Secrets and magic

Tim Senior

doi:10.3399/bjgp14X677284

Tim Senior

The most significant event in the health service is the closing of a door. Thousands of times each day a door closes, leaving a doctor and a patient in a room together. In the vast majority of cases these are the only two people who know what happens in that event. Doctors, like any good magician, are professionally bound not to give away the secrets of the closed door. Like watching magic, people’s attention is directed elsewhere for the crucial, rather mundane, secret that shows the reality. So good are we at this magician’s sleight of hand, that most people don’t even know they’ve missed a trick.

Everyone has seen a GP at some point in their lives, most people have seen one in the previous year. So everyone knows what their doctor has done and knows what doctors do. A small number of these people also research and make policy on health. They know what happens when the door closes because they get to see de-identified data as well. This shows that doctors do things like measure height and weight, measure blood pressure, prescribe medications, and ask people validated questionnaires. Discovering all this must be like pulling back the curtain on The Wizard of Oz. It doesn’t sound too difficult. Why does it take so long for some patients? Why are doctors so expensive? Can’t cheaper workers do this? They might even do it faster!

Those people who experience the magic at its most powerful know it when they see it, even if they describe it in other terms: communication, bedside manner, or art. This is the magic that takes place at the boundaries of multiple physical, emotional, and social problems, but also at those areas on the map whose clusters of physical symptoms have no medical names.

Here is where our magic is at its most powerful, where the land is uncharted. The symbols on the map look familiar; the blood pressures, the weights, the prescriptions look similar to those of other consultations. But show those back to the patient and it seems clear that although that all happened, it’s not a summary of what was really going on. So what was really going on? ‘Well. She listened.’

Almost every GP registrar at some point has the experience of seeing a patient leave the room happier than they came in. ‘I don’t know why, I didn’t do anything,’ This is often the point where the magician learns his own secrets. These are the hidden panels and mirrors that allow the documented actions to weave their effect. Unseen by those with attention on the computer output, they build the trust that enables documented interventions to work. There are only two people who know what happened behind that closed door. One of them can’t say, and the other probably doesn’t want to. If pressed, those words — communication, bedside manner, art — do as much hiding as revealing to outsiders, and the magic remains intact. And in that lies the magic. For the closing of the door is a significant moment because it can deal with almost anything brought in to the room. The magic lies in choosing the roles for any problem — diagnostician, counsellor, advocate, witness, — and the only way any problem can come in is because the door is closed and we can keep our secrets.