The Lost Traditions of Practice
Lessons from Magic School
This article appeared in an edited form in Medical Economics Magazine on November 18th, 2005.
Strange as it may seem, there are close parallels between the physician-patient relationship and the magician-spectator relationship: both the conjurer and the physician need to establish a positive connection with their "audience" in a short time: Both have to create an impression of skill and capability in their respective fields: Both have to direct attention to that which is important, and away from what is not: Both need to understand how to transform confrontational or disrespectful attitudes. Both have to deal with any past or unresolved issues that either party brings to the encounter.
Establishing a strong physician-patient relationship has always been the foundation of the therapeutic process, and one of the most important issues in any relationship is keeping the lines of communication open and direct. A magician's skills in voice control, ability to focus and eliminate distractions, and command of body language can also be utilized by physicians to create and maintain the sort of relationship that encourages patient compliance and loyalty.
During the annual convention for the International Brotherhood of Magicians in 2004, I met Jeff McBride and Eugene Burger, faculty from the McBride School of Magic in Las Vegas. As watched them perform and lecture, I realized that much of what they teach at their magic school could provide valuable skills and insights for practicing physicians.
In the many situations and locations they have worked, both conjurers have developed skills to quickly "size up" their audience and adjust their approach to minimize failure and ensure close cooperation. This ability seems casual, but represents the practiced nature of a Master. When Mr. Burger hands a deck of cards to a spectator, he knows exactly what to say and do to ensure that the spectator follows his advice correctly and completely. If we as physicians could be nearly as successful, what a boon to our patients' health that would be!
Doctor Nocebo Will See You Now
Because we are untrained in performance technique, our body language and voice inflection may conflict with our desired message. Without any intent to offend, a physician may communicate boredom, hostility, or contempt by gestures, facial expression, or posture. Miscommunication with people of other cultures may also result when physicians are not in command of their body language, facial reactions, and voice.
Yet, many of these mannerisms are controllable once you understand and apply some of the simple rules of performance that ritual and stage magicians have been using for centuries. Although those with an interest may be interested to learn the one on one performance skills of a magician at the McBride School of Magic, with just a little effort on your own, you can begin to strengthen and focus the messages you send to patients.
Set the Stage
Consider the first impression that patients have when entering your waiting or exam rooms. Sit down in both and try to imagine how they appear to a patient. Seedy furniture and messy magazine piles in a waiting room may communicate that attention to detail is not important in this practice. Worse, it may suggest that the doctor has a similar haphazard approach to diagnosis and procedures.
Exam rooms and restrooms which are not clean or organized will also create a negative impression. It may help to have a non medical friend or spouse offer an opinion after touring your office. If you periodically ask patients to provide feedback on your practice, be sure there is an area where they can comment on these areas. Be sure to also ask about the impression created by the parking lot and common areas, if you are in a facility shared by other practices.
If you're inclined to be inattentive to personal hygiene and matters of dress, patients will certainly take notice. Students at the magic school are taught to be especially attentive to their hands and fingernails, as they are prominently displayed when performing. This should also be a concern for physicians. Rumpled, torn or stained clothing does not present a professional image for either the conjurer or the physician.
I propose to Jeff that even the way a doctor enters an exam room might influence the patient's compliance. McBride agrees. "Your first impression has to be persuasive and focused on the effect you want to achieve", he tells me. "The word 'entrance' can be analyzed in terms of creating a particular consciousness: 'en-trance' means to enter a state of clarity. You must be focused when you walk onto a stage or into a room. And, you must also create this focus in your audience."
Composing your thoughts for just a few seconds before opening the exam room door is a very helpful exercise. Mr. McBride counsels that performers use an inspiration just before walking into a room to cue themselves that it is time to "in-spire". Once you have made your en-trance, take a moment to establish eye contact and observe the patient. This way you will pick up on subtle communications from the patient that would be lost if you are inattentive or feeling pressured to move quickly into your routine.
The Power of the Voice
How many of us have patiently explained a procedure or regimen to a patient, only to later discover that they retained nothing of what we felt was important? Some of the problem may be that you use medical jargon when simpler words would work, and some may be your delivery. How clearly are you speaking? If you are too soft spoken or have unclear diction many patients are too intimidated to ask you to speak up! Some simple exercises may help. If you have a video camera, you may be able to combine speech and postural training at the same time, but if not, you probably at least have a tape or digital voice recorder.
Set up the recorder four to six feet away, at about the height of a patient's head, and read an excerpt from a story or article. Even better is to say something that you regularly say while seeing patients. It is more useful to use words that are your own than those of a writer or storyteller, and you probably have some memorized "scripts" that you use on a regular basis.
Record two to five minutes of speech at your normal volume. Then, play back your recording while you stay the same distance from the recorder. Can you make out each word clearly? Do you have any tendencies to reduce your volume as you speak? Are you speaking too rapidly or running your sentences together? Most doctors tend to speak rapidly, resulting in a patient being overwhelmed with information. Remember that some of your patients may have hearing difficulties, or there might be background noises which interfere.
Ask a staff member or colleague to listen and tell you how you sound. Microphones are not as sensitive as the human ear, so if your speech is clear, the words are well enunciated, the volume is sufficient, and the speed is not too fast, you should be getting across to your patient. Repeat this exercise several times with different subject matter and vary your speed and volume to gauge the effect. Practice slowing your speech down and leave a pause between sentences so you have time to see if the patient is keeping up with you. Higher frequencies are somewhat harder to hear for older patients, so practice pitching your voice lower by just a bit, especially if you are a woman.
This exercise may help you to become aware if you are using excessive jargon or technical terms that may bamboozle a patient. Try to simplify your language and use more common terms.
Watch the Eyes
If you have been video recording your speech, it may become apparent how often you are looking somewhere other than the "patient". Performers understand that a steady, focused gaze has a great deal of power. In addition, there are subtle facial and body reactions to your communications which might be missed if you have a tendency to let your eyes wander. "It's not polite to stare", many of us were taught, and so maintaining a steady but not piercing gaze takes some effort. Practice with the camera will improve this skill.
If you do not have a camera, cut a few pair of eyes from advertisements in a magazine and tape them to a mirror at various heights. Practice moving your gaze among each of these as you speak, and try not to look down at the chart or elsewhere unless there is a reason to do so. If you are typing into an electronic health record or writing in the chart, note how much time you are disconnected from the patient.
A video camera or mirror work is also helpful in discovering if attention to standing or sitting posture would be helpful. Mr. Burger is a proponent of Alexander lessons, which teach an awareness of body use and methods for reducing habitual poor posture while sitting, standing and moving. I have myself found these to be helpful for improving my body mechanics, and have also referred patients whose postural defects have contributed to pain in their back, neck or extremities with very positive results.
Although voice and postural training that actors receive will often be helpful for physicians, actually performing on television or stage is unlikely to further the goal of enhancing clinical skills. Most acting venues are so removed from reality as to be irrelevant to day to day physician patient encounters. Patients don't want a performance; they want a mutually respectful relationship. When this is achieved through honest and open communication and shared commitment, the response of the physician will represent genuine empathy rather than theatricality.
Once you begin to practice these exercises, you will find that you begin to see how you might appear through the eyes of your patients and colleagues. As you put these suggestions into action, you might discover a different response when you more clearly focus your message and intention. After some effort and rehearsal you may find that it is possible for an "old doc to learn some new tricks" from performance masters such as Eugene Burger and Jeff McBride
In Part Two of this article, I will describe some of the fundamental differences between the path of the conjurer and the path of the medical professional.