Medicine, magic, and online performance
Authors: Roger Kneebone, Will Houstoun, Natasha Houghton
Journal: The Lancet (2021)

COVID-19 has transformed clinical practice; online consultation has become a daily reality for many doctors and clinicians have had to rethink what it means to perform. Patient-centred consulting requires the integration of knowledge, technical skill, and expert communication. This integration is partly achieved through performance. Yet clinical work is seldom framed in such terms within mainstream clinical curriculums. As part of the Royal College of Music–Imperial College London Centre for Performance Science, UK, our interdisciplinary research group investigates how skilled performers from diverse fields meet the complex challenges of their work, and what they can learn from one another. Virtual consultations have altered the nature of clinical encounters, and made health professionals re-evaluate the basics of our craft. Online consulting has muffled our ability to see and hear and deprived us of touch. But it has also brought unexpected opportunities. It is timely to consider what we have learned, and which pandemic-induced changes we might wish to retain and build on. Biomedical knowledge and procedural skill are central to the clinical consultation. Every clinician gains that knowledge and skill through years of application, study, and practice. Yet focusing on medical content can deflect attention from the human experience of clinical encounters. Equally central is a clinician's ability to listen, respond, inspire confidence, build trust, make sense of a patient's concerns as well as their symptoms, and respond to the unexpected. Like clinicians, magicians spend years learning the essentials of their craft. They study the techniques of other experts and accumulate knowledge of their field. But dexterity alone cannot create the experience of magic. For that, a performer must capture and shape their audience's attention, making them experience the seemingly impossible. In one way this is nothing new. In the 19th century, for example, Professor Hoffmann promoted magic as a means of developing not only dexterity but also social and interpersonal skills that young people would use throughout their professional lives, with his influential book Modern Magic (1876). For magic is a demanding art. Performers must remain alert and observant while appearing completely relaxed. They must register reactions unobtrusively, connecting with their audience and responding to the unexpected. No amount of textbook knowledge is a substitute for expert performing, honed through practice and experience. One of us (RK) has previously argued that viewing the consultation as a close-up live performance could provide insights into the human experience of clinical encounters. But that was before COVID-19. The pandemic has brought unimagined changes for performers of all kinds. Clinicians and magicians are no exception. There are, of course, fundamental differences between magic and medicine. Conjuring shows are for entertainment; clinical encounters are not. Magic is about deception; medicine should never be. The physical impact and risk of injury for those who watch magic is negligible; the impact of medicine can be profound. Yet in looking for similarity rather than difference, areas of overlap emerge. We have explored these ideas within the undergraduate curriculum at Imperial College London, UK. A popular form of conjuring is close-up magic, where short performances take place in intimate settings with audiences of just a few people. When a show starts, a magician must establish a rapport with their audience, as must a doctor with their patient. Here relationships of trust and care are crucial. Each audience member must be confident they will not be embarrassed or made to look stupid, and that deception will only be used to provide enjoyment. A magician must ensure that the audience attends to some elements of their trick (its effect) while overlooking others (its method) as it builds to a dénouement. Magicians must also look after themselves, ensuring that inevitable mishaps do not undermine their self-confidence or impair their ability to perform in future. This has clear resonances with medical practice. Clinicians must build immediate rapport with patients, establishing relationships of trust with people we may never have met. We must help our patients navigate complex narratives, capturing crucial details while ensuring that their recollection of the consultation is positive and confidence-inspiring. Although the context and purpose are different, magic and medicine require comparable expertise in performing. Yet in medicine, performing is a loaded word that often prompts mistrust. Despite its widespread use in clinical parlance, many people remain suspicious of the term. For them, performing smacks of something contrived or inauthentic. We believe the opposite is true. Performing is not something assumed or artificial. On the contrary, clinicians build on their shared humanity with every patient they engage with, selecting the most appropriate aspects of their authentic self for that encounter. In medicine, awareness of performing is often overshadowed by the needs of the patient. Yet clinicians must monitor and respond to their own state of mind as they perform, putting aside personal concerns and shaping the best possible experience for their patient. They must listen to the last patient of the day with the same intensity as the first, reframing their approach if a routine consultation reveals malignancy or other serious illness. Such challenges go beyond scientific knowledge, technical skill, and dexterity. They also require the broader skills of performing. The COVID-19 pandemic has changed how we perform as professionals, whether as clinicians or magicians. Unable to interact in person, we have had to read, respond, and engage with our audiences in new ways. The skills involved in online consultations have become crucial. Some magicians, recognising early in the pandemic that many traditional approaches do not work well online, stopped trying to perform in their accustomed way. Instead, they redesigned their shows from first principles. For example, online magic takes place within each audience member's domestic space, bypassing the need for a shared venue such as a theatre or restaurant. It also provides magicians with new control over what can and cannot be seen by those who watch. Yet taking advantage of these opportunities places new responsibilities on the performer. Magicians must design their environment carefully, projecting their professionalism and expertise through positioning, lighting, audio quality, and eye contact. This process also allows access to inconspicuous support, such as a script on a teleprompter for a new routine. The ability to control what is and is not seen by a patient can be advantageous during a medical consultation too. Clinicians can look up rare conditions without interrupting the course of the conversation. They can check drug information inconspicuously, or electronically request a colleague to give a second opinion, inviting them to join a virtual consulting room. This could be especially valuable in clinical education, offering timely support to trainees. These changes affect patients as much as clinicians. Remote consultation obliges patients and clinicians to share responsibility for an effective encounter. Of course this has always been the case, but the challenges of online interaction make this more explicit. Clinicians' capacity to see, hear, and feel is profoundly altered, and new strategies are needed. For example, patients can be asked to participate in their own physical examination, tapping out their pulse rate and rhythm for the clinician or even palpating their own abdomen in cases of abdominal pain. The clinician must guide such patients, ensuring that they can identify their pulse and represent its characteristics accurately. As professionals we must support our patients in becoming partners in each shared online encounter. This shift of responsibility mirrors developments in conjuring. Audiences at an in-person show have built an understanding of how to express pleasure during a performance, alternating rapt attention with appropriate applause. But they may be unsure how this applies in an online setting. A magician must guide the audience in experiencing the show to full advantage, emphasising that applause enhances enjoyment for everyone. Audiences must know where their responsibilities lie and how they will be taken care of by the performer, such as by making a video image appear full screen, positioning the camera so they can be seen, or muting and unmuting when they enter a virtual stage. This collaboration with the world of magic has heightened our awareness that performance in clinical practice is crucial for holistic medicine. It is partly through performing that knowledge, skill, and wisdom come together in a professional encounter. Whether face to face or online, the skills of performing must be learned, practised, and perfected. Clinicians can learn much from magicians about ensuring that their patients' experience is the best it can possibly be. Now, in a time of pandemic-induced upheaval, clinicians are reframing what it means to consult online. If performance is where medicine and magic intersect, the perspectives of experts outside medicine are more valuable than ever. We acknowledge the support of the Medical Education Research Unit (MERU) at Imperial College London. Performing magic, performing medicineRichard 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 materialise and vanish, banknotes rotate slowly in mid-air with no visible means of support, coins defy the laws of gravity. Full-Text PDF Dissecting the consultationAs a medical student, I saw medicine as a science. As a surgeon, it was about skills. As a general practitioner (GP), medicine was a performance. As a patient, I recognise all of these, although what I experience most directly is the performance. Underpinning the science of medicine and the skills of surgery is the consultation. This central act brings two people together in a relationship of care based on trust and integrity. Its aim is to make sense of a problem the patient brings. Full-Text PDF Improvising medicineFor many clinicians, the word improvisation has a pejorative whiff—it smacks of being lazy, unprepared, or unprofessional. But improvisation is essential to clinical practice and we should prize, embrace, and practise it. Full-Text PDF