AMA Journal of Ethics^®

Abstract

Hierarchy and status and power differentials in current health care practice persist, despite recognition of their ethical issues and movement toward collaborative practice. As interprofessional education continues to emphasize shifting from individual siloed practice to team-based approaches to improving patient safety and outcomes, addressing status and power is key to mutual respect and trust cultivation. What has become known as medical improv applies techniques of theater improvisation to health professions education and practice. This article shares how an improv exercise called Status Cards prompts participants to recognize their responses to status and how this awareness can be applied to improve their interactions in real encounters with patients, colleagues, and others in health care contexts.

Status as an Actor¹

Hierarchy and status and power differentials exist in health care professions and are based on the concept that the relative competence, expertise, and knowledge of groups of professionals determine the degree of power they can exert over patient service and care delivery.² Interprofessional collaborative practice (IPCP), defined by the World Health Organization as occurring “when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, carers and communities to deliver the highest quality of care across settings,”³ not only represents a team-based approach but also is intended to share power in delivery of patient-centered care.^4,5 This shift requires interprofessional education (IPE) that focuses on interprofessional communication, values and ethics, roles and responsibilities, and teams and teamwork, as delineated by the Interprofessional Education Collaborative (IPEC).⁶ However, the pervasive hierarchy in health care culture remains a barrier to effective IPE and IPCP. For example, the professional identity of a physician is that of a leader and decision maker, whereas other professionals—including nurses, therapists, pharmacists, dietitians, and social workers—often see themselves as team members.7  For health care professions students, professional identity formation is influenced by socialization during training.^7,8,9 For this reason, interprofessional socialization wherein hierarchy, status, and power are deliberately addressed is essential in IPE.

One method we use to address status in IPE is medical improvisation. Medical improv is the application of improvisational theater principles and techniques to the health care setting.¹⁰ Medical improv exercises rely on the experiential learning of participants, including during the debriefing on their experience, which allows them to unpack their emotions, reactions, and behaviors. When used in education, improv exercises are tied to learning objectives—such as empathic listening, naming emotions, and spontaneity—with the debriefing providing an opportunity for participants to reflect on and discuss applications of the exercises.¹⁰ For the successful use of improv exercises in health care education, it is important for instructors to create a supportive learning environment wherein learners feel comfortable trying something new, as many will not have encountered this type of teaching strategy in their training.¹¹

Status Cards as an Improv Game

To address status in health care, the authors each utilized in their respective communication and IPE courses and workshops an improv exercise called Status Cards,¹² which was taught to us by Belinda Fu, MD, an instructor for the Medical Improv Train-the-Trainer Workshop hosted by the Center for Bioethics and Medical Humanities of Northwestern University Feinberg School of Medicine.¹³ Improv actors use this exercise to practice embodying “high-status” or “low-status” characters in a scene.¹² We used this exercise at our respective institutions with over 30 different groups of students from diverse professions—including genetic counseling, medicine, nursing, occupational therapy, pharmacy, emergency medicine, physical therapy, social work, and veterinary medicine—between 2015 and 2021.

During this exercise, 8 to 10 students from different health care professions were randomly given a playing card ranging in value from “2” to “King,” where the “2” and “King” cards were equated with low status and high status, respectively, and the cards in between represented the range of statuses. The deck was prepopulated so that it contained two “2” and two “King” cards, which prevented any one person from being the lowest or highest status. Without looking at their own cards, students then displayed their cards on their foreheads for others to see.

Students were told to imagine they were at a party and to mingle with the other students. They were given instructions to interact with others based on the status of the other students’ displayed cards. As the students were blinded to their own cards, they were told to embody what they believed their own status to be based on how others were treating them. Importantly, students were told to act and behave authentically and honestly and not as a caricature of a high-status or low-status person. After about 10 minutes, students were asked to line up in order of high to low status based on their perceived status. Once in line, they were allowed to see their own card. We then debriefed the students. To ensure a safe space for debriefing, students’ responses were not identified or recorded. The information presented below is a highlight of the observations we made during the exercises and the discussions we held during the debriefings regarding students’ takeaways from the activity.

Observations and Debriefing

Observations. For the most part, students engaged readily in the activity after some initial moments of awkwardness as they figured out how to start mingling. The beginning of the exercise—when students did not know their own status—appeared to be the most challenging, as how students behaved depended on how others interacted with them. For this reason, the first conversations often started out with all parties acting impartially and equally. As the interaction progressed, students started losing their “veil of ignorance,”¹⁴ the state of being unaware of their personal circumstances, as they figured out their status based on how others were speaking and behaving. The tone and content of the conversations between a high- and low-status pair changed when, for example, the person with the high-status card asked the person with the low-status card to get them a drink or to run an errand; some students with high-status cards even walked away in the middle of the conversation to go talk to another high-status person.

Students found it easy to guess their own status based on how they were treated.

Although the instructions were for students to behave honestly and authentically, many students embodied caricatures of high and low status. For instance, some students represented their high status by standing in a “power stance” with their hands on their hips, talking loudly, or laughing boisterously. Students with low status cards stood with hunched posture, mumbled, or fidgeted their hands while they talked. A more subtle and interesting demonstration of status and the shifting of status was observed among students with middle-range status cards, whose posture became a little straighter, whose eye contact became more direct, and who took more of a lead in the conversation as they moved from an interaction with a person with a high-status card to a person with a low-status card.

Interestingly, by the end of the exercise, 2 separate groups of people consistently formed—one comprising students with low-status cards and the other students with high-status cards. Camaraderie developed among the students with low-status cards based on their shared experiences during the exercise. Sometimes a third group of students formed consisting of those with middle-range status cards, although more often these students reported trying to join one group or the other, even though they did not feel like they belonged in either group.

Debriefing. In general, students found it easy to guess their own status based on how they were being treated, especially those on the ends of the status spectrum. For example, as noted previously, students with high status cards would order those with low status cards to do things for them. That was usually sufficient to tip students off that they held low status cards. On the flip side, students with high status cards reported figuring out their status when people complimented them, asked for their advice, or, in a few instances, moved aside to allow them to pass when they walked by. When asked why they separated into 2 groups comprising those with low-status cards and high-status cards, students with high-status cards said they just naturally gravitated toward one another, whereas students with low-status cards said they actively sought each other out not only to get away from the high-status people but also to be with others who understood them.

Students had varied reactions to and opinions about the exercise. Some students shared that the exercise was challenging because they usually treat everyone the same regardless of status but that they felt the exercise compelled them to interact with people differently. A few students reported using their high status to do good, such as by seeking out people with lower-status cards to mentor them and guide them through the party. However, most students with high-status cards embodied that status in a negative way, even though those who did so later revealed feeling uncomfortable with their behaviors and how they treated others, especially those who reported identifying as lower status in real life. On the other hand, students who identified as higher status in real life expressed frustration with taking on a lower-status position, as they felt they could not stand up for themselves. Most students with low-status cards reported feeling marginalized and unimportant, although, as noted above, they found solidarity and built more connections with one another during the exercise. Students who were given cards that were incongruent with their perceived usual status expressed a keen awareness of how their actions aligned with and represented the status they were portraying compared to students who felt able to act naturally. Interestingly—and importantly for IPE—students expressed that, during the exercise, they stopped thinking about their professions and the health care hierarchy, which allowed them to interact on an equal playing field where the only status that existed was the one artificially assigned to them. This situation is unlike most IPE, in which students are identified by and represent their specific profession.

Discussion

The goal of the Status Cards exercise is for students to acknowledge that status exists, that people recognize status, and that status can be fluid. A person’s status can change depending on where they are, whom they are with, and the situation they are in. In health care, professionals cannot easily change their role on the team, but they can change how they portray their status. Status is a trait that can be deployed to support the team, patients, and families. Health care professionals need to have the ability to play high or low status roles based on the situation for the good of the team. For example, playing low status, kneeling on the ground to be eye level, and speaking softly may provide more comfort to a child and their terrified parent than standing in a higher-status position looking down on them. On the other hand, for a patient who is skeptical of the health care system and perhaps of a higher status, playing high status by interacting with clinicians who exhibit similarly high status—such as by making eye contact and speaking in a more forceful manner—may instill more confidence. If that same patient refuses to acknowledge a different team member in the room, then it could be helpful for the clinician to downplay their own status by stepping back or looking away and letting the team member take the lead in the conversation. Framing status as adaptable helps students to recognize that power can be shared and transferred among team members depending on the scenario.

An effective follow-up exercise is to repeat Status Cards with the variation in which students know their own card (and others do not) and are asked to practice portraying their status in a helpful way for the good of the team. During the debriefing, students identify helpful verbal and nonverbal demonstrations of status.

Conclusion

Hierarchy and status and power differentials of health professionals are a part of the hidden curriculum and essential to IPE and IPCP. Medical improv exercises, such as Status Cards, can be used to help health profession students, residents, and clinicians explore this topic. As status can be a sensitive topic and participants may feel vulnerable, having trained facilitators who are able to create a psychologically safe space run the activity and debriefing is important. Participants also need to engage in the activity with an open mind, especially as they are reflecting on their own portrayal of and response to status. In sum, the Status Cards activity is a different and innovative way to teach interprofessional learners to recognize and leverage status in the health care environment for the benefit of their patients and other team members.