UK JRSM: MEDICINE & MAGICIANS

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2587378/ Journal List J R Soc Med v.101(9); Sep 1, 2008 PMC2587378 Medicine as performance: what can magicians teach doctors? Daniel K Sokol, Lecturer in Medical Ethics and Law St George's, University of London, Cranmer Terrace, London SW17 0RE, UK, Email: daniel.sokol@talk21.com Author information ▼ Copyright and License information ► This article has been cited by other articles in PMC. ‘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. Go to: 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. Go to: 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. Go to: 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?’ Go to: 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. Go to: Footnotes DECLARATIONS — Competing interests DKS is a Lecturer in Medical Ethics and Law and a close-up magician Funding Not applicable Ethical approval Not applicable Guarantor DKS Go to: Acknowledgements Thanks to Ronald P Sokol, Helen Morant, and Thomas Palser for their comments on an earlier draft Go to: References 1. Haggard H. Mystery, magic, and medicine. New York: Doubleday, Doran & Company, Inc.; 1933. 2. Claflin E. Street magic. New York: 1977. 3. Lamont P, Wiseman R. Magic in theory; an introduction to the theoretical and psychological elements of conjuring. Bristol: University of Hertfordshire Press; 1999. 4. Ortiz D. Strong magic; creative showmanship for the close-up magician. 1994. 5. Brody H. The healer's power. New Haven: Yale University press; 1992. 6. Lloyd A, Hayes P, Bell P, Ross Naylor A. The role of risk and benefit perception in informed consent for surgery. Medical decision making. 2001;21:141–149. [PubMed] 7. Ortiz D. Designing miracles. El Dorado Hills, California: A-1 MagicalMedia; 2006. 8. Audi R. The good and the right. Princeton: Princeton University Press; 2004. 9. Wensing M, Jung HP, Mainz J, Olesen F, Grol R. A systematic review of the literature on patient priorities for general practice care. Part 1: Description of the research domain. Soc Sci Med. 1998;47:1573–1588. [PubMed] 10. Klitzman R. When doctors become patients. New York: Oxford University Press; 2007. 11. Gerbert B. Perceived likeability and competence of simulated patients: influence on physicians' management plans. Soc Sci Med. 1984;18:1053–1059. [PubMed] 12. Sanders T. The likeability factor. Crown Publishers; 2005. Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press Formats: Article | PubReader | ePub (beta) | PDF (166K) Related citations in PubMed Doctors and magicians: what we can learn from wizards.[J Med Pract Manage. 2012] Communication with the patient in clinical research.[Ann N Y Acad Sci. 1997] Understanding how physicians think: medical decision making and informed consent.[Pharos Alpha Omega Alpha Honor Med Soc. 198...] Enhancing physician-patient communication.[Hematology Am Soc Hematol Educ Program. 200...] Are physicians aware of what patients know about what physicians know?[Ann Oncol. 1999]

UK DAILY MAIL: ER DISASTER

Overworked doctors 'forced to look after up to 70 elderly patients during single shift and are missing vital signs of illness' Sir Richard Thompson attacked Government plans to cut NHS budget 'NHS is under-doctored, under-nursed and under-funded,' he said Said 'stressed' doctors run around 'like a scalded cat' on their 7hr shifts Many tend to 70 patients a shift - over the maximum of 20, he added Medics only spend five minutes with each patient so they 'miss things' By Mario Ledwith Published: 07:50 GMT, 5 April 2014 | Updated: 15:26 GMT, 5 April 2014 283 View comments Sir Richard Thompson attacked government plans to cut the NHS budget - saying it is already 'under-doctored, under-nursed and under-funded' +2 Sir Richard Thompson attacked government plans to cut the NHS budget - saying it is already 'under-doctored, under-nursed and under-funded' Overworked doctors are looking after up to 70 elderly patients during a single shift making it 'impossible' to provide adequate care, one of the UK’s top doctors has claimed. Sir Richard Thompson, head of the Royal College of Physicians, said that patient safety is being put at risk because doctors are so stressed and over stretched. He complained that some doctors can only spend five minutes investigating each patient’s symptoms - far below the recommended 15 minutes. Launching a strongly worded attack on the Government for cutting the NHS budget, he said that doctors 'miss things' as they are working under constant 'strain and stress'. The 73-year-old, whose college represents the vast majority of the UK’s 30,000 doctors working in hospitals, becomes the latest senior doctor to bemoan cutbacks to the health service. Criticising promises made by the Prime Minister to defend the NHS budget, Sir Richard said: ‘In spite of what weasly words people at the top say, money’s been taken out of the NHS.’ He said that ‘billions’ more needs to be invested in the NHS every year for it to operate effectively, calling for all political parties to devise additional funding strategies. Sir Richard also criticised Jeremy Hunt for 'slagging off the whole of the NHS', claiming the Health Secretary dwells on poor care over the good treatment received by patients. He added: ‘The NHS is under-doctored, under-nursed, under-bedded and under-funded. There are too few doctors to do the increasingly large job to a high standard, and safely, and compassionately.’ Guidelines suggest that doctors should treat a maximum of 20 patients during a single shift to ensure that they receive adequate levels of care. But Sir Richard said some medical professionals are having to attend to 70 people on one shift, including many elderly patients suffering from a range of medical problems - or what medics call 'multiply morbid.' He said this results in doctors running around ‘like a scalded cat’ during a typical seven-hour shift, with safety most concerning at weekends and on night shifts. ‘You try standing on your feet for seven hours trying to be on the ball, thinking of the various complications, being nice to patients, for seven hours. It’s absolutely destructive. Read more: http://www.dailymail.co.uk/news/article-2597558/Overworked-doctors-forced-look-70-elderly-patients-single-shift-missing-vital-signs-illness.html#ixzz2y3Hylyrp Follow us: @MailOnline on Twitter | DailyMail on Facebook

FILATOV- KOPLIK SPOTS

As a result of scientific nihilism against Measles immunisation, (1954 Enders & Peebles),among certain population groups,physicians are again seeing FILATOV-KOPLIK spots. Russian aristocrat Dr NIL FILAKOV (1847-1902)post-grad.studies : Berlin,Paris,Prague and Vienna. American Dr HENRY KOPLIK (1858-1927) NY Mt Sinai Hosp(25y) post-grad studies: Berlin,Prague,Vienna.

Dr.B.DAY MBChB(Manchester) MRCP(London- Int Med.) FRCS(Eng.) FRCS(Can.) PRIVATE CAMBIE SURGICAL CENTRE Vancouver.

Dr. Brian Day 2007-2008 President - Canadian Medical Association Health Care Quotes This page contains a collection of noteable quotes relating to Canadian Health Care. "Personally, I do not see in Canada it would be a feasible thing if any Ministry organized taking over both the Health and the Disease of the entire community... even in the most favourable circumstances... there would be that absence of competition and that sense of independence... I do not believe it would be good for the profession or good for the Public." - Sir William Osler in a speech to the Medical Society of the Canadian Army Medical Corps (1918) Sir William Osler "...our noble tradition that no sick person of any age, sex, race or religion whatsoever, shall ever suffer for need of medical care on account of poverty or any other cause...should be based on our willingness to give, and should be construed as an act of our charity. It should not be exploited: nor should it be assumed as a God-given right by way of its beneficiaries. Least of all should it be a right-of-way for needy and penurious governmental and administrative bodies." - Dr. J.H MacDermot Osler lecture (1939) Dr. J.H MacDermot "There will come a time when the Ministry of Health is the only Ministry we can afford to have and we still won't be able to afford the Ministry of Health" - Dalton McGuinty, Premier of Ontario Dalton McGuinty "The evidence shows that delays in the public health care system are widespread and patients die as a result of waiting lists for public health care" - Supreme Court of Canada, June, 2005 Supreme Court of Canada "The courts have a duty to rise above political debate" - Supreme Court of Canada, June, 2005 Supreme Court of Canada "I think we have to be very careful about empowering the consumer because they will make choices that are not in their own health interest" - Jonathan Lomas, Executive Director, Canadian Health Services Research Foundation (a $100 million plus tax supported non profit agency) Jonathan Lomas "When consumers apply pressure on an industry, whether it's retailing or banking, cars or computers, it invariably produces a surge of innovation that increases productivity, reduces prices, improves quality and expands choices. The essential problem with the health care industry is that it has been shielded from consumer control - by employers, insurers and the government. As a result, costs have exploded as choices have narrowed" - Regina Herzlinger, Harvard Business Review, 2002 Regina Herzlinger "In fact, the Canadian health care system is perhaps the most rigid and oppressive (to physicians) within the free world." - David J. Dandy, Vice President, Royal College of Surgeons of England David J. Dandy "In the wake of the Supreme Court of Canada decision (Chaoulli-Zeliotis), the Canadian Medicare system is about to be redesigned. Physicians must not just sit at the table, but must position themselves at the head, where they can lead and direct the nature of that design." - Dr. Brian Day "When it comes to physicians there is a common thread that is a major barrier to solving our concerns. We are divided. The result is a divide and conquer scenario, in which we negotiate as adversaries, first with government and then with one another about our relative worth, while the "conqueror" observes and continues to rule." - Dr. Brian Day

FREE WEBINAR:IMMUNOGLOBULIN Heavy/Light Chain Assay.

The Binding Site Group Ltd Hevylite® Webinar by Key Opinion Leader and Live Q & A Session ‘The Immunoglobulin Heavy/Light Chain (Hevylite) assay for diagnosis, response evaluation, and evaluation of biological aspects of multiple myeloma’ Presented by University Professor Dr Heinz Ludwig Wilhelminenspital, Vienna, Austria Dr_Heinz_Ludwig_with_Dr_Stephen_Harding Professor Dr Heinz Ludwig with Dr Stephen Harding, Research & Development Director at Binding Site Headquarters Birmingham, UK Monday 10th March 2014 07:00PM - 08:00PM GMT Register Now OR Tuesday 11th March 2014 10:00AM - 11:00AM GMT Register Now What will you learn from this webinar? The Hevylite assay improves detection and measurement of monoclonal proteins that are: Difficult to quantify by electrophoresis At low levels How to improve monitoring of Multiple Myeloma patients with Hevylite The Hevylite ratio lets you: Assess the presence of monoclonal protein production over polyclonal protein production Identify residual disease in some cases that are negative by electrophoresis Detect relapse in some cases where electrophoresis is negative After the webinar, keep listening for a Live Question & Answer Session with Binding Site's Research & Development Director, Dr Stephen Harding, who developed the Hevylite assay. View our Disclaimer. There is no fee to attend this webinar. After registering you will receive a confirmation email containing information about joining the webinar. System Requirements PC-based attendees require: Windows® 8, 7, Vista, XP or 2003 Server Macintosh® based attendees require: Mac OS® X 10.6 or newer Mobile attendees require: iPhone®, iPad®, Android™ phone or tablet Binding Site - Committed to improving patient lives worldwide through education, collaboration & innovation

USA ENTEROVIRUS ACUTE FLACCID PARALYSIS

Enterovirus 68 is associated with respiratory illness and shares biological features with both the enteroviruses and the rhinoviruses M. Steven Oberste1, Kaija Maher1, David Schnurr2, Mary R. Flemister1, Judith C. Lovchik3, Heather Peters4, Wendy Sessions5, Carol Kirk6, Nando Chatterjee7, Susan Fuller8, J. Michael Hanauer9 and Mark A. Pallansch1 + Author Affiliations 1Respiratory and Enteric Viruses Branch, Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA 2Viral and Rickettsial Disease Laboratory, California Department of Health Services, Richmond, CA, USA 3Clinical Virology Laboratory, University of Maryland Medical System, Baltimore, MD, USA 4State of Maryland Department of Health and Mental Hygiene, Baltimore, MD, USA 5Medical Virology Laboratory, Texas Department of Health, Austin, TX, USA 6Wisconsin State Laboratory of Hygiene, University of Wisconsin-Madison, Madison, WI, USA 7Wadsworth Center, New York State Department of Health, Albany, NY, USA 8Public Health Laboratory, Minnesota Department of Health, Minneapolis, MN, USA 9Missouri State Public Health Laboratory, Department of Health and Senior Services, Jefferson City, MO, USA Correspondence M. Steven Oberste soberste@cdc.gov Received 19 December 2003. Accepted 20 May 2004. Next Section Abstract Enterovirus (EV) 68 was originally isolated in California in 1962 from four children with respiratory illness. Since that time, reports of EV68 isolation have been very uncommon. Between 1989 and 2003, 12 additional EV68 clinical isolates were identified and characterized, all of which were obtained from respiratory specimens of patients with respiratory tract illnesses. No EV68 isolates from enteric specimens have been identified from these same laboratories. These recent isolates, as well as the original California strains and human rhinovirus (HRV) 87 (recently shown to be an isolate of EV68 and distinct from the other human rhinoviruses), were compared by partial nucleotide sequencing in three genomic regions (partial sequencing of the 5′-non-translated region and 3D polymerase gene, and complete sequencing of the VP1 capsid gene). The EV68 isolates, including HRV87, were monophyletic in all three regions of the genome. EV68 isolates and HRV87 grew poorly at 37 °C relative to growth at 33 °C and their titres were reduced by incubation at pH 3·0, whereas the control enterovirus, echovirus 11, grew equally well at 33 and 37 °C and its titre was not affected by treatment at pH 3·0. Acid lability and a lower optimum growth temperature are characteristic features of the human rhinoviruses. It is concluded that EV68 is primarily an agent of respiratory disease and that it shares important biological and molecular properties with both the enteroviruses and the rhinoviruses. Previous SectionNext Section The GenBank/EMBL/DDBJ accession numbers reported in this paper are AY426486–AY426531.

CMAJ LEPROSY in MONTREAL. Hopital du Sacre-Coeur.

CMAJ Feb. 16, 2014 p.206-209, M.ALBERT & F.TREMBLAY. 60y, pale skinned, car mechanic who visited Haiti & Philippines. Treated first for a year with Steroids and methotrexate for "Rheum.arthritis". Developed rash and periph.neuropathy. SKIN BIOPSY positive for Myco.leprae.incl.positive polymerase chain reaction. Prevalence of M.leprae infection Canada 6:1,000,000. In Canada at least 210 Lepers. COMMENT At first (?francophone)neurologist diagnosed as familial "sensitivomotor" polyneuropathy (probably meant familial SENSORY-MOTOR polyneuropathy.)