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Title: Music, Medicine, and the Art of Listening Journal Issue: Journal for Learning through the Arts, 2(1) Author: van Roessel, Peter, Stanford University School of Medicine Shafer, Audrey, Stanford University School of Medicine and Veterans Affairs Palo Alto Health Care System Publication Date: 2006 Permalink: http://escholarship.org/uc/item/501997g9 Acknowledgements: Keywords: medical education, medical humanities, music, doctor-patient relationship, communication, classical music, metaphor, music therapy, composers, medical training Local Identifier: class_lta_2521 Abstract: The use of the arts in medical education has become increasingly widespread. Narrative and visual media, in particular, have received great attention as tools for teaching skills of empathy, observation and reflection. Music, however, has been relatively less applied in this context, and may be perceived as lacking immediate relevance to medicine. In this article, we first review various areas of interface between music and medicine. We then describe a curricular innovation undertaken at our institution using musical performance to demonstrate the value of music as a metaphor for communication in the practice of medicine. Copyright Information: All rights reserved unless otherwise indicated. Contact the author or original publisher for any necessary permissions. eScholarship is not the copyright owner for deposited works. Learn more at http://www.escholarship.org/help_copyright.html#reuse eScholarship provides open access, scholarly publishing services to the University of California and delivers a dynamic research platform to scholars worldwide. vvaann RRooeesssseell aanndd SShhaaffeerr:: MMuussiicc,, MMeeddiicciinnee,, aanndd tthhee AArrtt ooff LLiisstteenniinngg Curricularreform inmedical educationhas encouragedtheuseofbothexplicit andimplicit methods toteachthehumanisticskills ofmedicine.Anexampleofan explicit methodis thestandardizedpatient program: students interact withactors portrayingpatients with predefinedillnesses and backgrounds.As well as testingaccurate historytaking,directedinterviewinganddiagnosticabilities,theseencounters areusedto evaluateinterpersonal skills,forinstance,empatheticlisteningandtheart ofbreakingbad news.Adequateperformanceofspecifictasks,suchas introducingoneself andallowing timeforthepatient toanswerquestions,has becomeacriterionbywhichstudents are judgedas theyseektopass theirnational medical boardexams.1 Less uniformlyappliedaremoreimplicit methods ofteachinghumanism in medicine: approaches that requirestudents tomakeconnections betweensituations encounteredintherealm ofhumanexperienceand theirownactivities inmedicine. Becauseofthenecessary limitations ofone’s ownlifeexperiences2,these moreimplicit approaches often relyon thearts as ameans ofillustratingtherange and complexityof thehumancondition.3Most straightforward are approaches usingliterature,dramaor othersources ofnarrative.4Drawingfrom fictional andnon-fictional sources,narratives ofillness andloss canbe usedtodevelopempathy inayoungpractitionerwhomight thus betterunderstandthestruggles ofanill,conflicted, orgrievingpatient.Allegoryand imagerycanteachayoungdoctortothinklaterally,beinsightful,appreciate ambiguity, andchallengethealgorithmicthinkingonwhichappliedmedicineis often based.More recentlythevisual arts havebeenpromotedtoimproveobservational skills bycareful, guidedconsiderationofpaintings and sculpture.5,6 Ofall thearts,however, musicmaybeviewed as theleast obviouslyrelatedtothe practiceofmedicine, and henceit offers the challengeofrelevancetomedical education. 11 JournJaol ufornr aLle faorrn Linega rtnhirnogu gthhr othueg hA rthtse, 2A(r1ts),, A2(r1ti)c l(e2 01046 ()2006) Nonetheless,theoverlap ofmusicandmedicineis broadandhas beenthe focus of various investigations.Inthis article,wewill brieflyreviewsomeofthediverse intersections between musicandmedicine.Theseintersections includethe relationships betweenmusicians anddoctors andartists and illness,musicas therapy, andthe neuroscienceofmusic. Wethendescribe acurricularinnovation,TheArt of Listening, that weundertook at our medical school toexamineconnections amongmusic,musical performance andmedicine.Theprogram explored musicas ametaphor for communicationinmedicineandmedicine as aperformance art.Wearguethat emphasis ontheskills oflisteningdemandedbyfull appreciationofmusicprovides a novel and fertilegroundforrelatingmusictothepracticeof medicineandprovides a point of departurefortheuseof musicinmedical education.Finally,weoutlinesomelimitations andconcerns regarding theincorporationofmusicintothemedical curriculum. Musicians andPhysicians Researchintothehistorical and current relationship betweenmusicians and doctors includes biographical literature about composers whowerealsophysicians,such as AlexanderBorodin,7as well as literaturedocumentingtherelationships between physicians andcomposers.Forexample, thefriendshipbetweentherenownedViennese surgical pioneer,TheodorBillroth,and thegreat romanticcomposer,Johannes Brahms, has beenwell documentedviatheirextensive correspondence.8,9Literature onmusicians anddoctors alsoexplores theroleofmusical performance as anavocationindoctors’ lives,thetraditionofdoctorandhealthcare workerorchestras,10,11andspeculations onthe potential benefit ofprior musical trainingonphysicianskills.12Thus,this literature broadlycovers musical talent from theamateurto theworldfamous. 22 vvaann RRooeesssseell aanndd SShhaaffeerr:: MMuussiicc,, MMeeddiicciinnee,, aanndd tthhee AArrtt ooff LLiisstteenniinngg Artists andIllness Asecondwide-ranging categoryofliteraturedescribes theimpact ofillness onthe lives andworkofthegreat composers and performers.LudwigvanBeethovenis archetypal: analyses focus onhis gastrointestinal disease,his psychological health,the etiologyofhis storieddeafness,andtheimpact of this deafness uponhis compositional life.13,14Someofhis mostsublimecompositionrelates directlytohis experienceofillness, notablytheslowmovement oftheOp.132quartet,subtitledthe“Heiliger Dankgesang eines Genesenen,”or“A Convalescent’s HolySongofThanks,”writtenuponhis recoveryfrom anearfatal episodeofintestinal inflammationinthewinterof1825. Numerous other composers haveincorporatedimages ofillness orbodily anxietyinto theirmusic,from thefirst irregularheartbeat rhythms at theopeningofMahler’s epic9th symphony(writtenwithfull late-romanticself-consciousness that aninthsymphony might beone’s last),tothelabilemusical moods ofRobert Schumann’s work,thought by manytoreflect Schumann’s ownstruggles withbipolaraffectivedisorder15,16. Contemporarycompositionhas alsobeenusedtoillustratemedical illness,suchas composerBrent Michael David’s “Tinnitus Quartet”whichuses ahighdronetoneplayed throughout asixteenminutecomposition toreveal toanaudiencethesensationoflife withthis persistent auditorydysfunction.17Furthermore,inresponsetothe impact of performance andpractice onmusicians themselves,thecross-disciplinary fieldof performancemedicinehas evolvedtoaddress the medical andmental healthconcerns of contemporarymusicians andotherperformingartists.18,19 33 JournJaol ufornr aLle faorrn Linega rtnhirnogu gthhr othueg hA rthtse, 2A(r1ts),, A2(r1ti)c l(e2 01046 ()2006) Musicas Therapy Numerous studies have assessedtheimpact music has onillness andhave measuredits effect onsomaticandpsychicsymptoms insettings from ICUtopsychiatric wardtonursingfacilitytooperatingroom.This extensiveliteratureincludes the evaluationofmusictherapyandothermusical interventions onpain,anxiety,cognitive development andpatient satisfaction.20-22Recent studies havealsoinvestigatedthebenefit oflivemusicperformanceversus recordedas atherapeutictool,concludingthat thereis a special qualitytoliveperformancethat conveys benefit tothelistener.23,24Thoughmusic has mostlybeenstudiedas it impacts thewell-beingofpatients,its effects ontheart of practitioners is alsounderinvestigation.Forexample,not onlyhas musicbeenstudiedas anagent promotingpatient comfort intheoperatingroom,25,26music’s effect onthe activities andperformanceofsurgical andsupport staffhas alsobeensubject to scrutiny.27,28Finally,thisextensivecategoryalsoincludes theuseofmusic as anoutlet for expression,reflectionandthebuildingofcommunityinthemedical setting.Forexample, programs commemoratingcadavericdonors to anatomyclasses caninclude musicto provideasenseofrespect, closure,riteofpassage andgratitude. 29 TheNeuroscienceof Music Theneurosciences provideafurtherareaofinterconnectionbetweenmusic and medicine.Understandingtheperceptionofmusical stimuli offers amyriad ofpossibilities forcomprehendingthestructure and functionofthenervous system,as musicoffers a windowintoneural processingfrom thelevel ofsensoryperceptionintheinnereartothe interactionofemotive,memory,andanalyticfunctions ofthebrain’s higher cortices.30 Variants ofmusical perception offer fascinatinginsights intosensoryprocessingand 44 vvaann RRooeesssseell aanndd SShhaaffeerr:: MMuussiicc,, MMeeddiicciinnee,, aanndd tthhee AArrtt ooff LLiisstteenniinngg memory,as seenthrough phenomenasuch as synesthesia31and absolutepitch perception.32Pathological entities includingTourette’s disorder,33 autisticspectrum disorders34andWilliams syndrome35have alsobeendescribedtointeract,oftenpositively, withmusical ability.Musical precocity,as famouslydemonstratedbycomposers suchas Mozart andMendelssohn, furtheroffers anapproachtounderstandingcreativityand humandevelopment.36 MusicAs AMetaphor For CommunicationInMedicine Theabovetopics represent inbroadstrokes much ofthevoluminous literatureon musicandmedicine.Our goal inthis perspective, however,is toadvance anothermeans forinterrelationofmusic andmedicine,onethat weexploredinasession forfirst year medical students, andthenagain inasessionopen tothegeneral public,inthewinterof 2005.This sessionwas ledbyRobert Kapilow,acomposer,conductor,music commentatorand educatorfrom NewYorkCity,alongwiththeSaint LawrenceString Quartet (SLSQ),aninternationallyrenownedstringquartet inresidence at Stanford University.Thetitleofthesessionwas “Music andMedicine: TheArt ofListening.”An outlineforthesessionwas writteninadvancebyRobert Kapilowand was informedby preparation,includingbothasitevisit byKapilowandtheSLSQtoamedical student psychiatrylectureonpatient interviewingand aneveningmeetingamongKapilow,the SLSQ,themedical school coursedirector,thefacultydirectoroftheArts,Humanities andMedicineprogram at Stanford,andasmall numberofinterestedmedical students. Thesessionthus conceivedfollows theformat of programs Kapilowhas frequently performedwiththeSLSQandother artists.This format involves takinga movement ofa classical composition(inoursessions,quartet movements byFranzJoseph Haydnand 55 JournJaol ufornr aLle faorrn Linega rtnhirnogu gthhr othueg hA rthtse, 2A(r1ts),, A2(r1ti)c l(e2 01046 ()2006) AntoninDvorak),andbreakingthemusicdownintoits component themes, accompaniments,phrases,transitions,and individual parts,whicharedemonstratedtothe audiencebyindividual andgroupedmembers ofthequartet.Indeed,the audienceis often askedtoclap, singandmemorizetheseelements inanattempt toengage anddemonstrate thecomplexityandintricacywithwhichevenashort moment ofquartet musicis composed.Thegoal is to engagethelistenerinlistening,andindoingso,todemonstrate that suchlisteningtakes activeattentionand focus,as well as theknowledge,emotions, memories andexpectations that anyindividual brings tosuchanencounter. After workingapiecethrough inthis manner,theaudienceis givenafull performanceofthe movement duringwhich theycan“test-drive”theirnewlisteningskills and understanding. As readers maysuppose, descriptionofsuchasessionintext omits thebrilliance brought totheencounter byaseasonedperformer andeducatorsuchas Kapilow,withhis uniquegift forstructuringanddeliveringsuchprograms and his abilitytoidentifyand elaboratethroughdiscussionwiththeaudiencethe myriadthemes that emergefrom considerationofthemusical experienceinall its facets,from perspectives ofcomposer, performer,historianandlistener.Similarly,this descriptionomits therareandcrucial gift ofvitalitygiventotheperformancebytheplayers oftheSaint LawrenceStringQuartet. Nonetheless,wepresent heremanyofthetopics identifiedduringthis sessioninthehope that theymight beexploredindependentlyinother formats andinfutureefforts to incorporatethemusical arts intoteachingofthemedical humanities. Innovativeprograms usingmusicintheeducation ofmedical students and residents havebeendescribedpreviously.37,38 Theseprograms appeartohaverelied heavilyoncontemporary musicandtheinterpretationofpopularsongs,as songs provide 66 vvaann RRooeesssseell aanndd SShhaaffeerr:: MMuussiicc,, MMeeddiicciinnee,, aanndd tthhee AArrtt ooff LLiisstteenniinngg bothameans toconnect withtrainees and apowerful sourceofemotional narrativethat canbeusedtoillustratediversepsychological and cultural issues. Another program has usedoperasimilarlyforits synthesis ofnarrative andpowerfullyexpressed emotion.39 Whilethesecourses doemphasizelisteningskillsas agoal ofmedical humanities education,oursession,usingtheclassical quartet as amodel,focuses more ontheprocess oflisteningoverinterpretation ofanyparticularnarrativeor emotional content ofthe works heard. Theinterfacebetweenmusicandmedicineconceives thedoctorpatient- interactionas adialogue withopportunity forlisteningand performance. Inthis sense, ourapproachis most closelyaligned withthat advocatedbyWoolliscroft andPhilips,40 whoargue formedical educationreform byconsideringmedicine as aperformance art, andextendan analogybetweenstringinstrument trainingandclinical education. TheArt of Listening Thegroundexploredinoursessions canperhaps bebest described byelaborating twoviewpoints: oneofthepractitioneras audience,and thesecondofthepractitioneras performer.From thefirst perspective, conceptualizingthemedical practitioneras a listener,oraudiencemember,theprimarygoal ofourprogram was toreinforcethevalue ofinvolvement andengagement inlistening. Indeed,Kapilowdescribes committed listeningas a“full-contact activity.”Bydemonstratingthesubtletyand inventionineven asinglephraseofquartet-writing,weareremindedofthedepthofcues andcomplexity ofelements that maycomefrom apatient as she orherelates ahistoryof present illness. Byencouraging listeners toconsiderpitch,rhythm,attack,voicing,repetition,color,and directioninmusic,weareencouragedto consider thesequalities invoiceandaffect of ourpatients.Music,bothharmonicanddiscordant, reflects theinterplayof multiple 77 JournJaol ufornr aLle faorrn Linega rtnhirnogu gthhr othueg hA rthtse, 2A(r1ts),, A2(r1ti)c l(e2 01046 ()2006) voices,andmuchofthe valueofKapilowand the SLSQ’s demonstrationcomes from isolatinginstrumental voices individually,thenshowingthewayinwhichthesevoices interact and complement eachother. Understandingthis,weare encouragedtolistenand attendbroadlytothemultiplestreams ofinformationthat maycomefrom ourpatients: forexample apatient’s words,behavior, appearance,medical history,andinteractions withfamilyall conveyrelevant andactionableinformationtoanastutepractitioner. Kapilowandthequartet encouragebreadthandsimultaneityofattention,understanding whichvoices areconcordant andwhichvoices conflict,colororalterthemeaningof what mayotherwise appearas aprimarymelody. Withagift forcontextualization, Kapilowencourages us toconsiderthediversityofthemes inourownlives as physicians. What themes inourown lives givemeaning?Withdemonstrationfrom Haydn,hepoints out that interest oftencomes not from thedominant ViolinImelody,but sometimes from thesubtlecolors andunexpectedrhythms of aViola/ ViolinIIaccompaniment.As he points out,small efforts,volunteersideprojects andincidental kindnesses mayhavea greaterroleinshapingouridentities as practitioners ofthemedical arts than those activities weconsiderourprimaryoccupation. Onefurthertopicofgreat relevanceinconsidering thepractitioner as listeneris theroleofexpectationin listeningtomusic.Along-standingseries ofKapilow’s at New York’s LincolnCenteris entitled“What Makes It Great?”and uses asimilarformat of breakingdown andreassemblingmusicviainteractionwithaudience and guest performers.Thesesessions aim at illustratingwhat makes afamous pieceofmusicgreat, byrevealingthecompositional choices that gifted composers make,thus settingtheir workapart.Quiteoften, great composers’choices challengelistenerexpectations ofwhat is tocome,byinvertingmelodies,quotingunexpectedthemes,makingsmall alterations 88 vvaann RRooeesssseell aanndd SShhaaffeerr:: MMuussiicc,, MMeeddiicciinnee,, aanndd tthhee AArrtt ooff LLiisstteenniinngg ofrhythmicpatterns,maskingdownbeats,generatingfalsecadences—ineffect creating all thesurprisingtwists andturns ofgenius and inventionthat separatethe workofgreat composers from themerely good.Bydemonstratingforus howgreat music is madeby challengingourexpectations,byshowingthat art exists at theedges andinterstices of familiarpatterns,the appositionofmusicand medicineherechallenges our ownhighly- valuedapproachtomedicine,thepatternrecognitionuponwhichsomuch ofmedical diagnosis is based.While recognizing established patterns ofsigns andsymptoms will always befundamental totheteachingandpracticeofmedicine,appreciationofmusic suggests thevaluetobe obtainedinrecognizingdeviations from thoseexpectedpatterns, theelements that reinforcetheindividualityanduniqueness ofeachpatient and presentation.Inthis sense,it couldbearguedthat understandingmusichelps us listen past theillness tothepatient. Medicineas aPerformanceArt Thesecondperspectiveusingmusicas ametaphor fordoctor-patient interaction casts thepractitioneras performer.This shouldbe familiartostudents ofmedicinein particular, as ahistoryandphysical is aperformanceofsorts,and as students werehearse lines ofquestioningandexam techniques fordeliverywithappropriatetiming,styleand sequence. Duringtheclinical portionofstudent training,great emphasis is placedonthe effectiveverbal communicationofmedical informationtoanaudienceofpeers and supervisingphysicians.Similarly—althoughweriskpointingout theobvious—the medical profession,particularlyinprocedural specialties,is richinpracticedskills, performedbyteams inlearned,protocol-drivensequences.Consideringthis,theparallels betweenquartet performance, forexample,anda surgical team are evident inthat both 99