, Preston. 

Preston: So, like- Yeah ... all this stuff has been fun. I've been enjoying, kind of having as a part of my life, so I wanted to use this as a chance to, share it. And that all being said, I think it's time for us to warm up a little bit.

that's what we call it in the improv scene. And normally this would be an icebreaker, but maybe this is an ice melter since we're warming up. So I will [00:07:00] actually turn it back on you for a second. I wanna give you the choice, and I'm purposely not giving you much description here, but I want you to pick between two warm-ups.

Margaret: Okay. 

Preston: So we have Top That and Pun-A-Thon. Those are our two warm-ups. I want you, and pick one. 

Margaret: Punt-A-Thon or Pun-A-Thon? 

Preston: Pun. Pun. P-U-N. 

Margaret: Okay. Pun-A-Thon. 

Preston: Pun-A-Thon? Perfect. So- 

Margaret: Yeah ... 

Preston: the game of Pun-A-Thon is essentially A, a back and forth almost like tennis match of however many puns you can make about a certain type of topic- Okay

that gets brought up. And so you solicit something from the audience, and then you just go as hard as you can punning about it. And the improv part is you make up a story or something and then fold it into a pun. So for example, let's say the topic was cats. 

Margaret: Mm-hmm. 

Preston: So you could say, "Oh my God, I [00:08:00] get, so frustrated with my, cat.

She has like way too many, toes on her hand- 

Margaret: Mm-hmm ... 

Preston: and she has polydactyly. So when I try to chi- trim her nails, it's just, there's always this awkward paws." 

Margaret: Got it.

Preston: And then, you'd come back with like, you know, "Well she's, you know, she's always delaying, going out the door by just screeching everywhere. And I'm like, 'Ma'am, get over here right meow.'" Something like that. Kinda understand the vibe of Pun-A-Thon. Just like paying by the puns. yeah.

Yes. Okay, got it You will die by the puns. And we basically just keep going until there's nothing left. Okay. And then we cut the scene or, we solicit one more so, or we solicit another one from the crowd. And we actually, we have the crowd here today. the fill-in is Rob, the producer. He's 

Margaret: been long told he will be here.

Preston: Hey, Rob. How's it going? 

Margaret: doing great. An honor 

Preston: to, So- ... 

Margaret: tell you what 

Preston: your 

Margaret: topic 

Preston: is today. Yeah. So, so what do you [00:09:00] do for work, Rob? No, I'm just kidding. I, I- This isn't a crowd work ... 

Margaret: I'm 

Preston: a youth pastor. but Rob, I do want, you to give us a type of activity you would do in the evening, like a hobby.

Producer Rob: well, currently I'm, painting a lot in the evenings, so we'll say 

Preston: I paint perhaps. Okay, painting. So, so the topic is painting. I really need to brush up on my painting skills. 

Margaret: I feel like I'm gonna be really bad at this. well, you know, I'd love to talk to you about, I have a friend who loves to talk about art.

Big, kinda like going to all the museums. Their favorite artist, you know, is Van Gogh. more than just like Starry Night. But once you get him started, he'll talk your ear off.

Oh my gosh. 

Preston: Okay. you know, I, wanted to get more into [00:10:00] painting, especially oil, but, I heard that they don't really, get any value until after you die. And I was like, "Where's the Monet in that?"

Margaret: da, Jason, I know you're not gonna cut this pausing out because that would be too that would be getting rid of the point of this. I was gonna do a Monet one, and so you sh- took it. That's so funny. I just 

Preston: stole it. 

Margaret: Yeah. 

Preston: I stole her Monet. 

Margaret: yeah, the, the Monet was under the table. No. 

Preston: the- You can still use Monet. Like, it's also kind of funny if you're, just like- Well, I was- ... "You took my Monet. I'm gonna take my, save my Monet anyways."

Margaret: Well, okay, I was watching this TikTok video earlier, and it was like Har- It was a video, that was an interview from a long time ago of Ryan Gosling and Harrison [00:11:00] Ford, who is, like, famously very grumpy during interviews, for movies and projects as he's gotten older. And there was a point where he was talking about art, and then they were talking about, like...

Now, like, I can't land this. I just realized I couldn't land the plane in the middle- No, just stick it. No, I truly can't land it. He lands it. In the interview, he's just, is like, sh- I, we need to, I need to find this clip. He ends with saying, "Show me the money," and I was gonna do a Monet one, but I can't do it- It's good ... 'cause I can't land the plane. And, I thought it was a stroke of genius, but it wasn't That's 

Preston: good. That's good. 

Margaret: So I landed the plane. 

Preston: Okay, perfect. All right. So I've been looking at getting, like a higher end apparatus to hold my paintings. but like the resale values of these things is it's so high up and everyone that I've been talking to try to get one of these like painting holder apparatuses, they're just terrible.

It's an awful market. And then I realized money is the [00:12:00] root of all easel

Margaret: Okay, can we pick another topic? 

Preston: Okay. Okay. Rob, I want you to give us, any kind of form of transportation going from point A to point B. 

Margaret: I'm gonna go train. 

Preston: A train Yeah, those, the train ones, th- they'll go off the rails pretty fast.

Margaret: I see. Margaret seems to be running out of steam. 

Preston: Oh. Margaret just got pun, pun mogged by Rob. 

Margaret: Feels like I'm falling behind. It feels like I'm the caboose in this conversation. Okay. 

Preston: Yeah. let me, get us back on track 

Margaret: You already 

Preston: used that It's 

Margaret: [00:13:00] You used the sente- you used the spirit of that one already.

Preston: Yeah, you're right. Yeah, that's true. That's true. sh- what? So, I was in Mexico, and- ... we were all playing, soccer, but they call it football down there. And, the best thing we had to set up, for the net, to score was, one of those, like a train car, and it was, f- fill, filled up with fuel for the train.

So when we, and when we kicked the ball in there, everyone just yelled, "Coloso." Instead of golasso What's a co- oh, colasso.

Colasso. 

Margaret: So I have a story to tell you about, like, one of my, like, clinical experiences. So I was talking with this patient's family about things that were going on for one of my patients at school, and she, like, loves playing the [00:14:00] trumpet. She's in her, like, high school band, but she's had, like, a ton of issues with being in and out of the hospital, and then some behavior stuff that has, like, gotten her suspended.

and one thing that had recently happened was at the start of last school year, they were just getting to meet all of their, like, new band people and everything going on, with, like, getting started in the year, and she has a reputation. And so they're in band, they're starting to play. They are getting pr- they're practicing for this, like, big football game they had coming up and, you know, their marching band.

And I end up hearing about this because they have this game, it's a big first Friday night game. The band is out there- Mm-hmm ... and she loses it on the field and throws her trumpet down just 'cause she missed a note. And she ended up having this whole big thing, and the football coach had to come over to the leader and the teacher of the band, and he was like, "What are you doing?"

Like, "Help her. Make her do something different." He goes, "Conductor, I can barely I barely know her." [00:15:00] 

Preston: Oh my gosh. See, that you, just did the Monet version of me because I was, pulling one of those. I was gonna say, I'm sitting on a train the other week, and one of the employees just, just grabbed one of the handrails, was immediately electrocuted to death.

He was quite the conductor. 

Margaret: Yeah. This reminds me of the, like, Norm MacDo- I, like, I mainly, I was doing that in the style of Norm Macdonald. 

Preston: That was great. And then- Conductor, I hardly know her. 

Margaret: Like, where is this freaking going? 

Preston: Okay. I think that's good unless you wanna go for one more 

Margaret: I think it's the end of the line.

Preston: I, agree. It's, our last stop. So we are gonna take a quick break, and when we come back, we are gonna talk a little bit about yes, anding. 

Margaret: Love it. Yes, we will. Do-do-do-do. And here's a break.[00:16:00] 

Preston: Margaret and I are very excited to tell you about a healthcare news podcast that just came out called Medlines. 

Margaret: It's a quick weekly wrap-up of everything in our field, from breakthrough discoveries and research, to politics, and of course, medical pop culture. 

Preston: I think the best way to conceptualize this podcast is it's like NPR's Up First, but for medicine.

So they're short, to the point, with episodes no longer than 15 minutes. 

Margaret: And it's written and created by an amazing team, some of whom you might recognize: Dr. Glaucomflecken and Lady Glaucomflecken, as well as many people here at the Human Content Podcast Network. 

Preston: With thanks for their inaugural sponsor, the New England Journal of Medicine.

New episodes of Medlines are out wherever you get your podcasts, with new episodes out every Friday.

Okay. And we are back to talk about one of the, the most fundamental principles of improv, which is yes and-ing. what... And this is, I think this is pretty, well-known to the layperson. So, so Margaret, what's your understanding of like yes and [00:17:00] as a concept? 

Margaret: In improv, you don't necessarily like, you're- since you're building something together, and it could be anything, you...

Yes and is that you kind of receive what the other person gives you and build on it, rather than trying to take it, like, by force into a totally different direction or contradicting the shared reality you're making. 

Preston: Mm-hmm. And the exact antithesis of yes and is no but. 

Margaret: Mm-hmm. 

Preston: So I'm denying it, and this is why it's not gonna work.

So the, like the very first exercise we did in like the 101 class was party planning. It was like you plan a party with someone, and every time they add something silly or dumb or nonsensical to the party, you have to say yes and. Like, "Oh, it would be so cool if we hired 100 clowns into my 500 square foot apartment."

"Yes, and- "

Margaret: And I have 500 go-karts that would go perfect with them." "

Preston: [00:18:00] Yes. And, we can turn off all the air conditioning." 

Margaret: I've always... Yes, 'cause I've always wanted to see 500 sweaty clowns.

Preston: Yes. and then... 

Margaret: And we'll analyze that. 

Preston: And then I will go home. Yeah, so it's, validating the, initial premise. Like, you have to... Like, the yes part is saying like, what you said is true. Because what, like, really kills an improv scene is if I say, "Oh, hello, Margaret, my long lost sister," and you say, "I'm not your long lost sister.

We don't even know each other." 

Margaret: I'm a sweaty clown. 

Preston: Yeah. What are you talking about? Then it's like, oh, like the reality doesn't even exist. But you, could say yes but. Like, "Oh, Margaret, my long lost sister," and you're like, "Yes, I am your long lost sister, but not anymore." 

Margaret: Right, exactly. 

Preston: Yeah Now it's kinda like, oh, I'm, [00:19:00] It's like the reality's right, but you've already contradicted it. 

Margaret: And I feel like similarly, like, it's like you could do that maybe s- like once in a while that can happen, but like if you kept repeatedly doing that, it would make the improv really not fun and not flowy, I would s- guess. 

Preston: and you're guessing right.

'cause even within like the w- the world of yes, and-ing, you can say something or people can contradict themselves and it will just like not even make sense to the scene. And, the, it, there's like this distinction between non-realistic and unrealistic. So something that's non-realistic is just like not operating within the bounds of like our known reality.

So something like, let's say, we're in a magical realm where gravity isn't real, and also we can talk to plants. Like those are non-realistic things. But unrealistic would be for me to say, "Oh man it's been 10 years [00:20:00] since I've seen my wife. And then you'd say, "Didn't you see her yesterday?"

"Oh, right, I did see her yesterday, or maybe it was a week ago. I don't know." And you're just like, what? Like, you... Th- this is, like, the person who's, like, supposed to be important in your life, unless you're, like, making a whole point about how, like, nonchalant you are about it. Like, those are, like, very, like, weird, inconsistent things.

Margaret: Yeah, I was gonna say, it reminds me of, like, the, in, like, the fantasy writing world, they talk about, like, the internal logic has to be very tight, even if it's, like, an unreality, a fantasy world, a fantasy land- Right ... whatever. But, like, you can't be like, "We have no gravity," and then only part of the time that applies or something like that in the world you're creating.

Preston: Yeah, so, so in this b- book, which I guess this is, like, the... If you guys are interested, this is the step one equivalent for, or what is it, fir- the first aid equivalent for improv. It's called the Comedy Improv Manual, and they give an example about that, [00:21:00] where they say they're doing this scene where they're like two dentists or a dentist and a dental assistant are going to, like, put someone under for a root canal.

And one dentist says, like, "Let me go get the anesthesia medicine," like the benzocaine to, to put you under for anesthesia. And then the other dentist goes, "I'll be right back with the brick." And the patient's like, "Why are you going to get the brick?" And he's like, "The anesthesia is the brick. I'm gonna knock you out."

Margaret: Yeah. 

Preston: And they're kinda like... So we could be living in a world where, like, yes, dentists do n- knock people out with bricks, and that's their way of, like, putting them under for the tooth. But the other dentist already said he's gonna get the medicine. And then, like, why would these two dentists, like, not be on the same page at all about...

Like, it, just, it kinda, like, breaks up the scene as awkward, and then the, the other character, like, calls that out from them. So I think that's kind of a good example of that. The, interesting thing, though, about yes, and-ing is that [00:22:00] you can accomplish a lot of the same things from a no, but While still saying "Yes, and," and I think that's where it becomes really helpful for, like, the clinical application of it.

You almost have to just, whenever you're conversing with a person, take no but out of your vocabulary, and realize that people just respond a lot better to, like, both the words yes and. So let's try a little exercise. Let's say I'm making up, a trip, like we're planning a road trip, and I say, "Okay, for the start of the road trip, we are gonna drive," from where I'm in Texas, "We're gonna drive from Texas all the way to Tallahassee.

We're gonna do 20 hours in the first step, the first time. We're just gonna go 20 hours straight." And then you would add, to that. Try it, try, and try it by saying, "No, but." Like, "No, but," and then change- 

Margaret: Okay ... 

Preston: the trip however you want. 

Margaret: I don't think so, but we [00:23:00] can bring your two cats along, and I'll give you halfway to Arkansas.

Preston: See, I don't like that, 'cause you told me no, and now I'm only in Arkansas, not Florida. But 

Margaret: you have your two cats. 

Preston: Right. And what if you said that with yes and? You were like, "Yes, we can go to Florida, and we can stop at Arkansas on the way." 

Margaret: yeah. I'm 

Preston: like, wait, a second. Wait. You're agreeing with me- The deal's changed

but you're not. 

Margaret: Yeah. 

Preston: I'm so confused. 

Margaret: I don't know what to do. It reminds me of, like, in motivational interviewing when we talk, and just in general, when we talk about, like, reflective statements, that there's, a similarity there that's there's always a little bit of at least yes.

But it's like, "I like where you're going, and even though I'm gonna say we have to go a different direction, here's the part that I think that you brought up that we can keep," or s- or something like that. Mm-hmm. 

Preston: Yeah, it's how you wanna order the change talk and the sustain talk, and the yes part is the validating and the and part could be the change talk.

Where if I'm [00:24:00] talking to you about smoking and I tell you that, like, the only thing I look forward to in my day is my smoke break, like, you, have to yes and that. You know? 

Margaret: Yes, 

Preston: and- Yes ... you're talking to 

Margaret: me about- ... this, so you probably- And you're thinking about quitting ... have other thoughts on it, too.

Yeah. 

Preston: Mm-hmm. 

Margaret: Yes, this is an important part of your day, and... 

Preston: You're worried about, your health ef- effects on your family. 

Margaret: Yeah. 

Preston: Yeah. 

Margaret: Guessing. 

Preston: So- 

Margaret: No but. No- Instead, you 

Preston: can be, no 

Margaret: but ... and you're a bad person. No, and you're stupid. 

Preston: y- yes, and fuck you. Like, wait a second. I don't know, I don't know if yes, and is that powerful that it can protect all that.

Margaret: You're gonna love what I have to say next. 

Preston: Yeah. But instead of being like, "You know, smoking's the only thing you look forward to during the day." "No, but you're thinking about its health effects on you." Mm-hmm. even just, like, subconsciously playing that in my head, I'm responding to it differently.

Margaret: Yeah, 

Preston: So [00:25:00] it's, almost like just, steal that verbatim. Like, it- and I think just knowing that you have to yes, and everything the patient says- 

Margaret: Mm-hmm ... 

Preston: it's gonna set you up for, like, a good, like, MI, Yeah ... approach. 

Margaret: Yeah. And not just from, like, a-- I think I could hear this as a patient and be like, "So my doctor's just trying to butter me up."

I think legitimately there's- There is something, like, valid that you can yes most people in what they're trying to advocate for themselves. And so I just wanna say, like, similar to when we were t- had the MI talk, this yes and is about encompassing both realities and, like, truly valuing the part that someone else values while also adding onto it in this metaphor, clinically speaking.

Just I think sometimes people hear that- Right ... and they hear that we have a bag of tricks that we, like, mischievously throw over our shoulder as therapists or psychiatrists, and then we're, like, trying to, like, s- trick them or sneak them into something. And so I just wanna say that out loud 'cause I don't want it to come off that way.

Preston: That's-- I think that's a great [00:26:00] point. I a- also don't see it as a bag of tricks. I think it's-- I think I see it as a way to be more transparent. 

Margaret: Mm-hmm. '

Preston: Cause ultimately we are trying to be helpful and validate, and then it's in the way we communicate that desire that we stumble. So this is a way to make it, like, clear to the patient that we do think that their concerns are legitimate, and we recognize and appreciate that there's tension here.

That's what the yes is. It's, ultimately a validating statement. 

Margaret: Yeah. 

Preston: Okay. So, not to, to belabor yes and much longer, but there's... And there's more stuff I want to get to. So the next thing that I, found kinda interesting is the-- there's this concept of a montage in, in, like, some of the improv, like, sets we do.

So basically, for, like, a, a short form show, you have, like, a couple different scenes based off of, like, suggestions from the audience. So one scene [00:27:00] might be, you know, a, a high school couple on a date at a, a carnival, and that, you know... But it turns out that the hot dog guy is all out of hot dogs, so he's just, I don't know, selling, like, ketchup and mustard with, like, a funnel cake in the middle, and then they're navigating the tension of eating something like that.

Like, it's weird. And then the, the next one is, like, a bunch of astronauts who are trying to walk on the moon, but they realize that they all forgot their helmets or something. So, like, those are these r- like, random different scenes. But then what you do at the end is you go around and you add context to those, and you create, like, a montage.

So for the carnival scene, you might, even say, like, "And cut to when the carnival guy was purchasing his supplies," and then the scene will come up. And then he's like, "Yeah, I think five hot dogs is probably good enough for the carnival." "How many people are even gonna be here?" Yeah, you're already laughing, right?

because then it gives us, like, an idea of how he came to this spot where [00:28:00] he's completely out of hot dogs- Yeah ... at, like, 6:00 PM. Or the, or it's like cut to when the astronauts are packing, and then he's like, "Hey man, how many pairs of underwear are you bringing?" Like, "Oh, probably like 100, 200.

You can't be too safe." He's like, "Oh man, I'm, we're starting to run out of room in my suitcase here." Like, "Yeah, well s- not like we would probably forget anything important." Something like that. 

Margaret: Yeah, 

Preston: You know? Oh, our helmets. Who would've thought? so but what- what's kind of important about these like montages that you put together, these scenes that you create, is you need to know when to cut the scene.

So you can kind of watch two people, like they, they flounder. They're trying to excavate like that metaphor we used earlier, but they're really finding nothing. 

Margaret: They're just- they're finding dirt. 

Preston: yeah. It's like when you're fishing and you're like, "Oh, I've got one." And like wait, the tension is consistent, and then you really pull and it's just like a fuck- like a clump of moss or something.

When you realize that they've got moss on the other end of that line, [00:29:00] then you kinda say like, "Okay, cut the scene." and what we'd literally do is we'll run across the stage, and that cuts the scene. And the rule is if you cut the scene, you have to start the next montage. 

Margaret: It's like in Who's Line Is It Anyway, when they would hit the buzzer.

Preston: It's exactly right. Like, the, it's the buzzer in Who's Line Is It Anyways. And I've found like- I-- It's a skill, though, watching the scene and saying like, "Oh, there's, there was some kind of conflict between these characters, then something was revealed, and this became humorous, and then there's resolution."

You kind of look for those like little, hills and valleys, 'cause multiple iterations of that can happen throughout a scene, but you need to, over the course of, you know, 30 seconds to 90 seconds, figure out like when to cut it. And I kind of realized that the same thing on a larger scale can apply to like clinical conversations.

So there are times when you have like a therapeutic utterance or a reflection or something that can like enhance insight for the [00:30:00] patient, but talking more about it or belaboring it can be like counterproductive. 

Margaret: Yeah. 

Preston: And sometimes things hit harder or are more effective if you cut the scene, so to speak.

Margaret: Yeah. It's like a sense of the kind of path- pathos and timing of the narrative you're kind of co-building, it sounds like in improv, but also I would say the same is true in like therapy or primary care, just with different timings and sets a little bit- Mm-hmm ... in terms of what's expected for it.

Preston: Yeah. And, in a more literal sense, even just like if you go into the patient's room because you're trying to talk to them about their order of protective custody, and they're irate, and they just curse at you, and they start, you know, like, you know, they throw a milk carton at your head, you're like, "This is a great place to cut the scene."

Margaret: Where did they get the milk carton from five hours 

Preston: earlier? Pro- probably [00:31:00] from their lunch tray, I guess. that's like another thing too that like sometimes it's good to just like terminate the whole encounter. and honestly, like the rapport that you can build with that patient is probably has a better chance if you like give them space and then let them cool off and then come back and talk to them again the next day instead of like trying to like force your way in and then eventually like now they have to get emergency medications.

I mean, a, a launched milk carton will probably result in emergency medication Regardless, but the, the intent's there that like I'm... if someone's already like angry, I'm not gonna rile them up and realize like this scene has run its course. And the other part of it I think would be like within conversation.

So like if somebody is like venting about a family situation or they're talking about like their job, like some of those topics you can kind of just spin your wheels on ad nauseam. Mm-hmm. Yeah. Yeah. And so also figuring out like, like this topic, like end scene for that topic. Like, you have some kind of like good summarizing statement or [00:32:00] reflection, and then use that as a way to say like, "Okay, what is the next subject I wanna like move things onto?"

Margaret: And sometimes you're end scene-ing against the oth- your scene partner's will. 

Preston: Yes. Yeah. Yes, 

Margaret: and- Trying to figure out a way to do that- Yeah ... again, in the frame of like what can we, what time do we have? What can we accomplish? Like, let's say, I guess the meta, the like- metaphor or similar thing would be like you're an opener and you have 10 minute- like, you don't have 60 minutes or a full show.

So we gotta- 

Preston: Mm-hmm ... 

Margaret: one of you is aware of that and one of you is maybe less aware of that, and that's what's happening in primary care all the time. 

Preston: And it's, yeah, you're yes and-ing them and you're hoping that they yes and you back when you're- 

Margaret: Yeah, 

Preston: When you're like, "And medication side effects, yes."

Margaret: And yeah, and you- "And let's talk about those medication side effects" ... sent me messages that you were worried about this thing, and we have two minutes left. 

Preston: You, reposted a meme on your story the other [00:33:00] day. It was like 

Margaret: the, the- I 

Preston: did. Yeah, it was like the Bernie Sanders and he's like, "I am once again asking you-

to apply your judgment and not open up your telehealth appointments while driving." 

Margaret: I got a lot of DMs about that one after. They're like, "Why do people do this?" 

Preston: I've gotten, I've logged into a telehealth appointment and been in someone's propped up against someone's grocery cart in the cereal aisle.

Margaret: At least they aren't gonna probably die doing that. 

Preston: yeah, Very true. I'm like, "Is this okay with you?" They're like, "Yeah, I don't... People in the grocery store can hear. I don't care."

Margaret: I'm like- You're like, "Okay, maybe we're a little too casual right now," but- 

Preston: Like, all right. But the, like, that's the scene where you're like, "Yes, I'm so glad that you're driving, and let's pull over right now." 

Margaret: Yeah. I- it's, interesting 'cause, like, the added part clinically is, like, sometimes that conflict or [00:34:00] that, like, "No" is also therapeutic and purposeful, which I see less of a role for in improv.

Like, being... Someone messaged me related to that meme. Someone messaged me and goes, "How," like, "Do you have this happen all the time, too?" And I go, "No," 'cause a lot of my patients think I'm strict 'cause I pretend to be strict for the first couple of visits. It's good. But I don't think being strict- It's a good strategy

is probably a, like, has a pro in improv. 

Preston: Mm-hmm. I think having them think that you're strict- 

Margaret: Yeah ... will, have a pro. Yeah, but that's different than actually being like- 

Preston: Mm-hmm ... 

Margaret: what I, than, like, being, I don't know. Yeah. 

Preston: Yeah. so yeah, ending the scene is good, and then, not dominating the scene has been also, like, helpful for me.

I don't tend to talk all the time, but I think I'm, I can be like kind of a ham when I get on, like- Like, on stage and I'm, like, interacting with people and I ... it's called a gift when [00:35:00] you introduce a new premise. And I'm just, a gift giver. I'm throwing a bunch of stuff out there. And I, realize that, like, the scene goes better or sometimes it's, like, easier to interpret ambiguity if you just shut up.

So I'd almost, like, tell myself, like, "Never miss a good opportunity to shut up when you're, on stage." and that's, like, a fun lesson that I've been bringing back to, clinical practice too. I framed it differently before as like silence can be, like, a good tool, but almost, like, seeing it through the lens of, theater where, like, your patient is your scene partner and, like, you let, like, let them build the scene more.

Like, don't even wait, try to, like, jump to an interpretation. Just kind of- 

Margaret: I was gonna say, it reminds me of- ... quietly react to it ... there's this Winnicott, piece where he says, "I shudder to think of all of the patients whose, like, wellbeing I interrupted by insisting on an interpretation." Like, which is, it's functionally the same thing except for British and written in the 1950s of like, "I shudder to think [00:36:00] about when my, I disserviced their silence that was actually better than what I had, whatever the hell I had to say."

Preston: Yeah, absolutely. And I don't know why, but that, that's reminding me of that, like, Ronald Reagan quote where he's like, "The, the seven most feared words in the English language are, 'I'm from the government and I'm here to help.'" 

Margaret: Oh. 

Preston: Yeah, I mean, I don't know why that lands similarly to me. But all right, and, it's cool though because you, can yes and without saying anything.

Margaret: Mm-hmm. 

Preston: Like, I could say, like, in the scene like, "Wow, Margaret, you've been super calm ever since you got stung by that bee." And you could l- you could, like, you know, reveal- ... without saying anything that you've been stung by a bee or that you're, like, lathering yourself with cream or something.

Like, things that acknowledge the premise and move it forward without being, like, needing to talk. And the, the same applies to, like, even just, like, your body language when you're going through a scenario with a patient. Like, you [00:37:00] can show your genuine reaction to what's happening, and that's, like yes and-ing the patient and being validating without needing to offer your interpretation or your analysis.

Margaret: Yeah. Well, and that's a clinically, like, a non A, a body language cue and not filling the space, especially when someone's anxious and they really don't wanna talk about what they're about to talk about, is, definitely a response of the physical version of, "Go on, say more," as I like to say. 

Preston: Yeah. 

Margaret: Which my patients get sick of me saying.

Preston: Say more. 

Margaret: Say more. 

Preston: That's good. All right. Well, we are gonna take a quick break. When we come back we'll talk about, last couple kind of connections. And then if you are a Patreon subscriber, we'll be doing some, scenes with the- Lord ... suggestions of Rob. So try our best at some live improv. Lord, 

Margaret: help me.

Preston: Okay. We'll be back in a little bit.

Okay. And we are [00:38:00] back with a couple more silly improv tactics that, that may actually be helpful in the clinic as we yes and our way along and- 

Margaret: You know what I was surprised you didn't start this episode with, is- What? ... one of the great questions that a- is often asked on TikTok, which is what is your favorite clinical bit to lead with or end with?

Preston: Yeah, I saw a lot of people doing that. That, feels more like stand-up- 

Margaret: Okay, 

Preston: fair ... actually. 

Margaret: But I- 

Preston: Like, I remember seeing some-- Oh, go ahead. But 

Margaret: you don't do it the same way every time. Like, I feel like those bits are, like, very dependent on the person in the room. Like, I don't know. It-- I, I hear you saying that it's, like, repetitive.

maybe it's like it feels like a, a starting prompt sometimes of- 

Preston: Mm-hmm ... 

Margaret: how they'll respond, but continue with our 

Preston: planned, points. No, yeah. But I think that, I think it is a good point. Like, I think people just-- they're thinking of, like, sketch comedy or, like, quips going back and forth with the patients.

I-- and you know how you were saying [00:39:00] earlier, like, it gives patients the idea that we have, like, our own little bag of tricks? I actually think when you s- when you talk about, like, your one-liners or your bits that you lead into, that, actually I think makes it seem more like the bag of tricks kinda thing, 'cause it's like it- it's like stating this is a performance, and I have a bunch of boilerplate jokes that I'm gonna throw at you, just like I do with every other patient.

Margaret: Interesting. Yeah, I mean, I think at least for psych, people have more of a negative connotation of us being manipulative and secretive. And so I'm more worried about people thinking that I'm, like, emotionally doing something to them than every single kid calls me Dr. Dunkin' Donuts, and so I lead with something about donuts, and it's a different one each time.

But- That's good ... and slash people don't compare within patients, so I don't know. I think there's more-- What I've heard from people is more, like, the feeling of not wanting to be judged by psychiatrists or therapists and stuff like that because also-- especially psychiatrists, actually. [00:40:00] 

Preston: People just don't like being judged by psychiatrists.

Margaret: People just don't like psychiatrists. And honestly, girl, sometimes fair. 

Preston: Yeah. 

Margaret: But so- 

Preston: Very 

Margaret: real ... I guess I also think for a lot of people, the bit things are, like, disrupted. Like, something small and sort of funny that you work with. I don't know. Yeah. I guess they also evolve. 

Preston: Nuggets, to bring levity to- Yeah

an otherwise, like, pretty dread- dreadful encounter. Yeah. That being said, I think my favorite bit during peds was to ask people what they had in-- like, ask kids what they had in their ears, like if they were gonna find bats or something, or, nickels. I did intern year for a while. I would have a bit I would do with patients where when I would tell them that they were gonna go get like a study done, like an MRI, or they're gonna go get a procedure done.

I'm like, "Yeah, so like you're gonna go get your MRI done this afternoon. It's gonna be in the basement, and it's really cool. Like you won't even have to like walk there or anything. They're just gonna come like push your bed [00:41:00] And the patient's been here, they've been here for months. They've, like, traveled.

they're like, "Yeah, I get it." And, I'm like, "Yeah, isn't, like ... Isn't that amazing how they just, like, move stuff around here?" And I would just l- just lead into how, like, dry it is. Like, I'm, like, so amazed and surprised by, like- Did they 

Margaret: know you were doing a dry joke? 

Preston: No. Yeah, they would.

Margaret: I'm just picturing, like, someone, like, half delirious and you being sardonic. 

Preston: no. I would always, it would always be to, like, like, a peer-type patient. Got it. Like, a contemporary patient. Yes. Okay, that 

Margaret: makes sense. 

Preston: Like, someone that, like, like, early mid-30s or, like, late 20s. And I'm just like, "Yeah, no, it's, like, really cool.

We have this whole service bell system." Like modern medicine. And then, like, these dudes will just, like, push your bed. And, like, and your bed has wheels on it, too. So it just, like, it doesn't even hit bumps or anything in the hallway. It's ... Yeah. You ... So you didn't have to move, but they'll take you downstairs.

Why did 

Margaret: you stop doing this bit? 

Cause psych is less ... You're not ... That's not happening. 

Preston: because, yeah. Because intern year had a lot of internal medicine patients, and then once we moved on to psych, [00:42:00] it just wasn't ... Didn't, really apply as well. 

Margaret: Didn't apply anymore. Yeah. 

Preston: Yeah. Single tier. 

Margaret: One of my bits in psych is I didn't

Is when someone's like, "Sorry, but I don't like this medicine," and I'll be like, "I didn't invent it, so you're good, girl." Like, "Tell me about why you don't like it." 

Preston: That's, good. yeah, I didn't invent it. I have no stock in this medicine. 

Margaret: Yeah. But 

Preston: yeah. 

Margaret: I'm like, "Damn, they were gonna pay me before that.

No, they aren't." okay. I talked, I took us off track. Yes, and- Preston's sixth point ... 

Preston: so the, the next point was focus on the relationship, not the thing. So it's a really common trap or, like, reflex when you're building an improv scene that you become obsessed with, like, the object that's connecting you two as characters.

So a great example could be, like, you're in a scene, like, the scene is, like, you know, we, were like, "Rob, give us a [00:43:00] suggestion," and Rob goes, "The Arctic," and that's our suggestion. So, so now we're in the wilderness and we're trying to build a fire. And the whole scene just becomes about us trying to build the fire.

And I'm like, "Go get these sticks." And you're like, "Okay, I got the sticks." And I'm like, "Oh, I can't, figure out the flint. Darn it. Do we have anything else that we can use?" And you're like, "I'm not sure. I didn't check anything." Like, those, those scenes become, like, pretty boring pretty fast because ultimately, like, the audience, like, they don't care that much about the thing.

they ... People always care about, like, the stakes. that's, like, what draws someone to a story is the stakes. So there's some implied stakes which are if we don't get this fire going, we're gonna die. So that's a good way to add stakes to it. But if the whole thing is just, like, about building a fire, then the, it loses its, spark pun- I knew it was coming.

I knew it was coming ... pun games are coming back. Yeah. Yeah, lose ... There's not as much, oomph to it. But instead You can use the thing as a way to focus on the relationship [00:44:00] and build the relationship between the characters. So you could say, "Oh, you know, why was this your idea for a honeymoon?" And then I introduce to the audience, like my gift is that y- we're a, an unprepared couple who thought it'd be a good idea to elope to the Arctic without supplies.

That 

Margaret: you promised me 

Preston: you 

Margaret: worked on your pyromania. You promised me. Yeah. It was in the vows. 

Preston: And but the couple's therapist just, they were on back order, and my credit card kept getting declined. Y- you know I've been trying, but it's not enough. Like, you know, now, we've introduced like some tension to it.

Now it's interesting. You're like, huh, like why'd she marry a pyromaniac? And you can even say like, "Why would I marry a pyromaniac?" my mother was right." 

Margaret: I'll have pyromania and no fire to keep me warm. Classic, just like your father. Yeah. It's 

Preston: like, well, kind of funny that you keep ending up with, Capricorns and pyromaniacs, huh?

Well, stop, put this all on [00:45:00] me. 

Margaret: Moths to a flame, baby. 

Preston: yeah. Exactly. That's, what's it? Where there's smoke, there's fire. That's, what makes it interesting. And the same kind of implies your, like, clinical encounters. And I think this, this one is more unique to psych because I think for a lot of, like, standard, body medicine, just not to be too reductionary, encounters you can, like, very much focus on the thing.

But I think sometimes it also becomes too much about the thing and if you could just fix the thing right away, like that's awesome, but that's not probably 80% of medicine. 

Margaret: Yeah. 

Preston: I would say there's like 30% of the time you're like, "This is a very, like let me look at the thing. This is very straightforward.

I will solve this problem for you." But the rest of the time it's gonna be something that's gonna be stuck with you, so you need to go back to your relationship with the person. And, this actually kind of almost-- [00:46:00] Before we get into the psych aspect of it, it's making me think about even, like, when we had, like Lady Spine Doc on here and she was talking about spine surgeons deciding when to operate on a patient with their back pain.

Like, I think that's a great example. Like, you can-- If you're the surgeon in that case, you can focus on the thing, which is do I do the operation and your back pain, like those, those two things. But if you pivot and focus on the relationship, the thing that, like, makes the scene matter to the person, like that's gonna be more effective in kind of coming to a resolution or a solution because these aren't problems that you can just solve like that.

Right. And, and- Questions kind of thing ... that's pretty much all of our cases. We don't have- 

Margaret: Yeah. I also think it's interesting to think about it from like in a therapy perspective, like-- Or not even therapy, but like if you have a patient where it's like they come in, they've been doing really well on the medicine, and then they come in the next time and they see you and they say, "Doc, my [00:47:00] like, my medicine's not working anymore.

We have to change it." And you spend the first 25 minutes of the visit talking about the medicine and you get into these details that are like really deep-diving into, "Maybe I had a little bit of whatever." And then at the end of it, they tell you they just found out, like, that their parent has some form of cancer.

Mm-hmm. And it's like, that's not to say people aren't valid in asking us for things, but it's why taking a holistic view, ourselves included, right? Like you can't psychiatry or therapy yourself. Like there's no auto doing it. Like taking in the whole picture and not getting too fixated on one particular thing is our job, like when we're doing it well.

And so I just-- I think that the idea of even just in a therap- in our work, like coming more from the patient side of or either of us getting stuck on, "No, we need to talk about this, this thing has to be the thing that we change or this thing has to be the reason" and- Zooming out and saying like the whole thing, the relational part, all of this together at once instead of getting kind of concrete.

Preston: Yeah. Yeah, exactly. And [00:48:00] then with that, I think you, you brought a good example up, which could be amplified by you even saying like, the patient is-- they're, they trust that you're cl- in a, like a collaborative relationship or something. So you could even say like, you know, "Do you, like, do you want to work on this?"

Like, be-- getting meta saying like, "Do you wanna work on this now in the context of everything that's happened?" Like, that's a great step back to ask about the relationship, right? 'Cause I'm not saying like, what about the side effects? What about the inef-ineffective part of the medication? It's do you and I, vow, want to address this problem right now?

Margaret: No objectifying in our psychiatry. 

Preston: Right. And like that's, that, that's what like kind of gets at, like the e- the more, I guess I, wanna use the word efficient, but I [00:49:00] don't think that's, like, best there. I think it's just, it's more accurate probably. Oh, 

Margaret: yeah. The word that was coming to mind was, like, seeing, like correctly seeing.

Preston: Mm-hmm. Yeah, also true. And I think the focusing on the relationship is also helpful when there's a misstep or if there's, like, a loss of rapport. So, we do kind of like a group supervision for our psychotherapy training, and one of my, co-residents, she didn't wanna prescribe one of her patients a benzo, and it was kinda one of those situations, I, think everyone in mental health has had one of these intakes where the patient comes in and the chief complaint is expectation to be prescribed Xanax.

Margaret: Yeah. 

Preston: And, like, this was, I think, a really challenging encounter because the, like, like my co-resident really wanted to focus on the symptoms that were, like, leading to the patient to request the benzodiazepine, but the patient was very fixated on the [00:50:00] be- benzodiazepine, and ultimately ended with her saying, like, "I'm not gonna prescribe this to you," and the patient terminated early and, like, stormed out.

And it was... You know, called her a bunch of, like, terrible names, like, "You're the worst effing doctor I've ever had." Like, stuff like that, right? 

Margaret: Yeah. 

Preston: So it was really hard on her, and we're kinda debriefing with it, and then the next week the patient rescheduled and was, like, showing up again. And they were really confused, like, why is the patient doing this?

And my s- my supervisor goes, "Well, they're obv- the patient's obviously ambivalent. They said all these things about how they don't like you, they left early, and also they're coming back. Like, there's inconsistency there, and it's gonna be your, like, inclination to, like, wanna go back to focus on the thing or they're gonna wanna bring up the thing, but start with the relationship."

Margaret: Yeah. I think that's great. 

Preston: So when they come back in, even, like, s- the first thing, like, op- the opening line being like you're probably still upset with me. 

Margaret: Mm-hmm. 

Preston: Like, I think that's a great way to just, like just break the ice and acknowledge, like, [00:51:00] this, the relationship is why you're here.

and it doesn't have to mean because it's, like, a positive, great collaborative relationship. Sometimes it's tense, but that's still the thing to focus on. 

Margaret: Yeah. I love it. 

Preston: Yeah. So those, are the things I kinda think about, too, and, it's helpful, like, when you realize there's conflict building up with a patient.

I'm like, "Okay, focus on relationship, focus on the relationship," 'cause I know my instinct's gonna be to focus on the thing. Okay. and then, yes, and m- last one, as we kind of wrap up here, is I'm gonna call it pimping delicately, but ultimately it's, pointed or, passive observation. So there's, this concept in improv 

Margaret: that- I'm gonna nope, but you can use it.

I know we still use it. 

Preston: Yeah. Well, no, so, so improv calls it pimping, 

Margaret: actually. 

Preston: Oh, 

Margaret: really? 

Preston: I was so thrown off. Like, the- Huh ... our instructor goes, "Don't be afraid to pimp your, like, [00:52:00] your scene partners." And I was like- Huh ... "What? Say that word again. What did you just say?" and I think they borrowed it from medicine, but pimping is essentially when you as a character in the scene, like, declare something about yourself, and the other person, like, calls that out.

So for, for example, like, I try to-- I'm telling you that I'm from Texas and I talk like this 'cause I'm, from-- I know-- I'm Texan Preston and I know Texas through and through. So if you wanted to pimp me, you'd be like-- you c- even just open up with, "What part of Texas are you from?" All right. I'm from all over Texas.

I, I-- And then-- Or you'd be like, "What's your favorite Texan city?" All of them. I just, every single city I love equally. Like, that, that's a

Or there's, like, [00:53:00] funnier ones, like-- And, even just, like, with the accent, right? So, so my accent might start out like this, and then it kinda ends up a little bit more like this. Atlanta- 

Margaret: Your accent's changing. You feeling okay? 

Preston: Yeah. Yeah. Like, you all right, bro? Like- A different part of Texas active 

Margaret: right now?

Like, what part of Te- what part of Texas are 

Preston: you from? Alabama? Like, Montgomery? Like, so- 

Margaret: Or Paris, Texas. 

Preston: So what's funny is that, like, they'll pri- like, it kinda primes you, like, when you go into the scene to just watch the other person and point out things about them, and even, like, small, like, little tics that they have or phrases that they say.

You know, like, "You, keep saying this thing," or, like, "This is kinda confusing." There's... Have you ever seen, Semi-Pro with Will Ferrell? 

There's a scene in that movie where it's just, like, a bunch of the guys, you know, it's like the '70s, and the guys are all playing poker around the table. And one guy's like...[00:54:00] 

I think... He's, like, packing tobacco or something, like putting in dip. And one of the guys are like, "Why are you always using that dip?" And he's like, "Well, it's the only thing that could get, like, could get my mind off the shit when I was in the war." Like, like when he was in 'Nam. 

And then the, the other guy goes, "Was the shit in Ann Arbor?"

"Because that's where you were during the war." It's a great example of pimping somebody. Yeah. And, what's fu- And, like, and that's also a great way to, like, to yes, and them. Like, he didn't-- he could've no, butted. Like, "No, but you weren't in the war. You were in Ann Arbor during the war." But he said, "Yes, you were in the shit, and was that shit in A- in Ann Arbor?"

"'Cause that's where you were during the war."

So he actually, like, he completely flipped the premise while still yes, anding him. And which I think, like, those are like the kind of the really, like, eloquent super moves that you can do, [00:55:00] in improv. But, the, concept of, like, monitoring your scene partner and then pointing out things. And you don't even have to interpret them or comment on them, pass judgment on them.

You just have to state them back. Like, as simple as like you said, "Your accent's changing a lot." 

Let them deal with it. Let the, let them offer an explanation for why their accent's changing. 

Margaret: I will say, this is one of my favorite therapy moves, and my super- my original, like, mentor in residency did it a lot.

But, like, especially if there's, like, conflict that I think that the patient doesn't want to bring up, especially if it's, like, a long-term patient that we, like, have more of a established therapeutic relationship, is I will say, like, "I noticed at the end of our last visit you, you usually end by saying this, and last time it was different, and you did this instead, and it felt kind of abrupt.

Am I reading that right?" And then like offering kind of soft openings to [00:56:00] things, especially if it's maybe being- Mm-hmm ... avoided or pushed down. so the noticing and then like asking them to expand into a detail is- 

Preston: While also saying like, "I could be way off here." Yeah. Like it, it softens the interpretation- 

Margaret: Mm-hmm

Preston: too, which you don't necessarily need to soften the interpretation when you're doing a scene with someone, but I do think like, like you're doing there is helpful 

Margaret: in a- And I could be wrong, 

Preston: right? Like- ... a clinical encounter. We could all be wrong all the time. 

Margaret: And so, yeah. Like, but yeah, but the like noticing, I think...

I also think it, it communicates something in medicine, not just psychiatry, of like, "I'm paying attention to you. Like, you are occupying my attention, and I am not split-minded in 800 different places. Like I- you matter to me. Like I am here with you, and I notice even the small things about you," which I think is important, especially when you're seeing someone regularly for therapy, that they in many ways feel that they have the, your full presence.

Preston: Yeah. to kind of, to add onto that, one, [00:57:00] one thing that I've been mise-ering on lately is, intonation. So You, ask someone, like, "How are things going with your boyfriend?" You know, this is what we've been talking about the last couple of sessions, and they g- they hit you with this, "Good." 

Margaret: So I hit them with a, "Girl, what was that sigh?"

Literally, I will say to my patients, "Girl, what's the sigh?" 

Preston: Yeah. You're sighing a lot when you say that. Like 

Margaret: Your sigh is from Texas, girl. What's going on? 

Preston: Yeah, Tell me about that sigh. Like, that's the, the correct observation where I think even, like, a couple years ago or even as a student, I'm like, "So I'm hearing things are going good.

No, you're not. You're absolutely not hearing that things are going good." Like you said the word, you said the word good. That actually would, that would be a great response. "Well, you said the word good." 

Margaret: That would be a great 

Preston: response. Knowing full [00:58:00] well that things are not good. I sense... Yeah. or I'll be, I'll, say like, "You really drew out that, O there, you know?"

The O in good got a lot of hang time. 

Margaret: This is also when I would say something like, "Would you like me to comment on the way you said that, or would you like me to F off?" This depends. I feel like I literally- 

Preston: Oh, 

Margaret: that's good ... depending on how like- 

Preston: That's really 

Margaret: good ... Gen Z they are, be like, "Would you like me to comment on that, or would you like me to keep it moving on to a different topic?"

And then we laugh, and then they often stay- Mm-hmm ... with it. 

Preston: And then you say, "I'm, screenshotting this and saving it for later." I'm gonna screenshot that, and we'll talk about it later. 

Margaret: Yes, exactly. Like, I'm gonna save it to my to-be TBR. We can read into that later. 

Preston: Yeah. Like this, it's so helpful, and it's easier to do 'cause I think it takes the burden of, like, needing to offer interpretations to everything 'cause sometimes, like, I think the good with the big sigh, like, that's a pretty obvious one, but sometimes people [00:59:00] will say stuff and you're like, "I actually don't know how you feel about this."

Margaret: Yeah. "

Preston: But I'm just gonna tell you what I saw and how you said it." 

Margaret: Mm-hmm Yeah. I mean, I like when it co- I love to not interpret. I like to just say like, "Did that mean anything? That I... What do you think?" 

Preston: Mm-hmm. Like... Yeah. Yeah, exactly. Did that mean anything? And that's what you're saying to your scene partner when you're like, "Why do you keep, why do you keep scratching your nose?

Like, are you, like, are you going for something with your character, or is that just you?" Okay. This- Okay, so the- That was the last one 

Margaret: So the four- Oh, go ahead ... were the yes and was first. 

Preston: Yes and. 

Margaret: Yes and, where you keep building on something with someone and kind of try to make the same thing, and you can also do that, that with your patients.

The second one was when to cut the scene, cut it out. and kind of know- having a sense for the timing in improv and, like, when it's [01:00:00] working, when it's over, when it's reached its arc, which also occurs in our clinical medicine encounters, especially a psychiatrist that I would argue, like you did, everywhere.

The third, is pimping? No. 

Preston: Relationship. 

Margaret: Relationship. Okay, focus on the relationship and kind of- 

Preston: Not the thing ... 

Margaret: the tension, not the, like, concrete single thing. Don't get over-fixed on it. Yeah. 

Preston: Like what, like you're doing object work, but remember it's a relations-- it's- Yeah ... it's object relations- 

Margaret: Relations

at the end of the day. It's not thou. It's on it. and then it's the I- pimping, which I don't like using as a word still for-- but, kind of calling people out- Pub- pub-serving ... pointing, yeah, observing, pointing, noting. 

Preston: Clocking T. #

Margaret: Noticing as they say on Twitter. Yeah. Yeah. Clocking the T. 

Preston: Yeah. We'll just call it clocking.

You gotta clock. Have you seen this? Just the, 

Margaret: Noticing. Just a comment. 

Preston: That's funny. 

Margaret: That is half of [01:01:00] therapy. I'm noticing. and I think that it's all right. I also think for people who are, like, in earlier parts of training or transitioning to parts of care they're not used to, As you practice, like improv, I would presume you get better at being in this, like, strange new place.

Like, we know this from talking to a patient once and then for that versus the 10th visit, we have much more, like, ability to predict and flow with one another. But I think what you're showing also is what we learn-- what you learn in improv can be applied to also figure out how to navigate in the moment uncertainty and in, in relationship and making a story together.

'cause I think that's so much of medical training is being like, "How do I do this in this space with other people?" 

Preston: Yeah, and so much of just being a human. The, things I didn't touch on, I guess bonus round, is commit to the bit. 

Margaret: Period. 

Preston: Like, you have to-- No matter what you're doing in improv, like if you're going for the Texan accent, [01:02:00] you just gotta do the Texan accent.

You can't just, you can't back out now. and the same goes to any kind of like interaction that you're having. It's just a s- a sh- a way to show integrity and honesty. 

Margaret: Yeah, if you're going for the Monet, go for the Monet. 

Preston: Yeah. Right. Even, if you're chewing their ear off telling them about it. And i- if it's it'll make a, it'll make a Russian leave.

He'll be like, "Ivan, go" 

Margaret: I'll be ... And then you know what you'll ... At least we would say, that train has left the station. And you've If you want more of this, you can come to our Patreon We're ... 

Preston: Yeah, which we will be transitioning to right now 

Margaret: You can catch the next part of this on Patreon. 

Preston: It's patreon.com/happypatientpod.

Thanks again for listening. We are your hosts, Preston Roche and Margaret Duncan. Our executive producers are me, Preston Roche, Margaret [01:03:00] Duncan, Will Flanary, Kristin Flanary, Aron Korney, Rob Goldman, Shahnti Brooke. Our editor and engineer is Jason Portizo. Our music is by Omer Ben-Zvi. If you want to hear more from the pod, we are on Spotify and Apple Podcasts.

Anywhere you get your podcasts, you want to see us on video, we are on Spotify and YouTube as well. You can find us over on that, channel at itsprezro. You can find Margaret @badareveryday. She is on Substack, on TikTok and Instagram as well. Follow How to Be Patient on our shared Instagram page. It is our growing neoped where we dump a lot of our clips there and let you guys know about new episodes.

Margaret: Talk shit as well. We- ... talk plenty of 

Preston: shit 

Margaret: Shout out to the Mass General, thoracic surgery intern lab, w- like, internship program. They had me come give them a lunch talk that was just asking about psychiatry. They're a bunch of pre-meds in undergrad or in gap years. And that was this week- That's awesome

and it was lovely. And shout out to Megan and Mo. Mo in particular, I think you are a regular listener of this podcast, and apparently was too nervous [01:04:00] to cold email me to ask about this- Ooh ... so Megan did it. So shout out to Megan. Lean in, girl. 

Preston: Yeah. 

Margaret: Love you, Megan. Love you, Mo And shout out, Mo, for being lis- being one of our day ones 

Preston: Shout out to all the students that rotate with me that, like, drop that they listen to the podcast.

It's, like, such a compliment 'cause I, I think I've a, I, always forget that people know about it outside of TikTok or that, like, are in the medical space. So- I forget that- ... keep listening, guys ... this 

Margaret: is not just some random thing we do- Yeah ... and that no one ever hears. 

Preston: Yeah, it's not just some- Rob Berkner was like, "

Margaret: Girl, you better think people listen to 

Preston: this" It's not a game you play on Spotify Yeah.

I was just like 

Margaret: a fun- 

Preston: Yeah. To, us it's like a ... Yeah, it's a mobile game where we, put out a episode on Spotify and see what comments come back on 

Margaret: Literally. I, we'll ... And we'll see you next time in the Spotify 

Preston: comments We will. To learn more about our program disclaimer and ethics policy, submission verification, licensing terms, and our HIPAA release terms, go to howtobepatientpod.com or reach out to us at howtobepatient@human-content.com with any questions or concerns.

How to Be Patient is a Human content production.[01:05:00] 

Thank you for watching. If you wanna see more of us or if you wanna see... This is Lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac, point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They pr- they probably exist for real.

But in the meantime, I'm just gonna pet Lilac, and then I'm gonna go dance in the [01:06:00] background