Yes, and

I think in possibilities. I like to think that’s a strength. When a 59 year old has a spot in his vision I can think of all the possible reasons why and test most of them.

And still ultimately refer to ophthalmology.

When you’ve got belly pain we can come up with the 14 most likely scenarios and check them off one by one. Never fear that you will leave my office with the dreaded diagnosis “Belly Pain NOS.”

(Because at the very least you will have been diagnosed with “Abdominal pain – poorly characterized, which seems unlikely to be fulminating hepatitis or acute abdomen, and all the labs are normal and whatnot, and nothing about it sounds remotely like the gallbladder or kidneys or liver or pancreas or any known intraabdominal entity, but what the hell is it? Could it be gas? Anticipatory guidance for infinitesimally small possibility of catastrophic pathology in early developing stages given.)

It’s something I learned from my college Improv team. When you’re under the gun (performing in front of hundreds of bored college students vs. 1 terrified patient) and something is suggested, you roll with it.

Example from Improv:

Player 1: How nice we’ve gone out to sea on this raft!

Player 2: Yes. And I can’t believe we’ve fit a dinosaur on board as well.

= interesting. We all know where we are and hope we don’t sink.

Example of what not do to in Improv:

Player 1: Here we are buying carpets in Turkey.

Player 2: No. You fucking idiot. This is a night club and we are DJ’s. Is that caviar or boba?

= confusing. Where the hell are we? Also player 1 is an idiot, but player 2 is a jackass.

In Improv you never say No. You say “Yes, and.” It’s an exercise we do to warm up, and it’s a philosophy we live by onstage.

Thus, I have a really hard time with no.

Examples from more or less the last week in the Improv of my life:

Patient: I have a sore throat. Last time I had a sore throat it was immediately bettered by penicillin from Mexico. Please prescribe me penicillin from Mexico.

Me: Yes, and actually you have a viral syndrome and I don’t believe you need penicillin at all. I will now explain to you supportive measures for 10 minutes and hope you believe me.

Patient: I don’t understand.

Patient: I have pain in my arm. I need an MRI.

Me: Yes, and it turns out you have pain in your arm. And it turns out you have lateral epicondylitis which is tennis elbow and let’s all laugh together because you don’t play tennis. And it is not diagnosed by MRI but rather by me pulling on your wrist like so and you shouting in pain as you have just demonstrated.

Patient: I don’t understand.

Me: Shall I offer you a brace?

Patient: I fell over. I need an MRI so I can be cleared to go back to work.

Me: Yes, and. Wait. I don’t understand.

Patient: I have seasonal allergies. I need to see a specialist.

Me: Yes, and what if first we try some allergy medicine while we hope to recruit an allergy specialist to this county.

Patient: My back hurts. Generally I take 50 Lortab a day to stave off the pain and so please give me some.

Me: Yes and how about instead we discuss non-pharmaceutical measures we might take for chronic back pain. Here is a list of 15 other ideas we could consider.

Patient: No. I tried all of those.

Me: Yes and also you were taking cocaine the last time I saw you and so we will be avoiding the narcotic class of medications in the future.

Patient: I don’t understand. Give me Lortab please.

Me: Yes and actually I will not.

Patient: I was not taking cocaine myself, but unwittingly did visit my sister, who was smoking crack, immediately prior to my office visit that day.

Me: Yes and how is that related to our discussion?
Patient: Obviously I must have inhaled it from the room and so that is not my fault and please give me Lortab.

Me: Yes and it is unfortunate that as far as I know that is physiologically impossible.

Patient: Lortab.

Me: Yes and

Patient:?

Me: And no. (Dammit. No. What I mean to say is no. I cannot, will not give you Lortab. I could lose my license. It is not what you need. You have a problem. You need help. We have policies.) (I don’t actually say most of the portion in parentheses)

Patient: I don’t understand

Me: Yes and shall I print you a handout? I’ll be right back…