Why Hospices Must Set the Stage for a Positive Patient Experience

Neonatologist Ricardo Rosenkranz, M.D., is on a mission to bring magic into medicine.

As assistant professor in clinical pediatrics at the Northwestern University Feinberg School of Medicine, Rosenkranz has focused on the development of patient-centered, quality-driven health care delivery models for multiple settings. Informing these efforts is a link between performance art and medical practice that he found in his second vocation as a stage magician.

Rosenkranz at Northwestern developed the nation’s first medical school curriculum for the study of magic and medicine to explore the performance aspects of health care and the anthropological relationship between the two. The goal from a clinical standpoint is to develop more sophisticated and deeper understanding of the doctor-patient relationship, according to Rosenkranz.

Hospice News sat down with Rosenkranz at the National Hospice and Palliative Care Organization (NHPCO) Leadership & Advocacy Conference in National Harbor, Maryland, to discuss this approach to understanding the patient experience and its application to end-of-life care.

The below was edited for length and clarity.

Three questions in one: Would you tell me about how you became interested in magic, what drew you to medicine, and then what brought the two together?

I realized that there are all sorts of performative dimensions to the medical moment, whether it was in the space of the hospital bedroom, or giving somebody a diagnosis, or in my case as a neonatologist, sometimes in the delivery room right before that.

In medicine, I was very much the person who communicated, who spent a lot of time with patients and sometimes my colleagues. I was very much about communication, but no interest in magic. I got into magic later in life.

I’m originally from Mexico City. I went downtown with my family, and there was this magic store that time forgot. A friend of mine said I should meet Eugene Burger, who lived five blocks away from my house. He was the greatest magician you’ve never heard of.

He sort of created this notion that magic has meaning in it. The performance of magic has meaning. When the magician tears a newspaper and puts it back together. Even if it’s done in comedy, it is about death and resurrection.

Magic always deals with transformation. It really is about all the impossible things that we would like in our life.

Can you describe the Magic in Medicine course that you are teaching at Northwestern?

A lot of what I was learning in magic, I already knew from being a good communicator in medicine. The course would be a chance to explore our profession through the lens of the performing arts. Performance artists are amazing at engaging an audience. We can learn how they can inspire an audience, and we as health care providers might be really good at doing that in medicine.

I taught a lot of classes at the medical school, so I had an audience. Magic was a really good way to make a point, or express something. It became part of the class. Then I was asked to create this medicine and magic curriculum in our Humanities program. This course was about the doctor-patient relationship, because I felt that there was a big disconnect with how we were connecting with patients.

A lot of American medicine was based on the principle of autonomy. You have doctors in other cultures that are more involved in the decision-making.

Autonomy sometimes might become detachment. If the performance choice for the health care provider is to sit back and say, “What do you want?” The patient is going to interpret that to mean that you really don’t care what decision they make.

So I created this course, based on this idea that it would be a chance to explore our profession through the lens of the performing arts. In both settings, we have to engage our audience.

I performed a 12:30 a.m. show at the Magic Castle in Los Angeles, and almost the entire audience was drunk. I had to ask myself how could I connect, how did I have to change the show to engage with this audience. We have to ask similar questions when engaging with different patients.

What is the goal of integrating performance and medicine in terms of outcomes?

An organization that is trying to have really good outcomes for patients needs to assess how they can modify behavior to optimize a relationship.

It’s about people. We need to better understand the patient experience and what we give to patients. Are we really giving that person in the home the same thing that we’re giving them in the facility? Are they really having that dignified outcome? We have to look at all of that and see it as a performance. See the script. See the process.

As a neonatologist, we often tried until the very end to save a child. But there were times when really this was a very difficult scenario. I do my own palliative medicine as a neonatologist. It’s a different, very tragic kind of palliative medicine.

I went into that field, in part, because I felt that there were times when it was the right time to stop.

The step before that is not so seamless, the step where the person is in the hospital. I wonder how well hospitals really do talk to hospices. How can the palliative care teams interface? What happens when the hospital doesn’t really have a palliative care team? What happens with an oncologist that just doesn’t know how to stop?

When something bad happens, it’s almost as if a veil of concealment is cracked. You can see right through. So what happens there and how do we help people cope with reality? These are the things that are on the performative side.

You have spoken about the idea of “belief creation.” Can you add some color around that concept and how it fits into medicine?

The root of this is historical. Up until the 1820s to 1850s, people didn’t believe in conventional medicine. Medicine was a young science at that time and surgery was its own young science. So doctors and surgeons needed to convince patients that what they were doing was right. So there was proselytism, which eventually became scientific research.

For most doctors in the 20th century, if you said the word “science,” everyone’s like, “Let’s do it.” But now we’ve hit a point where there is a counter argument to it, and we find ourselves having to sell ourselves again. We lost it because we weren’t creating relationships built on trust. Most of the medicine became institutional. Most of the doctors are part of a cog in the wheel.

We still have our trusted family doctor in some instances, but many people don’t. They have whatever doctor will see them next in the institution. We have to build trust. We have to work towards that, and institutions have to work towards that. The patient experience is marred if you don’t have it.

There are people that come to magic shows begrudgingly. They’re there because somebody else wants them to be, but they might not have a good time unless I break the mold. But the stakes there are not high.

The stakes are so high in health care. You have to ask yourself how belief is created in somebody’s mind. We have to understand a little bit about how our brain works and understand how there’s diversity among us. Some people might be very engineering oriented and just want the numbers. One may be more emotional, another more intellectual.

When we think about performance, part of that is the stage or the environment that you create. We’re now seeing more care is moving into the home. Do you think there is some application of those concepts in the health care setting?

A lot of medicine can happen at home, in the right environment. I’ve thought about this a lot because I’ve been a caregiver to several people – my mentor Eugene, my brother, my dad.

My dad died at home when we did hospice for him, and it was just the most beautiful, comfortable situation for him. For my mentor, Eugene, it all was very sudden. He died [in a hospital].They had a great palliative care team. But I had to work really hard to make sure it was the place he wanted it to be.

At the end of life, I think that this transition to home can work really well. I think part of the outcome is that we want this to be meaningful and dignified. I think that outcome always works better at home.

Nurses in facilities are wonderful, but there’s coverage issues. You’ve built a relationship with someone, and then if that end-of-life moment happens to come during night shift you have a completely different crew. They are warm and kind and as they can be, but is this the person you want holding your hand when you’re going into the next world?

That’s why the patient experience is so important to me. Care must be designed around the patient experience.