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The Art and Magic of Medicine

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The Art and Magic of Medicine THE ART AND MAGIC OF MEDICINE The Art and Magic of Medicine Georges M. Halpern, MD, DSc with Yves P. Huin 1 THE ART AND MAGIC OF MEDICINE [Disclosure: Since 1973 I have the great honor of being a Fellow of the Royal Society of Medicine; the September 1st, 2008 of its Journal –under the editorship of Kamran Abbasi- is largely devoted to the magic of medicine. Much of the article that follows is a compilation of articles from that issue, and editorials published in The Lancet in 2017 by Roger L. Kneeborn, and by Deborah Padfield, Tom Chadwick and Helen Omand. These sources, and others, appear in the References]. "These good or white witches are commonly called blessers, healers, cunning wisemen or women (for there are of both sexes) but of this kind, many men." (Bernard, “Guide to grand jury men”, 1629) The debate on whether medicine is an art or science is as old as medicine itself, but is it magic? ‘Mystery, magic and medicine, in the beginning they were one and the same. Although doctors and magicians have since parted ways, they both want to leave their ‘client’ better off than when they met.’ For a magician, this is the greater feat, as the client’s initial view is one of suspicion and distrust, a desire to expose the magician’s trickery. A talented magician will leave you aghast at the sleight of hand that has occurred, but a talented doctor might persuade you to consent to a procedure or change of lifestyle. Daniel Sokol, a magician and medical ethicist, proposes that magicians and doctors both practice deception but in different environments. ‘Mystery, magic and medicine: in the beginning, they were one and the same’. So starts Howard Haggard's little book on the rise of scientific medicine (Mystery, magic and medicine Doubleday, 1933). In centuries past, a medicine man in some aboriginal tribe might have extracted an unwelcome stone or bone from a patient after showing his hands empty, much as a modern-day magician would pluck a sponge ball from a child's ear. The doctor strives to improve health or prevent further deterioration, the magician to raise the spectator's spirits or instill a pleasurable sense of wonder; looking at doctoring through the lens of the magician may provide insights for the practicing clinician. Aside from close historical links, there is much that still unites doctors and magicians. Both groups deal with people, often in an intimate and intense context, and strive to 2 THE ART AND MAGIC OF MEDICINE effect a positive change in their audience. Both possess skills that their patients or audience do not have. They rely heavily on trust, fairness and clear communication for their success. Magicians, however, operate in an atmosphere of initial distrust and hence have developed expertise at creating trust in difficult conditions. They have learnt, through centuries of experiment and reflection, to influence people in subtle ways. I have tried to show that these lessons can be helpful to doctors, if only to make explicit certain techniques that may be used subconsciously. Aware of them, doctors can choose to use or avoid them as they see fit, although Sokol suggests they adopt a less permissive stance towards deception than their magician counterparts. Since one goal of a doctor's performance is to leave patients satisfied with the consultation, likeability is a desirable trait. But what is likeability? Or, rather, what characteristics, attitudes and behaviours lead to likeability? A literature on the importance of likeability exists in the domains of personal life, business interactions and advertising. Tim Sanders, who wrote a book on what he calls the Likeability Factor (Crown Publ, 2005), defines likeability as the ‘ability to create positive attitudes in other people through the delivery of emotional and physical benefits’. Sanders correlates likeability with success and happiness – the more likeable people are, the more likely they are to obtain desired jobs, acquire friends, have happy relationships, and so on. He identifies four elements of likeability: friendliness (expressing an appreciation of the other person through body language such as a smile or kind look or by verbal means), relevance (establishing a connection with the other's needs and desires), empathy (identifying with the other's situation and being sensitive to their feelings) and realness (appearing authentic and genuine to the other, being humble and honest). Hence a key question, relevant in both the fields of magic and medicine, is ‘can likeability be taught?’ Yet verbal and non-verbal communications – the arts of a magician or clinician – are no longer sufficient to fully inform patients, although they are vital elements. Our information-rich, interconnected world makes it harder for clinicians to gather all the information required for a single consultation, while placing high literacy demands on patients; indeed, the greatest demands are often placed on the patients who are least well equipped in terms of literacy. Around 20% of patients will have too low a level of health literacy to understand health information provided to them. Patient information leaflets can be useful but are insufficient to support doctors in 3 THE ART AND MAGIC OF MEDICINE their day-to-day practice as patients, like any group of learners, will learn best in different ways and via different formats and media. Anthea Colledge et al. explore the landscape beyond patient information leaflets and find a rich and varied landscape that requires further evaluation but is already showing promise. Health professionals and health services have an important role to play in guiding patients to high-quality information and supporting their access to that information. But that information is increasingly delivered by different methods. We already have some evidence for success of pictograms and pictures alongside written information, multimedia games for children, audio recording of consultations, text messaging, DVDs and websites. These are all tricks that doctors can pull out of their magician’s hats but they all require skill, patience and hard work to master and deliver effectively. Both individual health professionals and health services have significant opportunities to improve health communication. Health professionals can actively guide and support patients to access and engage with high quality sources of information, as well as developing strategies to improve their own communication. These strategies are widely recommended, but conclusions about their effectiveness are currently limited by a lack of rigorous evidence. In many circumstances, alternative format resources are an effective and viable alternative to the printed patient information leaflet. The other strategies appear promising, but have not yet been rigorously tested and evaluated. If you can’t be bothered with all this complication of medical practice and find hard to know where to begin with all this prestidigitation, you may find solace in Richard Smith’s piece on the value of procrastination. WH Davies asked ‘What is this life if, so full of care, we have no time to stand and stare?’ Kurt Vonnegut went further. After describing a ‘wasted’ morning that might make him a near-terminal case of chronic procrastination he writes: ‘And I tell you, we are here on Earth to fart around, and don’t let anybody tell you any different.’ A bit more procrastination and we might have avoided the tragedy of Iraq. 4 THE ART AND MAGIC OF MEDICINE Similarities and Differences The magician comes to your table while you are having a meal at a function with your friends. He’s an attractive person and you can’t help liking him. Although you’ve never seen him before he makes you feel completely at ease, as if he’s another member of your party who has just dropped in to join you for a few moments. It turns out he’s a close-up magician. With no apparent effort, he slides into your conversation and for the next few minutes performs astonishing tricks, inches from your face. Cards materialize and vanish, banknotes rotate slowly in mid-air with no visible means of support, coins defy the laws of gravity. Then the magician dislimns as quickly as he appeared and is gone before you quite realize what has happened. Somehow he has created a bespoke performance for you and your friends, enriching your meal without disrupting it. Clinicians have similar skills. A patient comes to a doctor with a pain in the abdomen or the arm. Although they have never met, doctor and patient quickly establish a rapport and start to talk. Within moments the doctor is palpating the patient’s 5 THE ART AND MAGIC OF MEDICINE abdomen, examining wrist or elbow, pressing and probing while continuing the conversation. This physical contact seems completely natural and paves the way for a discussion about what the problem might be and what to do next. Then the consultation is over, the patient leaves the room and another one comes in. What have both these experts done and how have they done it? Each of these encounters is a close-up live performance, constituted jointly by a performer and an audience. The audience is very small—in the case of medicine, often just one person. Though seemingly effortless and natural, each performance is highly constructed, actively shaped by the performer. Beneath a semblance of normality, a lot is going on. Contrary to popular belief, magic is not about concealing things but about building a shared narrative that makes sense for audience and performer. The magic is in the telling, constructing a compelling world through story. Without the story, you’re left with just tricks. Medicine too is about creating a shared narrative that works for patient and clinician, accounting for each person’s problem in the context of their life.
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