"Music as Metaphor in the Practice of Medicine"


By Prof. Susirith Mendis


At first glance, we feel that medicine and music are two independent disciplines. We have come to understand them as two disparate and mutually exclusive activities; even though there are too many men of medicine who are excellent musicians to consider it just serendipitous coincidence.

But after years of dabbling with some random thoughts and getting to know individuals like Prof. Valentine Basnayake, who was Professor of Physiology in Peradeniya and immaculate pianist, Prof. Earle de Fonseka, who was Professor of Public Health and Preventive Medicine in Colombo as well as the Conductor of the ‘Symphony Orchestra of Ceylon’ and the inimitable Prof. Carlo Fonseka, I came to see connections where connections did not seem to exist: ‘music and medicine’ are somehow interconnected.

In an article published in AMEE MedEdPublish titled "Music and Medicine: being in the moment.", Tim Dornan and Martina Kelly of the Queen's University Belfast and University of Calgary, say this:

"What has music to do with being a doctor? For me, (says Martina Kelly) it’s about that total engagement with another in a moment. We talk a lot in medicine about listening to the content of people's speech; but what about tone, timbre, pauses, silence, breath, associated body movement, eye contact, touch, and smell, which are vital to how we interact with each other? Listening is not content, it is ‘intense presence’. To develop the analogy, before I see someone, I like to pause, to just focus on the person. That pause doesn’t even take a moment, but It’s like gathering oneself before the start of the performance. When I am with a patient I try to pay attention to everything; what they say, how they say it, what they don’t say, sometimes anticipating. I try to follow their tune and react. Even if it’s a well-rehearsed encounter, it is never quite the same. There is a movement to the interaction; something about ‘the live performance’ that resonates with how, as doctors, we interact with patients."

To put it another way:

HM Evans, in his article on "Medicine and Music: three relations considered." published in the Journal of Medical Humanities in 2007 writes:

"Two well-recognised, but inherently reductionist, relations between medicine and music are the attempted neuro-scientific understanding of responses to music and interest in music's contributions to clinical therapy."

There is a near million references on ‘the neuroscience of music’ and ‘music as healing and therapy’. Music therapy has been used for over 40 years to help autistic children communicate. Hospitals have found that piped in music has therapeutic effects – including helping premature babies to grow. Raymond Barr, Head of the Coronary Care unit at Baltimore's St. Agnes Hospital has also quantified it. He says: "For adult patients, half an hour of music produces the same effect as ten milligrams of diazepam."

The list is near endless. In other words, that is a bit old hat now.

There is a more interesting third relationship between Music and Medicine that Evans postulates.

"… music is seen as an ‘organising metaphor’ for clinical medicine as a practice. Both music and clinical medicine affirm human well-being, and both do this, among others, through varieties of skillful, crafted yet spontaneous mutual engagement between a 'performer' and an 'audience'."

Doctor as audience (Listener)

The critical first step in this direction, in this relationship between 'performer' and an 'audience', is ‘listening’. Both in music and medicine, listening is a critically important skill. In both cases, if that first step is done unskillfully or with limited skill, the very essence of the rest of that critical interplay may be completely ‘lost in translation’. But we must admit that the ambience of a quiet auditorium at a classical concert is quite different to a busy clinic. May be the equivalence to the busy clinic is, for instance, when a parent attempts to listen to some music at home while there is a raucous din of boisterous children in the background. Or is it?

We know that when we put on a radio there is the disturbing background static that we call "white noise" that makes listening to the music impossible. We need to tune in and even fine tune so that the static disappears, and the music can be listened to in all its pristine glory. Similarly, most electronic apparatus used in medicine, in electromyography for instance, eliminates ‘background noise’ and accentuates the true signal.

In the case of listening to the patient the same principles apply. The doctor needs to tune in to the patient. Not just the voice, but to fine tune to the tempo and the tone of it. The fluctuating cadences of the patient’s voice. Sometimes, it will tell more about the patient’s feelings than the words used to tell the doctor of his/her ailment. The doctor must not just tune in your ear, but needs to also tune in his/her mind.

In a live performance on stage, we focus not only on the music, but also the musician. The facial expressions – even contortions - of a player. It is only then that we can truly understand and appreciate the full impact of that piece of music. Similarly, it is through the attention to the details of a patient’s expressions that a doctor is able to discern the worry, the fear and the pathos of ‘unwellness’.

Imagine this scenario:

The medical students are awaiting their first lecture on ‘Introduction to clinical training’. They expect the professor of medicine to come on stage. But there is no lectern and there is no projector for a powerpoint presentation. The students are a bit perplexed. To worsen their perplexity, in walks an ensemble of a string quartet. Without preamble, they start playing and soon the students resonate. They begin swaying to the music and even clapping.

The performance is sponsored by the Arts, Humanities and Medicine Program of the Stanford Center for Biomedical Ethics and that is how the programme - "Music and medicine: The art of listening" begins. Discussions follow between teacher and students on the importance of tuning in, listening and understanding not only music, but also patients.

This is what they say about it:

"If you can listen properly and hear properly, then you're open to the necessary information to affect change in somebody's life, be it medical or personal. The obvious, immediate benefit is serving your patients better, but it's much wider than that. It's exploring this idea of listening and how on the surface something looks and sounds one way but on deeper examination—through active listening—a number of stories and messages you didn't hear on your first listening are suddenly obvious."

"And then the beautiful part of this is, even if you get none of that, hopefully you'll enjoy a nice afternoon of music: There's no admission charge, you're not getting graded, and there's no homework."

Van Drie, in his book ‘Training the auscultative ear’ writes:

"A renowned cardiologist, Dr. Proctor Harvey, introduced medical students to auscultation by playing Beethoven’s symphonies. Afterwards, he asked if they had heard the music – of course, all put up their hands. But, when asked how many had heard the French horn or kettle drum, students put their hands down. Harvey used this simple exercise to demonstrate the need to listen attentively within human beings’ complex acoustic space for isolated sounds. Listening to the body is not easy, especially when, as a beginner, you don’t even know what you are listening for! Yet our ears learn to discern harmonies of health amidst the soundscape of the body just as our eyes learn to distinguish signs of disease from patterns of normality."

Listening is one-sided. Listening by itself does not help when more than one person is involved as in a doctor-patient relationship. We then need to take a step further. Listening must progress to communication – a dialogue – for it to be enhanced and become meaningful. The ‘oohs’ and ‘aahs’, the clapping, encores and standing ovations is the response of an appreciative audience. A relaxed smile and an almost inaudible sigh of contentment is how a patient has responded in appreciation.

In the concert hall, there is clarity as to who the ‘performer’ is and who the ‘audience’ is. But in the medical consultation, it is not that clear. Who, in fact, is the performer’? The patient or the doctor? Who is the ‘audience’? the patient or the doctor? When we spoke about listening, the listener (the audience) is the doctor; and the performer is the patient. Or is it?

Here is what Peter van Roessel and Audrey Shafer of the Stanford University School of Medicine say it in their article titled "Music, Medicine, and the Art of Listening" in the ‘Journal for Learning through the Arts’ (2006):

"What happens to an inexperienced musician in a situation of great stress? ... such players stop listening and concentrate instead on their highly practiced and memorized role, repeating from rote their trained behaviors. Without listening - the rhythms and tempos become unstable, intonation is off, coordination with fellow players suffers, and the spontaneity of performance is lost."

"How do doctors fail in stressful situations? In the same way: we fail when we miss important medical cues, when we neglect to heed our colleagues, and, most basically, when we cease to listen to our patients with full patience and attention, and thus lose the sense of connection and empathy that only such listening can achieve."

Let us look at another aspect in this communication. The music of a performance is decided in advance. It is scripted. There is a musical score. The performer/s play in accordance with the score. Furthermore, in an orchestra there is the conductor who keeps a multitude of players in harmony.

The patient-doctor communication is scripted too – up to a point. Patient history, history of the presenting complaint, chief complaint(s), present illness, past history, family history, personal and social history and so on ... Questions by the doctor and answers by the patient. The audience/performer (listener/player) dichotomy keeps fluctuating. As you can see, here, unlike in classical music, the listener (‘audience’ – the doctor) and the player (patient) roles interchange rapidly.

The interaction is more immediate and individualized than that between the listener and the performer in a classical live musical presentation.

But one can also see similar immediate audience responses in popular music performances as against a classical music audience where ‘silent listening’ is the imperative. The clapping, the whistling, the dancing while the music is being performed is a resonating immediate interaction between player and audience – similar to that between doctor and patient.

So, there are two viewpoints: one is the doctor as the audience (the listener), and the other of the doctor as performer. In the first instance, the doctor is a listener or audience member. This is the primary function of the doctor. The mental concentration required of an audience in understanding and appreciating a piece of music and a doctor listening to a patient will depend on the complexity of the music and the complexity of the presenting complaint. But, as I said earlier, this aspect is a performance scripted in advance.

Doctor as a performer (Player)

The doctor takes on the role of the player when he askes probing questions from the patient as well as when he proffers advice. To do this effectively and well, the doctor needs skills developed by rigorous training during clerkships and internships. Medical students know that they had to be familiar with the techniques of history-taking and physical examination. It was a performance of sorts. As students they even rehearse lines of questioning patients and examination techniques for delivery with appropriate timing, style and sequence – sometimes in accordance with peculiar idiosyncrasies of particular clinicians.

Medical students and doctors are expected to ‘perform’ in the presence of their peers and superiors during ward classes in ‘reciting’ case-histories and discussing differential diagnoses.

The musician too must master the skills of playing an instrument with hours of practice. Practicing scales till the fingers over a keyboard or strings are flowing with smooth assurance. Repeatedly playing a piece of music until it is perfected. A live performance on stage is far more stressful than a medical student or medical registrar presenting his case at a clinical examination. A false note reverberates louder than a missed physical sign.

It is in this context that Woolliscroft and Phillips authored the article titled ‘Medicine as a performing art’ published in the journal Medical Education in 2003. In this profoundly illuminative article they consider 3 parallels between the performing arts and the practice of medicine.

"1. In musical performance, musicians combine technical skills and knowledge of the ‘rules’ that define a musical genre with the ‘interpretation’ needed to create a performance. Within, and often across, musical genres, there is a commonality of musical knowledge among musicians. Similarly, within and across the specialties of medicine, there is a shared understanding of the scientific and cultural bases of clinical medicine.

2. Within performing groups, musicians play different roles and have developed expertise on different instruments. There is a shared knowledge and purpose; however, at the individual level expertise differs. Likewise, many patients require the care of doctors from different specialties. There is a shared focus on treating the patient, but the contributions of different members of the care team are unique.

3. In music, no two performances are identical; the listeners, the musicians, the venue all shape the performance. At the most basic level, what the audience considers quality music depends on the culture of the listeners; for example, some Eastern music sounds ‘foreign’ to Western ears. Similarly, each patient encounter differs. Even when the underlying disease process is the same, the approach to the patient and treatment is modified by patient expectations and bounded by cultural definitions of the patient’s and doctor’s roles."

Hence, the development of the concept of the doctor as performer. There are a few differences. The ‘performance’ of a musician may depend a lot on the highly personalized training by a consummate teacher – a maestro. Today, medical training under clinicians is occurring in increasingly larger groups. Individual talents or weaknesses of students are less likely to be discovered.

Content loaded medical curricular and finer specializations have inevitably fractionalize medical care. We are today inundated with a flood of medical minutiae and detail. In consequence, the old holistic approach to medicine and clinical practice has been lost to increasing reductionism. Thereby, the doctor, more often than not, becomes an egotistical soloist and not a player in a great medical orchestra.

Can we go off-script? Outside the musical score?

Doctor as improvisor

A patient presents a set of symptoms and signs. These constitute a pattern for a given medical condition. The difference between an experienced clinician and a rookie intern is rapidity of ‘pattern recognition’. The more experienced a clinician is, the more easily and quickly, patterns are recognized. Conversely, more patterns one recognizes the better is the clinician. There is a large body of evidence in the literature that pattern-recognition is the foundation of expert diagnostic performance.

In music a melodic pattern is a cell - serving as the basis for repetitive pattern. Every piece of music also has a foundation of rhythm patterns and tonal patterns. The difference between music and noise is these patterns. But repetitive patterns become predictable and boring. But, there are differences between different interpretations of the same musical score. For instance, a score created and written down by Beethoven or Khemadasa represent the music in their own mind’s-ears. Each conductor or orchestra that brings sound to the silent pages of the written score, have their differences - different interpretations, subtle as they may be. Even in classical music, for instance, each soloist playing the same musical score can ‘sound’ different to the trained and highly discerning ear.

But a musician can go off script or change the pattern.

In Jazz, it is the improvisation that a musician creates that sets it apart. The jazzist can improvise on the spot by changing the rhythm or the key or the pitch while echoing the original melody. While playing, he ‘does his own thing’ – going off the written music or even the original pattern. It is the improvisation that makes one jazz musician more special than another.

Improvisation is the key to a good clinician. All patients with similar set of symptoms are not the same. They are unique and different. Though the pattern generally fits. But the good clinician approaches each patient differently depending on the circumstances. Both the jazz musician and the good clinician are good with patterns and observe the basic sequences. But sometimes they "push" at the edges of the pattern and change it a bit; turn it around and look at it from a different angle. They see somethings different that may even be better than the previous original pattern.

Paul Haidet, Professor of Medicine & Public Health Sciences at Penn State University Medical School, in his article "Jazz and the ‘Art’ of Medicine: Improvisation in the Medical Encounter" published in the Annals of Family Medicine (2007) writes appreciatively of the famous jazz trumpetist Miles Davis. He uses Miles Davis’ jazz playing as metaphor for providing space for a patient to tell his story. He says:

"To hear a solo by Miles is to hear space. Miles does not play a lot of notes, he just plays the right ones. He conserves notes, plays them at a relaxed pace, plays on the "back end" of the beat, and drops musical hints that allow the listener to use their imagination to fill in the phrases."

"As a physician, I strive to use communicative space as Miles did. Rather than take up all the space in the conversation with strings of "yes/no" questions or long physiological explanations, I find that I am at my best when I can give patients space to say what they want to say, using my communications to gently lead patients through a telling of the ‘illness narrative’ from their perspective, rather than forcing the narrative to follow my biomedical perspective. In this space, patients often either tell their story, allowing me to understand the context around their symptoms, or ask the questions that allow me to tailor my explanations to their unique concerns."

Paul Haidet has imbibed the Jazz of Miles Davis to nurture his own communicative style with his patients. To gain insights into the patient’s deeper feelings about his/her illness.

Let us get back to patterns.

For instance, if the symptoms, signs and lab reports all fit into the pattern, and if both the doctor and the patient feel comfortable with the original pattern, the music ends there. The management then is typical and straightforward. Usually, the same old tunes are often reassuring. They don’t disturb the ‘pattern tranquility’ of both doctor and patient.

But what if a single sign or lab report is incongruent? That it doesn’t fit the original pattern? And it disturbs the provisional diagnosis? What if it disrupts the cadences of the tune and refrain of a well-recognised syndrome? Will it not disturb the ‘tranquility’ of the original pattern? Then, like the expert jazzist, the experienced clinician is adept at making quick decisions. Changes the immediate management of the patient to suit the altered pattern. It’s a different tune now. The innovative jazzist takes cues from the audience responses and changes track; changes his pitch, beat or rhythm. The audience is alert again, listening attentively once again to something new and different. The clinician rethinks and reworks its diagnosis.

Sometimes, disrupted patterns and unexpected happenings that characterize both live music and clinical practice, can be an exhilarating experience; sometimes, it will give a sleepless night to the clinician. Some clinicians have been known to observe that this is what makes clinical practice fascinating and absorbing; in music, in the same way, are we drawn to live music - one never quite knows what is going to happen next.

The good clinician is an improviser who can quickly change track and discern new patterns. Like the classy jazz musician – like Louis Armstrong, Duke Ellington, John Coltrane and Miles Davis who made Jazz what it is today through their improvisations.

Finally, let me quote Dornan and Kelly once more. (‘Music and Medicine: being in the moment.’)

"Music and medicine, we have argued, are states of being, in the moment, with other people. Musicians do not ‘do’ music to their audiences, but engage in simultaneous, two-way communication that can transport both parties to better places. We have argued that medicine is, likewise, an act of being there, whether or not doctors do technical things to patients. The practices of medicine and music have subjective, non-verbal, dimensions that can engage all the senses. These dimensions, which are present in all cultures and societies, form connections that are deeply located in the human psyche. Good doctors, like good musicians, tune in to patients ‘in the moment’, and allow their own beings to connect with patients’ beings. Music can help students develop auditory skills but much work remains to be done on how it could make a non-instrumental, existential, contribution to medical education. This, we suggest, could help students and doctors reflect on their experiences of being in the world, and how shared experience can relieve suffering."

In this article, I have attempted to bridge an unseeming gulf between music and medicine and between musicians, physicians and their respective techniques. Their techniques seem not so different after all. They are all players and performers. To paraphrase the words that Shakespeare put in the mouth of Macbeth, we are all ‘players who strut and fret our hour upon the stage to be heard no more……..’.

(This article is excerpted from the Valentine Basnayake Oration 2018 of the Physiological Society of Sri Lanka delivered by the author)

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