‘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.1 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.2 Today, doctors and magicians have largely parted ways, operating in different environments and sharing only the ambition to leave the ‘client’ better off than when the two parties met. The doctor strives to improve health or prevent further deterioration, the magician to raise the spectator's spirits or instil a pleasurable sense of wonder. In this article, I ask if contemporary magicians still have something to teach doctors. In particular, I identify several key components of the art of magic and suggest that looking at doctoring through the lens of the magician may provide insights for the practising clinician. Psychology and suggestion Doctors are rarely indifferent when obtaining consent from a patient. They want the patient to undergo the medically indicated treatment or procedure. Thus a surgeon might tell a colleague “I must get in early tomorrow, as I need to consent Mrs Smith”. A failure to obtain consent would raise eyebrows in the surgical team. However intent on neutrality of presentation, doctors may reflect this preference in their disclosure to patients. Magicians have myriad techniques to psychologically manipulate the spectator and doctors doubtless use some of the same techniques, whether consciously or not. Unlike magicians, however, doctors have the added luxury of operating in an atmosphere relatively free from suspicion. Magicians will use their eyes, body language, movements, voice and other subtleties to direct a spectator's attention away from a particular area. For example, a spectator will tend to look where the magician looks, to follow moving objects, to tense up when the magician appears tense and relax when the magician appears relaxed, and to look at the magician when addressed directly by name.3 These psychological observations are often used to mislead the spectator while creating the desired illusion of fairness. In medicine, a doctor who wishes to influence a patient's decision can use similar techniques to indicate approval or disapproval. Of course, verbal manipulations can influence a patient, such as talking of a growth or neoplasm instead of cancer, but irrespective of the verbal content, techniques such as looking at one's watch, crossing one's arms, adopting an authoritarian or pleasant tone of voice, nodding, smiling or frowning, can be used to create an impression in the patient's mind. When disclosing the benefits of a proposed procedure, a doctor can emphatically and slowly enunciate his or her words, maintain eye contact and a serious air, and nod at regular intervals. These actions frame the information as crucial and the nodding may suggest approval. When disclosing the burdens and risks, the doctor can relax, drop his or her shoulders, accelerate the tempo of delivery, adopt a monotonous tone of voice, glance at surrounding objects or events, even subtly check his watch (while making sure the patient spots this). The implicit message is that the important part of the disclosure – that concerning the benefits of the procedure – has passed and that the present information is of secondary importance. Aware that a precise exposition can make a performance more convincing and dramatic, Darwin Ortiz, an eminent card magician and theoretician of magic, advises magicians to ‘always say the same thing at the same point in each trick you do’.4 It is not just what is said that is important, but when and how. Ortiz calls the change from tension to relaxation intensity misdirection. Spectators and patients cannot sustain attention for prolonged periods and will take cues to decide when to pay attention and when to relax. In magic, the period of reduced attention is ideal for making a delicate sleight or other secret move. This is the primary function of humour in magic. In a medical consultation, which is usually an intense encounter, using intensity misdirection could be ideal to deliver information that must legally and ethically be imparted but that goes against the personal aim of the clinician (e.g. obtaining the patient's permission). The context of the doctor-patient relationship, in which one party enjoys more power than the other, gives additional meaning to these physical behaviours. Howard Brody identifies three kinds of power held by doctors: Aesculapian power, acquired through a knowledge of medicine; social power, arising from the doctor's social status; and charismatic power, derived from personal qualities such as courage, firmness and kindness.5 A charismatic personality, coupled with a white coat, stethoscope or other symbol of authority, will combine the various types of power and facilitate the control of the patient's thoughts and attention. I do not, of course, advocate that doctors use these techniques of suggestion and misdirection. As doctors may employ these strategies subconsciously, however, it may be useful for them to be aware of their existence and influence. Used effectively, they give the illusion of respecting patient autonomy while actually representing a paternalistic approach. The above techniques reveal that a transcript of the doctor-patient conversation alone would be insufficient to determine the quality of the consent process. In magical terminology, ‘magician's choice’ refers to an apparently fair, though forced, choice. There is also a medical equivalent, ‘doctor's choice’, in which the patient is unaware that he is imperceptibly guided towards one option. Clarity For magicians, clear presentation and communication are as important as technique and sleight-of-hand. The desired illusion of impossibility is harder to achieve if the spectator is confused. Robert Houdin, a famous 19th century magician, noted that before you change an apple into an orange, the audience must clearly see that you are holding an apple. A glimpse of colour and a spherical shape are not enough. In magic, clear presentation is important for several reasons. First, it leads to a stronger effect and a more magical experience. A convoluted story or too many props detract from the effect. Second, an engrossing presentation helps to prevent spectators staring at the magician's hands and hence reduces their chances of detecting secret moves. Finally, magicians want the magical memory to persist long after the trick is over and a crystal clear effect is more likely to do so than a confused one. In medicine, clarity is also central to obtaining informed consent. Confusion undermines the validity of consent. As in a magic performance, the goal of making the information ‘stick’ in the patient's mind, rather than vanish soon after it is given, should also be pursued. Good magicians will spend as much time practising the presentation of a trick as they will the technical aspects, and given the higher stakes and the frequent misunderstandings between doctors and patients, clarity of presentation about a patient's condition or proposed treatment should be as important as the content.6 As Ortiz observes, ‘there can be a considerable gulf between what the performer feels he is presenting and what the audience perceives is happening’.4 He draws a distinction between ‘inner reality’ (what you, the performer, sees) and ‘outer reality’ (what the audience sees).7 For doctors obtaining consent for a highly familiar procedure, there is a risk of delivering a memorized ‘consent speech’, whilst forgetting that, for the patient, the procedure may be completely alien. In medical ethics lectures, we teach students about the conditions for informed consent – information, voluntariness and competence – but we seldom teach them how to present information to secure informed consent, or indeed where and when to obtain consent. To use Robert Audi's terminology, even if we fulfil a duty of matter, such as the duty to obtain consent or tell the truth, we may still have duties of manner which dictate how we should properly discharge our duty of matter.8 Audi writes: One reason we have duties of manner is that the way we do things is often morally important and broadly under voluntary control. We are properly judged morally […] by how we do what we do, as well as by what acts we perform.8 [author's emphasis] In other words, in teaching about consent and several other areas of medical ethics, we tend to focus on substance and far less on process. Communication skills sessions are designed to cover this area, but I suspect that the real learning occurs ‘on the job’ when doctors find out what works and what does not. This is yet another reason for having ethics teachers who are aware of the realities of clinical practice. Academic medical ethicists, unfamiliar with life on the wards or in the surgery, are generally of little help in dealing with duties of manner. They will struggle to go beyond the assertion that such-and-such action should be performed respectfully. Likeability Authority, or perceived competence, makes it easier for magicians and doctors to exercise control. Another useful trait for both professions is likeability. For magicians, likeability makes deception easier by enhancing trust and reducing suspicion. If spectators like you as a person, they do not want to see you fail and are more apt to enjoy your performance. It turns confrontation into cooperation. All magicians will have seen skilled performers get lukewarm reactions. For some reason, the spectators do not warm to them. Likeability thus fulfils two main roles for the magician: it makes the deceptive manoeuvres less detectable and adds to the spectator's enjoyment. For the doctor, likeability has similar advantages. It puts patients at ease, enhances or maintains trust, and is likely to lead to more open discussions and increased rates of compliance. A systematic review of the literature on patients' priorities for general practice revealed that the most important factor was ‘humaneness’.9 This ranked higher than competence and patient involvement. A recent study by psychiatrist Robert Klitzman showed that doctors who become patients prioritize bedside manner over technical skill in choosing their own doctor.10 Humaneness, or goodness of character, goes hand in hand with perceived likeability, and so may bedside manner. It is surprising, then, that likeability has received such scant attention in the medical literature. Published work has focused mainly on the impact of patients' perceived likeability on doctors' professional behaviours.11 It would be fascinating to examine what qualities are necessary to engender likeability and to determine how this likeability affects the behaviours of patients. Some doctors will be naturally likeable. For others, likeability will not come so easily. Doctoring, like doing magic, is a performance, requiring the adoption of characteristics that we may discard once we leave the situation. Table-hopping magicians may perform the same effect hundreds of times in one evening, maintaining their enthusiasm at each performance and delivering their well-rehearsed lines as if uttered for the first time. Similarly, doctors may explain familiar procedures over and over again or disguise their true beliefs and emotions at the end of a long day or faced with a disliked patient. In both cases, this acting is part of professionalism. Good doctors, like good magicians, will give the impression of performing just for the individual in front of them. The ‘client’ must not be aware that you have performed virtually the same routine for dozens of people before him. 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, defines likeability as the ‘ability to create positive attitudes in other people through the delivery of emotional and physical benefits’.12 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?’ Conclusion 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 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 I suggest they adopt a less permissive stance towards deception than their magician counterparts. Source
