I come reeling tonight from a performance of Berlioz's Symphonie Fantastique, performed by the Columbia University Medical Center Symphony Orchestra, through which, I had the wonderful opportunity to reignite a dormant love of playing clarinet (not played since high school!). I thought I'd share, below, the program notes I was invited to write for the program, which, as it happens in the spirit of this Synapse, suitably has its own art-science (music-medicine) link!
"Like music a man's life means more than the sum of its parts. It is a composition with many themes and one transcendent meaning. This is a fact of all life and the life of Albert Schweitzer is not an exception but an example."
Dr. Schweitzer was organist, philosopher, theologian, and physician. After almost a decade in the other professions, he turned to medicine at age 30, against the advice of his friends and family who questioned whether "service" wasn't already found in the professions he was currently engaged in. Dr. Schweitzer was determined to serve once he turned 30, and had his eyes set on medicine. Upon receiving his medical degree, he traveled to Africa where he founded a hospital.
Dr. Gawande, my sister, and me at Dunkin' Donuts--jk, The New Yorker Festival!
My sister Lucy and I half-run half-skip to Gramercy Theatre in East-side downtown NYC. I check my watch as we exit the 23rd St 6 train subway—"Lucy, we're making good time: 6:55 pm!" Just 5 min before the show...
As we enter the there's this suspiciously festive red glow which reminds me of a BBC Proms moment in London's Royal Albert Hall, except it's The New Yorker Festival and I'm equally nerding out to see Dr. Atul Gawande and musician Andrew Bird in conversation. "Whoa, Lucy...I was kind of expecting a lecture hall or something..." Are you serious
Are you serious—no question mark—is the new album of Andrew Bird's. Andrew's music makes me think of the intimacy of Zoe Keating's one-woman looping cello orchestra with the energy of Joy Kills Sorrow's folksie-stringy-plucky drive. A classically-trained "true goth," as Dr. Gawande describes, Andrew casually remarks, "well, there's a reason why conservatories are called conservatories." A rebel, he wields his violin like a ukulele-turned-fiddle-turned-harmonica as he whips out what The New York Times describes his "inner operatic folkie." Lucy turns to me and whispers, "he makes me want to play the violin."
We listen as "Puma" fills the theater:
'Cause it gives rise to the rumor she's a girl and not a puma And that light that shines is not a pearl, it's just a tumor ... But the doctors, they told me to stay away Due to flying neutrinos and the gamma rays, oh
"What is cancer?" Andrew ponders aloud, first as an aside; then, his eyes light up as it hits him—he's talking to a surgeon..."What IS cancer???" And in childlike curiosity, "I mean, does cancer have a reason for being there?" It was one of my favorite moments of the evening, as Dr. Gawande explains in true physician-educator style the mutations that give rise to cancer, and that the cells are trying to survive...
"Ah! So they have a will..." Andrew replies, somewhat-satisfied.
"I write about things I don't understand," says Andrew. Cancer. Fake palindromes. He also writes about "a lot of things we're not talking about as people," and sometimes his approach is from a "scientific angle that shows us what we're made of."
An audience member asks Andrew about the social responsibility of the artist. He says, "when it speaks from the heart, do it." But when the responsibility comes from external pressures, from "duty to speak out," it "usually doesn't go well."
I think music is one of the best mediums in which external motivations can start to dissolve, because art allows us to so naturally connect and start the feel that intrinsic understanding rather than the prescribed duty; the sense of what I get when I read a piece of fiction, like George Eliot's Middlemarchrather than one of those "develop kindness" books like David Brooks' The Road to Character (Rebecca Mead further makes the point).
After the talk, Lucy and I discuss over pizza and chocolate mousse cake (a delicious combination, by the way): how does the social responsibility of the artist compare to that of the physician? It's a question for us all as we ponder the boundaries of our professions, but in medicine in particular, there is the toxic notion that as long as we treat the biological disease, we're doing our job. But Dr. Gawande and many know otherwise. Gawande writes in Being Mortal,
We’ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive...
The chance to shape one’s story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone’s lives.
I think tonight's conversation is about a sense of will. Why are we alive? It's about creating our own meaning, of crafting our own song, of breaking from classical traditions to create something richer—looping and whistling along. And the will of connecting with another, of seeing how our experiences are inherent in another's—whether between physician and musician, or any number of communities and identities. It's a testament to the power of listening and relating through music.
Premiere of David Lang's "the public domain" for 1000 voices at the Lincoln Center. Lyrics: "Our power to choose"
"Where have you been? I wondered about you..." says the patient lying on the bed in front of me. Light streams in from the Hudson River, and I think how peaceful a time this is, how unchanged and natural it feels, to be seeing the searching calmness on this man's face. He has a gentle smile on.
Except that everything is not the same. It had been a week since I had seen my patient. On my last day on the wards, I told him I needed to help this world make music. And he said, "go do it."
I came back for a practical purpose--to pick up my tablet. I had stalled long enough. Part of this seemed symbolic. I'd given him my tablet so he could talk to his family; I'd entrusted a part of me to him. So maybe I stalled because telling him felt like a statement bigger than any meeting with a dean or signing of a contract.
Donned in my white coat, he asks me the usual questions--
"What do records say?" "What's happening to me?" Eyes alight.
The tablet is on the table. His phone, now fixed, is in his hand. I sit down on a chair beside him. And I have to I tell him I didn't know what was happening--I hadn't been a part of the team for the past week. I see the dejection in his face; I feel my own disappointment. And then he says,
"go do it."
I will go forward caring for others in a different way: it's uncertain, but I believe in it for us all--and if I don't, I will forever ask, what if? I have to give it a shot or live with regret. I have a deep sense of what I'm fighting for and why, and no matter what path or profession I end up in, I'll never lose that: music at the core--about connecting with humanity.
Before going, something compels me to ask him, "what makes a good doctor?" His answer:
1. Be loyal
2. Be prepared
3. Be charismatic
4. Believe in god
A doctor comes into the room. I'm about to say--"I'm just a medical student," but I catch myself.
From Jeff Nunokawa's note today:
"One thing essays have always been about (not all of them of course, but enough of them to notice and call part of the tradition) is everyday life: things that come with everyday life (the death of a moth; the rise of the sun). Well, there’s something about everyday writing, especially the kind that aims to help keep you company while you start everyday that reminds me of the morning as it’s been handed down to me. It’s a little repetitive (to say the least, as my mother would say), but also a little hopeful. It’s some weird combination of routine and experiment: writing everyday, starting everyday. I guess what I’m trying to say is this: the faith of our mothers and our fathers you can also find in the everyday writing I’m trying to do here. That faith inheres in a hopeful feeling that goes along with and a little beyond the less than hopeful feeling that you have when you first wake up and realize you have to to get up and do the same damn thing you did yesterday and the day before. It’s the faith that believes that there’s something on the other side of our everyday trying and it’s not all dark."
And a poem my classmates and I discussed today in our Narrative Medicine session:
We climb the slopes of life with throbbing heart,
And eager pulse, like children toward a star.
Sweet siren music cometh from afar,
To lure us on meanwhile. Responsive start
The nightingales to richer song than Art
Can ever teach. No passing shadows mar
Awhile the dewy skies; no inner jar
Of conflict bids us with our quest to part.
We see adown the distance, rainbow-arched,
What melting aisles of liquid light and bloom!
We hasten, tremulous, with lips all parched,
And eyes wide-stretched, nor dream of coming gloom.
Enough that something held almost divine
Within us ever stirs. Can we repine?
Tomorrow, I'll have my evaluation on history-taking and the physical exam ('H&P' History & Physical, in med-speak). I'll share songs written for patients and evaluate the impact of those songs. I'll write a final patient case write-up on chest pain. Next week, I'll take the Shelf Exam in Ambulatory Medicine and give a presentation on the songwriting project. Lots to study, learn, write, present! But in the spirit of Jeff's note and Henrietta Ray's poem, I shall climb the slopes of life with throbbing heart / and eager pulse, like children toward a star. It’s the faith that believes that there’s something on the other side of our everyday trying and it’s not all dark.
So many moments to remember. The 90 year old man in the ICU, head down, back hunched—I needed to hold his hand. I know it matters. Wife also hospitalized—lupus and dementia—he kept saying "oxygen." The defeatedness in his face. "Lymphoma" his first whispered words. The bright, white hospital light—too bright. There needed to be tenderness for this frail, strong man. As the resident and intern walk away, the patient turns to me, eyes bright and wide, hand still in mine, squeezing. I lean in close to listen: "I need oxygen or I get violent." The resident waits for me, at the door. O2 sat 94%, fine, but he was short of breath. Resident shrugs, "he's okay."
I wanted to stay. I wish I could do more. We are in the presence of such vulnerability, such humanness, and every little thing—touch, listen, glance, leaning—matters, I think, I hope, as I walk down the hall with the residents, back to our ward.
There have been a couple of encounters like this in the past weeks (another week gone by, already?). It's hard to stop and write and think. It's hard to collect my thoughts and process them. It's easy to let my emotions dictate myself. I wanted to write about Obama's State of the Union Address. About America the Philosophical. About e.e. cummings at Book Culture. But right now I need another kind of mental processing. I'm yearning, toiling, praying, loving.
is not something I could imagine myself easily sharing, much less in front of rows--at least ten rows filled--within the confines of the St. Aloysius Catholic Church, much less to follow that statement with a personal speech interjected with casual fluency interspersed with shouts from the crowd. Yet it is what I witnessed alcoholics do this Saturday evening. As a medical student non-alcoholic observing the proceedings of an Alcoholics Anonymous meeting, I was an outsider even before I stepped in. Crossing across the Harlem streets between Frederick Douglass St and 132nd St, I paused before the church with some uncertainty, before a man asked, 'Where you going, sweetie?" and as we both approached the entrance, I replied with awkward cheer, "here!"
At the entrance
Certainly he was not the first person to raise an eyebrow at my entrance--I, an Asian American twentysomething carrying my backpack, felt quite conspicuous in the midst of the middle-aged mostly black crowd. Thinking back to my visit to the Frick Collection earlier in the day, I started to reflect that my feeling of awkwardness was something these people experienced daily in entering the kind of 'white spaces' which have unconsciously become so natural for me.
Despite feeling rather out-of-place, I also felt a great sense of camaraderie in the crowd--so that rather than feeling like an uninvited stranger at an official meeting, I felt like a new acquaintance joining a close-knit group of friends, whose inside jokes went over my head. And rather than a therapy session in which I imagined myself as a wallflower, I found myself smiling and nodding along with the shared stories like a (somewhat-clueless) audience member at a comedy show.
For their stories were reminiscent of those from The Mothradio hour where members of the public share gripping personal tales with a receptive audience--they were fun, casual, personal; they elicited laughter and cheers from the crowd; they were told with flair and comedic effect. A man with a blazer and T-shirt went up in front of the crowd, half-grunting half-laughing, "I am certified NUTS!" (laughter from the crowd) "I know I'm crazy," and, referring to his alcoholism, "I know I gotta get out." He goes on, "Alcohol removes," and with dramatic pointing, "Table.... Leg... (laughter). Brain... Kidney... Liver." And a woman with camouflage cap and shirt announces in clear, stately tones, "If it weren't for AA, I wouldn't be here today."
The last speaker was celebrating her 14th Anniversary--that is to say, it was her 14th year as part of AA, and celebrated with candles and cake. She spoke with flair, spunk: "I was loud. I'm still loud. " And then, sincerely, "My baby teaches me to be better. You all teach me to be better." And, "Others help us see what we don't see in ourselves." As I approached her after the session, along with many others who expressed their congratulations, she turned to me with a bright smile and extended arms--"Are you new?"
I left with the feeling I get when I attend mass at a church and religion I don't "belong to," and why I attend in the first place: that the world is a better place, and can become a better place. That despite our differences, we all seek to be better. And that matters, for alcoholics and for me.
...he carried to his studies in London, Edinburgh, and Paris, the conviction that the medical profession as it might be was the finest in the world; presenting the most perfect interchange between science and the art; offering the most direct alliance between intellectual conquest and the social good. Lydgate's nature demanding this combination: he was an emotional creature, with a flesh-and-blood sense of fellowship which withstood all the abstractions of special study.
He meant to be a unit who would make a certain amount of difference towards that spreading change which would one day tell appreciably upon the averages, and in the meantime have the pleasure of making an advantageous difference to the viscera of his own patients. But he did not simply aim at a more genuine kind of practice than was common. He was ambitious of a wider effect: he was fired with the possibility that he might work out the proof of an anatomical conception and make a link in the chain of discovery.
'If I had not taken that turn when I was a lad,' he thought, 'I might have got into some stupid draught-horse work or other, and lived always in blinkers. I should never have been happy in any profession that did not call forth the highest intellectual strain, and yet keep me in good warm contact with my neighbours. There is nothing like the medical profession for that: one can have the exclusive scientific life that touches the distance and befriend the old fogies in the parish too...'
He was saved from hardening effects by the abundant kindness of his heart and his belief that human life might be made better.
There have been writings about the relation between
medicine and the listening aspects of music, but nothing
on the playing of music. Why do so many doctors pursue
music? Why does the orchestra of doctors in Boston (the
Longwood Symphony) receive audition inquiries on a
daily basis?
Mark Jude Tramo, a neurologist, songwriter/musician,
and director of The Institute for Music and Brain Science
at Harvard and Massachusetts General Hospital, feels that
“there is overlap between the emotional and social aspects
of relating to sick patients and communicating emotion to
others through music…Some would speculate that there is
[also] an overlap between aptitude for science, which most
premeds major in, and for music.”
Lisa Wong—violinist, paediatrician, and president of
the Longwood Symphony Orchestra—speaks for the
many who came to medicine after years dedicated to
serious musicanship. “The music we create builds in us
an emotional strength, sense of identity, and sense of
order. Then it is given away—we play for others, we play in
ensembles. We come to medicine and it is the same thing.
The giving, the service—in music and medicine—is a natural
connection.”
I was surprised to find my eyes watering after reading the article. Surprised
to find myself laughing sighs. It struck me as a deeply personal grasp of my
own motive for becoming a doctor, and I suppose an afirmation of it in some way
other than my own head was more than just reassuring.
The musician touches others through music--a statement banal enough.
What gets less noticed are transformations music brings upon the musician. Music
is a beautiful gift, and all the more beautiful because it has helped me realize
that medicine works the same way, and beyond. Music and medicine are about
sharing something beautiful, about creating something extraordinary together—musician and listener,
physician and patient. Musicians may craft an experience to bring their
listeners adventure, escape, relief; Doctors may craft an experience to bring
their patients life. Sometimes life
seems so ordinary that we forget that it is extraordinary. Yet, life—is
something more beautiful, far richer than any song could express. Medicine,
music, and most things I suppose, are about touching others.
“Music has Charms to soothe a savage Breast / To soften Rocks, or bend a knotted Oak.”
-William Congreve
I came across Regimens: Soothing Melodies for Cancer Patients from the New York Times this morning, stating that new research suggests that listening to music may reduce pain and anxiety in cancer patients. This research isn't new per say, the original paper is actually a systematic review paper that put together data from 30 trials.
Here is the plain language summary:
Having cancer may result in intense emotional, physical and social suffering. Music therapy and music medicine interventions have been used to alleviate symptoms and treatment side effects in cancer patients. In music medicine interventions, the patient simply listens to pre-recorded music that is offered by a medical professional. Music therapy requires the implementation of a music intervention by a trained music therapist, the presence of a therapeutic process, and the use of personally tailored music experiences.
This review included 30 trials with a total of 1891 participants. The findings suggest that music therapy and music medicine interventions may have a beneficial effect on anxiety, pain, mood, quality of life, heart rate, respiratory rate, and blood pressure in cancer patients. Most trials were at high risk of bias and, therefore, these results need to be interpreted with caution.
Although music has been used for pain relief since the ancient times, only recently has music come under empirical scrutiny for pain management in clinical settings, with a focus on postoperative, labor, and chronic pain, three common types of clinical pain.
Looking at various papers on music interventions, the mechanism underlying music’s pain reducing abilities have been largely attributed to the psychological factors of distraction and relaxation. Other physiological explanations seem to relatively neglected. However, in the end, the psychological mechanisms are inherently physiological themselves, perhaps mediated by a spinal mechanism. So in the end, the gate control theory of pain may serve as an uniting mechanism to explain the beneficial impact of music intervention on pain management.
Though it may not be clear how music heals, one thing is clear: it doesn't hurt to have music. Research isn't necessary for us to know that. As a doctor, I'll take advantages of music to connect with patients. Doctors spread happiness through health, and musicians do so with music. So, why not do both?
Chronicles of Boston Breakout: Day 3
After the music therapy session, we went to the Massachusetts General Hospital to visit Dr. Conrad, a surgeon and the Director of the Music in Medicine Research group . Here is a bit of background information about Dr. Conrad:
Claudius Conrad, Director of Music in Medicine of the Department of Surgery and the Benson Henry Institute for Mind Body Medicine, is well-known for his work understanding the role of music in modern medicine. He holds an MD, a doctoral degree in stem cell biology, and a doctoral degree in music philosophy from the University of Munich. He has been awarded several honors for his work, including the Excellence in Research Award, the Leadership Award of the American College of Surgeons, Steinway Artist, and many others. As a trained concert pianist and lecturer, he promotes the scientific use of music in medicine at prominent institutions around the globe.
Dr. Conrad gave us an informative lecture on his research on how listening to music (Mozart) helps performance (performing surgical procedures and motor control tasks). The results of his studies show that listening to Mozart decreases stress (by measuring stress indicators in the blood), and improves motor performance. In one study, subjects were asked to perform motor tasks, similar to surgical procedure tasks, in either a silent, dichotic music, mental loading, or Mozart condition. The results showed that subject's speed and accuracy in the tasks increased in the Mozart condition. Also, the blood samples taken from the participants showed that those in the Mozart condition had lower indicators of stress and that nurses (blind to the study) rated those subjects as more relaxed. See the paper, "The effect of defined auditory conditions versus mental loading on the laparoscopic motor skill performance of experts" published in Surgical Endoscopy, 2010.
What really astounds me is how Dr. Conrad is able to do such research, be a surgeon, and a touring concert pianist at the same time. He told us he attended medical school and a music conservatory at the same time!
For more on the music in medicine research Dr. Conrad does, check out this video: "Music in Medicine--Dr. Conrad"
