Intended for healthcare professionals

Feature Christmas 2023: Marginal gains

Medicine: a performing art

BMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2710 (Published 11 December 2023) Cite this as: BMJ 2023;383:p2710
  1. Roger Kneebone, professor of surgical education and engagement science
  1. Faculty of Medicine, Imperial College London, London, UK
  1. r.kneebone{at}imperial.ac.uk

Many clinical acts are performances—and we should think of that as a strength, not a weakness, writes Roger Kneebone

I think of medicine as a performing art, although to many people the word “performing” sounds suspect, almost insulting. It smacks of inauthenticity, of putting on a mask and presenting something that is not the “real you.” This is a fundamental misunderstanding. Whenever we engage with other people, we select from multiple authentic selves. Whether it is dinner with parents, an evening out with friends, a job interview, or a clinical consultation, we are constantly making choices about how we present ourselves and gauging how those choices are perceived. Within medicine, instead of asking “when are we performing?” clinicians might ask “when are we not performing?”

Theatre, music, dance, and public speaking—as with medicine—are rooted in a protracted grind of rehearsal, memorisation, and preparation. You spend endless hours in practice rooms and rehearsal spaces. You pluck up the courage to go out and do something in front of other people, putting your credibility on the line and taking responsibility for what happens next. You must connect with your audience, keep their attention, and remain vigilant in case things go off track. You learn to respond to the unexpected and to improvise. You develop courage and confidence to make radical decisions in the heat of the moment and cope with the consequences. If things go wrong, you do what you can to resolve the situation. Afterwards you “come down” as the adrenaline rush subsides. You may experience loneliness, isolation, and a sense of anticlimax. It is a relentless and demanding process that can lead to long term problems such as exhaustion and burnout, so you must find ways to sustain your energy and build resilience.

Clinicians experience these things too. I have been a medical student, junior hospital doctor, consultant surgeon, general practitioner, and GP trainer, and now I am an academic. As clinicians we often think of our experiences as specific to the world of medicine, whatever our career stage. Of course some are specific to medicine—the operating theatre, the clinic, the consulting room, and the emergency department are all unmistakably medical and all present challenges peculiar to healthcare. But many clinical experiences have a wider resonance.

Although performing is how we do our work, it remains an under-recognised dimension of clinical practice. As medical performers, our audiences include patients (who experience us directly during consultations and procedures), colleagues (with whom we carry out collaborative work), and ourselves (as we observe and critique what we do). In medicine, this ability to perform evolves as we acquire scientific knowledge and master procedural skills. Our initial focus is on ourselves, as we build experience and pass exams. We learn the wider performative aspects of care by mimesis, copying the behaviour of more experienced colleagues.

Art that conceals art

Expert clinical performing is an “art that conceals art.” Its subtleties are easy to miss when we watch expert clinicians who make consulting or operating seem effortless. Learning these hidden skills is not straightforward, especially when our attentional focus is still on ourselves. We may miss important cues from patients and colleagues because we over-focus on recalling factual knowledge or mastering procedural details. We may misread how what we do and say “lands” with those around us. That can be disastrous.

Framing clinicians as performers, with patients or colleagues as audiences, offers a bridge between medicine and other expert domains. In the performing arts such as music, theatre, dance, comedy, or close-up magic, the audience’s response is recognised as crucial. Their reaction may be experienced immediately (by applause at a concert or play) or later (through reviews and social media). A performer’s reputation and profile evolve over time.

We can think of clinical care as a close-up live performance too, albeit with a small audience. This framing has several components. Care for patients entails recognising how what we say and do is experienced by those we treat. Care for ourselves and our professional colleagues is equally important, as we cannot look after our patients effectively without it. This means paying attention to our own health while developing our relationships with others.

In the clinical world, the spotlight is usually on individual consultations or interventions, but a series of challenging encounters can lead to different kinds of stress. This cumulative impact is easy to overlook, especially in the busy settings of primary and secondary care. Yet we need to “re-set” after a taxing consultation that concerned serious illness or bad news, ensuring that our next patient is not put at a disadvantage because of that previous encounter. We must avoid longer term negative responses in ourselves too, such as dysfunctional detachment or cynicism leading to problems with mental health or burnout. Giving each patient our full attention can be a major challenge, especially within a pressured environment where the demands of the system can overshadow the needs of individuals within it.

Learning from other performers

All these concerns are familiar within the performing arts. Although musicians, magicians, and dancers spend years studying repertoire and mastering physical skills, they still grapple with anxiety, physical injury, and insecurity as they engage with audiences. They must learn to deal with criticism, whether positive or negative. They have to put everything into their next performance, even if the last one had poor reviews. They must build the resilience to continue if things go wrong, such as making a mistake in the first movement of a recital or experiencing a negative response from the audience. This longitudinal aspect of performing is becoming a major focus at music conservatoires such as the Royal College of Music.

Many of these strategies could be helpful within medicine. Yet such insights are seldom shared. To address this, the Imperial-Royal College of Music Centre for Performance Science has established an unconventional group of experts who are interested in sharing insights across disciplinary boundaries but who do not fit into traditional categories of the performing arts. These experts include a puppeteer, a close-up magician, a fighter pilot, a hair stylist, a textile artist, a radio presenter, and a chef. All provide insights into aspects of the clinical world.

These performers in residence have helped our team to identify aspects of performing that often escape notice. During his performance, close-up magician Will Houstoun subtly directs his audience’s attention, using powerful techniques he now shares with clinicians to apply in their consultations. Textile artist Fleur Oakes uses her experience in repairing fragile vintage fabrics to support trainee surgeons learning to operate on elderly patients with diseased blood vessels or fragmenting tissues. Fighter pilot Phil Bayman teaches his trainees to identify a “place of safety” they can access in rapidly evolving difficult situations, instinctively gaining a stable “altitude and speed” so they have time to make sensible choices without panicking—as a trauma surgeon uses pressure to gain temporary control of sudden bleeding before weighing alternative strategies. Hair stylist Fabrice Ringuet has perfected the art of entering a client’s personal space without causing disquiet or discomfort—a common challenge for students learning ophthalmic examination and other close-up clinical procedures. Puppeteer Rachel Warr highlights the crucial importance of warming up fingers and wrists before a performance, ensuring that all team members have prepared for the hours of demanding dexterity that lie ahead—insights that could become a routine element of surgical practice alongside the World Health Organization surgical checklist.

But exploring such parallels poses the challenge of how to gain access to unfamiliar professional environments. Outsiders are excluded from clinical work, for obvious reasons such as safety and confidentiality. Access is restricted to students and practitioners with legitimacy to participate. It is the same in the performing arts. Unless you have undergone a demanding programme of study you do not have permission to enter a specialised world such as high level music performing, let alone participate in its practices. So how might clinicians share experiences with experts in the performing arts, bypassing those years of study and preparation to engage directly with the experience of performing?

Simulation

Simulation offers one solution, although not in its common form. Most simulation is designed for people within a profession to practise things as they are currently done. Cockpit simulators enable pilots and aircrew to practise routine and emergency procedures without risking harm. Clinical simulators have a similar purpose, allowing clinicians to rehearse drills and procedures and receive expert feedback. Sometimes this rehearsal is virtual, but much of the time physical spaces recreate emergency or other clinical situations as closely as possible, allowing participants to experience thought processes and emotions that parallel real life. Such simulation is created for insiders by insiders, and those outside the discipline are not invited.

Yet simulation can also offer a way to share selected aspects of performing more widely, avoiding the need to master the specifics of a professional domain before exchanging insights at a deeper level. Musicians and surgeons might compare their anxieties about committing to an irreversible step, whether walking out onto the concert platform before a live audience or starting a complex operation. Magicians and GPs can explore how minor adjustments to the position of chairs or computer screens might improve sightlines within a consulting room, enhancing the attention of patients in subtle yet effective ways. This use of simulation requires a switch from excluding outsiders from a professional setting to welcoming them in and learning from them.

One barrier to this approach is cost, as full scale clinical simulation is expensive and resource intensive. Yet simulation for cross-disciplinary exploration may not require the same level of detail as training for insiders. We know from the world of theatre that even the most rudimentary stage set can convey a compelling experience for the audience. English director Peter Brook’s opening chapter in his book The Empty Space begins “I can take any empty space and call it a bare stage. A man walks across this empty space whilst someone else is watching him, and this is all that is needed for an act of theatre to be engaged.”

Distributed simulation is the term my colleagues and I at Imperial College have applied to our concept of low cost, portable clinical simulations that do not attempt to recreate every detail of an originary world. Like Brook, we focus instead on what is criterial for the purpose at hand. Distributed simulation selects objects, people, and activities that enable participants to “buy in,” highlighting essential cues and removing jarring notes. This deliberate simplification recreates what it feels like to be part of a professional environment by presenting what is salient rather than replicating every detail.

Simulation is more widely established in medicine than in the performing arts, but new possibilities are emerging. In many music conservatoires the focus is more on practice and rehearsal than the experience of performing in public. Yet performing in a major venue can be extremely stressful, especially when musicians early in their career step out onto the concert platform in a sensory environment they have not previously encountered. Until recently, realistic concert hall and opera house simulators have not been available. From November 2023, state of the art simulation facilities at the Royal College of Music will recreate auditory and visual characteristics of major performance venues worldwide. This counterpart to clinical simulators will also allow musicians and clinicians to experience one another’s worlds, sharing insights and developing collaborative strategies.

The importance of rehearsal in an ever more pressing world

Knowledge, skill, and commitment in medicine are expected and taken for granted. It is clinicians’ skill in performing that patients and colleagues experience when they interact with us. This human engagement is a two way process between performer and audience, where the quality of our attention is crucial. People are acutely sensitive to this attentiveness, especially when anxious or ill. This requires us to be present and focused during each encounter, despite outside distractions or our own anxieties. Mindful presence must be genuine, not assumed, and inauthenticity is easily spotted by patients. That requires practice, thought, and repetition.

In times of increasing pressure on healthcare, clinicians have much to learn from performing artists. Through acknowledging our common identity as performers, we can share the highs and lows of work that impacts on us and the people our work is for. Yet such opportunities are often overlooked. By harnessing the power of simulation to share our insights, we can focus on those relationships of care on which our work depends—care for our patients, ourselves, and one another.

Biography

Roger Kneebone directs the Imperial College Centre for Engagement and Simulation Science (ICCESS), based within the Division of Surgery. Roger and his co-director Fernando Bello lead a multidisciplinary research team whose aim is to advance human health through simulation, collaborating closely with clinicians, scientists, patients, the public, and experts outside medicine. His current work explores science, medicine, and engineering as performing, researching the human experience of conducting scientific work and drawing on the perspectives of the performing arts. He jointly directs the Imperial-Royal College of Music Centre for Performance Science with Aaron Williamon from the Royal College of Music. Roger is the presenter of the podcast Countercurrent, which invites scientists, artists, musicians, clinicians, craftspeople, and writers to free-flowing improvised discussions, with more than 200 episodes to date (https://www.rogerkneebone.co.uk) .

Reading list

  • Kneebone R. Expert: Understanding the Path to Mastery. Penguin UK, 2021

  • Brook P. The Empty Space. Macgibbon and Kee, 1968

  • Kneebone RL. Simulation reframed. Advances in Simulation 2016;1:27.

  • Kneebone RL, Oakes F, Bicknell C. Reframing surgical simulation: the textile body as metaphor. Lancet 2019;393:22-3.

  • Kneebone R. Discovery through doing. Nature 2017;542:294.

  • Kneebone RL.  Performing surgery: commonalities with performers outside medicine. Front Psychol 2016;7:1664-1078

  • Kassab E, Tun J, et al. “Blowing up the barriers” in surgical training. Exploring and validating the concept of distributed simulation. Ann Surg 2011;254:1059-65. 

  • Herman RJ, Clark T. It's not a virus! Reconceptualising and de-pathologising music performance anxiety. Front Psychol 2023;14:1194873.

  • Miller R, Hotton M, Williamon A, et al. Surgical performance anxiety and wellbeing among surgeons, Ann Surg 2021;275:632-9.

Footnotes

  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.