I attended a meeting of the Hartford Medical Society last week to hear a presentation by Dr. Lisa Wong, a pediatrician who plays violin with the Longwood Symphony in Boston – the doctor’s orchestra. She’s written a book, Scales to Scalpels, about the orchestra and the role of music in medicine.
As I was chatting with the Society’s librarian, I was introduced to her father, Dr. Frank Davidoff, an internist and former editor of “The Annals of Internal Medicine.” Last year he published an article titled, “Music Lessons: What Musicians Can Teach Doctors and Other Health Care Professionals).” Dr. Davidoff is well-suited to write such an article; he is a serious piano student, and takes lessons from Anne Kan, who frequently subs with the Hartford Symphony.
Dr. Davidoff chose to write his article in sonata form.
In the Exposition, he wonders how professional musicians’ training could benefit health professionals to learn to be better clinicians and achieve high levels of performance.
In the Development, he explores 10 ways in which musicians can teach physicians:
1. Performance. He compares learning music theory and history to learning the science of medicine, but insists that clinical practice is a performance, though the focus is on learning. “Recognition of music’s laserlike focus on performance could help us regain a more appropriate balance in medicine between knowledge and performance (between knowing and knowing how).
2. Coaching. Great teachers in the world of musicians are coaches, not lecturers. “Coaches watch, listen, and provide the feedback that closes the experiential learning cycle.” Yet so much of the physician’s training is through lectures, reading, and discussion, Dr. Davidoff believes that coaching should be the model for teaching clinical practice. “Unfortunately, mastery of coaching in medicine is still not seriously taught, rewarded, or studied. It must be.”
3. Stardom. Outstanding superstars are rarely great teachers, and great teachers are rarely international stars. Most musicians are “rank-and-file performers.” Similarly, most physicians are not international experts, but rank-and-file health care providers. It’s important to identify what makes a great teacher who can enable students to move back and forth between being an actor and an observer.
4. Talent. Not every successful musician has perfect pitch, and not every successful doctor has the medical equivalent of perfect pitch. Having a few basic abilities, and lots of practice, will lead to success.
5. Time. Becoming an accomplished classical musician requires a lot of time. “The real essentials are the extended, focused involvement with every aspect of the discipline and the hours of practice.” Medical school and residency takes 7 years and 10,000 hours of practice. Surgeons may need substantially more time. Because of the exorbitant expense of medical school, “some medical educators are exploring accelerated systems for “training to competence.’” Dr. Davidoff warns against rushing to approve these new systems, lest they produce prodigies who lack wisdom and maturity. “Growing up takes time.”
6. Art. A brilliant technical performance can be mechanical, just as an artistically wonderful performance can be sloppy. Musicians must combine technical mastery and artistic expression to achieve a truly artful performance. Dr. Davidoff quotes Vladimir Horowitz, who is reputed to have said to a woman who told him she loved watching his hands as he played, ‘Thank you, madam, but what makes you think I play with my hands?’”
Musical technique is teachable, but we do not understand the sources of musicality. “Exploring the nontechnical aspects of performance should be a serious research endeavor in both disciplines.”
7. Practice. As we all know, musicians must practice often, long, and constantly. Dr. Davidoff stresses the importance of the quality of practicing – the mindfulness one uses while practicing, the importance of listening, slowing it down, and breaking it into parts. “At its best, practicing includes learning how to practice; it involves both reinforcing what is already known and pushing the envelope into what has not yet been mastered.”
Current clinical training does not replicate the manner in which musicians practice, though the use of technology and role-playing is helping. And it’s unrealistic to think medical students can take hours away from real-time clinical care to practice. One solution might be “to find ways to make daily clinical work serve simultaneously as practice in both senses of the word: delivering care and refining the skills of delivering it.”
8. Teamwork. Musicians almost always perform with others, in groups of varying sizes. In group performances, musicians learn to listen to others, share control, and send and receive signals. “Group performance becomes, in effect, a part of their musical DNA.” Doctors, on the other hand, are still socialized to act autonomously. Peers can learn to function informally as a team, but the harder part is reconciling teamwork with the diversity in age, experience, power, and status of most working clinical groups.” Dr. Davidoff urges that the medical profession find ways to adapt training to realize these realities so it can begin to end “the unnecessary and disruptive cacophony.”
9. Repertoire. Dr. Davidoff describes the various kinds of repertoire for different musical styles, and states that even when playing a “chestnut,” musicians must make it fresh. The best analogy to clinical practice is perhaps the jazz musician, who can improvise and create a space with other performers. The clinician similarly needs to respond to individual patients in specific contexts.
10. Specialization. Instrumentalists generally play only one instrument, or a family of instruments (oboe/English horn). Composers may play several instruments but they are really focused on music’s “unknown possibilities” rather than “interpreting what has already been discovered.” Dr. Davidoff suggests that perhaps conductors are the only true generalists in music.
Similarly in medicine, there is a drive to specialize, perhaps “an inherent quality of all highly demanding performance arts, a hypothesis supported by the seemingly endless emergence of medical subspecialties and sub-subspecialties as new technologies and biological developments emerge.” He suggests that the medical system needs a great deal more conductors to help adjust the mix of specialized practitioners.
And finally, he has a few thoughts about musical structure:
“Examining musical structure also reveals some intriguing parallels with the structure of clinical practice. Take tempo, for example: Rushing a musical performance ruins its effect, much as pushing patients through the system too fast can distort their care. Take rhythm: Getting things in synch, achieving flow, is enormously valuable, particularly in such high-stakes, time-constrained clinical situations as surgical procedures. And take counterpoint: A clinician’s structured line of diagnostic thinking moves forward both in synch with and in response to a patient’s free-flowing words. How can we learn to hear both simultaneously?”
In the Recapitulation, Dr. Davidoff wonders what medical training and practice would look like if it became a world shaped by the type of training that produces professional musicians. Sophisticated coaching would be the rule; all elements of the experiential learning cycle would be at work; teamwork would be a major element; assistance would be available to convert clinical episodes into learning experiences; and finally, “the health care research agenda would include uninterrupted, deep exploration of such issues as the nature and acquisition of coaching skills, drivers of specialty choice, factors that affect the development of clinical judgment and empathic care, and the essentials of improvisation.”
Dr. Davidoff ends with a Coda:
“The case being made here is not that we would all be more effective clinicians if we were also musicians (although it would be fascinating to ask the many doctors and other health professionals who are also accomplished musical performers to reflect on how music has made a difference in their medical careers). At the very least, however, those of us in health care might want to keep firmly in mind what all musicians and other performing artists take for granted: You’re only as good as your last performance.”