More than clowning aroundBMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39593.639063.CE (Published 07 June 2008) Cite this as: BMJ 2008;336:gp198
- David Wheeler, GP trainer and programme director for Greenwich GP specialist training programme
David Wheeler gives a GP’s view of clown improvisation workshops and tells how they have helped him to cope with the emotional workload of everyday consultations
I am a general practitioner in a large inner city practice and a third of my patients come from Africa. We have 10 minute appointments, with 18 patients booked for each surgery. I call the next patient in. She is a middle class woman who has recently moved to the area, and this is the first time we have met. She presents with vague pelvic pains underlying which she has some concerns about her fertility, for which she would like further investigation. She also complains about waiting to see the doctor and has a list of other health concerns.
Should I retreat to the safe ground of a clinical assessment of pelvic pain and, most likely, duck the whole problem by referring her to a gynaecologist? Or should I try to fulfil the Royal College of General Practitioners’ definition of a good doctor and explore the problem holistically in all of its context (psychological, social, and cultural) so that the patient feels understood, informed, supported, and likely to see things through with this doctor? 1 Mistakes are more likely to occur when there is poor communication and lack of understanding between doctor and patient.2 In only 10 minutes I must begin to deal with this patient’s problems; negotiate further management and follow-up; find some empathetic, trans-cultural meeting point; and, hopefully, not make any mistake that will land me in court, at a General Medical Council hearing, or in the newspapers. And how should I maintain my humanity and appropriate concern for the 18 patients booked for each surgery session when under this kind of pressure?
Plenty of models and techniques exist to help doctors structure a consultation to explore patients’ problems and arrive at some mutually agreeable plan of action, 3456 and some attention has been given to how GPs might remain emotionally intact during each consultation.37What I need is a practical method to explore emotional challenge.
I attended my first clown improvisation workshop in 1993. The advertisement put out by an organisation called Nose to Nose, founded by Vivian Gladwell, said, “Discover your clown within,” which, as a form of self discovery, sounded interesting, if a little challenging.8 This was clearly something quite different from circus clowning. Each day of this two day workshop began with a series of physical exercises in which we explored how we could use our own body movements, voice, and the space around us to convey feelings and be receptive to those of others. This prepared us for performing improvisations, starting with simple solo exercises and progressing over time and subsequent workshops to more complex situations with two or more clowns on stage. Fellow participants formed the appreciative audience, and Vivian gave us encouraging feedback after each performance. The daunting prospect of appearing on stage was alleviated by the warmth and humour of the group.
Like all games clowning has rules and skills that may be learnt through practice and feedback. Clowns are professional empathisers who have to listen and respond to other clowns on stage, to their own feelings, and to those of the audience. They are improvisers and have no script. They like problems and do not rush to solve them. They are encouraged to stay with a problem, explore its possibilities, and resist blocking ideas and propositions from other clowns. Instead they accept the challenges posed by these propositions and, through their own character, transform them. Clowns are sensitive to emotion but are not overwhelmed by it. They distance themselves from it sufficiently to understand the drama objectively and to play with it. In so doing they have to be sensitive also to the audience’s response and expectations. They are transparent and vulnerable and make mistakes. They can be subversive and break rules and challenge conventions but only after establishing and following the convention in the first place.
I have found these ideas mirrored in everyday “patient centred” consultations. If one steps into the patient’s world one often finds the biomedical script to be of limited use. It becomes increasingly important to be receptive to the patient’s ideas and propositions and to attend to his or her emotional expressions. Being able to distance oneself from the drama, sufficiently to play with it, is a valuable lesson to learn here. I need to remain emotionally intact, not just for the patient in front of me but for the other 17 on my list.
The most difficult lesson to take from clown improvisation is vulnerability. General practice is a hugely complex discipline. As a GP I can never be right all of the time; I am lucky if my diagnosis and management of patients’ problems are correct most of the time. Of course I can use risk management strategies to improve my chances, but this is ducking the issue. At the end of the day, I am vulnerable, and there needs to be an understanding between me and my patient that this is so. One way is to share the decision making with the patient, using the humility and sensitivity of the clown to achieve a genuinely shared decision.
When clowns touch on deeper levels of understanding they also entertain us with their naive playfulness. It is this light touch combined with irreverence that liberates us, at least momentarily, from the dead weight of our everyday concerns. Being the clown in one of these moments is quite magical, and I therefore look for opportunities in my daily routine to be playful and clown-like. Humour can contribute positively to a consultation provided it feeds sensitively into the dialogue between the doctor and patient.
So, how does the doctor with experience of clown improvisation face the consultation with the patient described above, trying hard to understand what various physical symptoms mean to her while negotiating a rational, medical plan of action? For me this is about demonstrating the clown’s ability to handle emotions and feelings (my own and others) delicately, yet objectively, without feeling overwhelmed. The pay-off is, firstly, my ability to keep listening while maintaining sufficient control of the consultation to ensure that both of us emerge with a sense of achievement, and secondly, to feel at the end of the day that there is no work I would rather do than this.