Halifax, Nova Scotia
|Robert Pope, Visitors (1989) “This painting is like a psychological
ecosystem, where the worlds of healthy and sick meet.” (Pope 1991)
I sat on the piano bench, head down, staring at the space between middle C and the key above it. I could see my teacher out of the corner of my eye, sitting forward in her chair, no longer relaxed nor casually listening to the first movement of a Haydn piano sonata. She had halted me halfway through the exposition, sparing any further insult to the Classical-era master. “I’d pay big money to be a fly on the wall in your practice room,” she said. I had arrived at a particularly fast and difficult passage, and with my tempo already rushing, everything predictably fell apart. I felt my tongue pressing hard against the roof of my mouth while my teacher fell into a familiar lecture: I had made no improvement on this piece despite weeks of lessons and there were now hard truths to be considered. I had thought that if I pressed hard enough and buried myself in the space between those keys, I might save myself the embarrassment of breaking down in front of my teacher. But in that moment, I felt confused and betrayed by my own ear that was supposed to have been listening to what was happening and pleading with me to react.
I was not very good at playing “in tempo,” that is, keeping time in a relatively stable manner. My first teacher had been more of a big kid as opposed to a disciplinarian; she chose to nurture my playful and emotional instincts at the instrument. However, on a spectrum where at one end sits complete freedom of self-expression and at the other complete and crippling self-awareness, I rested too comfortably in the former. I lacked the skills to control my pacing and sound, forcing it to adapt to different situations, such as performing a difficult Haydn sonata for a supportive yet demanding university professor. Too often I found my best intentions—formed by a love of music and a desire to connect with my audience—derailed by a breakdown of consistent self-monitoring. Thankfully, different teachers and mentors encouraged me to truly listen to what I was doing, forcing me to develop self-awareness and a capacity for control and communication at the piano. In studying medicine, I have found that these musical mentors also taught me how to speak to my patients with intention, and how to use what I hear to inform that intention.
I was introduced to the music of Joseph Haydn when I suggested to a former teacher that we work on a Beethoven sonata. “No,” he replied. “You need to play Haydn before you play Beethoven.” What followed was an exploration of the piano’s potential to communicate musical ideas by virtue of Haydn’s lyrical and often humorous writing. The virtue of my teacher, on the other hand, was demonstrated by a constant grounding in two principles: musical intention and active listening. The former was taught by “knowing” and “doing”: building a set of intentions and discovering how to confidently execute them at the piano. The latter was developed through experiential listening: a quick and sensitive feedback loop through which I could critique my performance and use it to adjust my musical intentions.
At the hospital, this musical training has translated into a comfortable and flexible approach to working with patients. One of my first medical consults in the emergency department was for an elderly man with congestive heart failure. A triage note came with the label “poor historian,” which conjures a variety of feelings and biases. I was surprised when I met the patient and found him to be entirely lucid and conversational. He was soft spoken due to a previous mumps infection that had paralyzed one of his vocal cords; but he was a kind man and eager to share his complex medical history. His daughter was at the bedside and was reticent to let her father expend valuable energy recounting his tale for an endless stream of inquisitors. She mirrored her father’s kindness and generosity in her attentiveness to my questions, filling in the silence when her father paused to rest. I felt pressed to gather the information I needed quickly and efficiently, as he was making it clear that he desired comfort at what he believed was now the end of his life. Each word I spoke needed to be justified, full of intention and purposeful execution.
This idea was demonstrated again by another music teacher who instructed her students to “order” their sound. She used an analogy of stepping up to a take-out counter and carefully and deliberately selecting exactly what you wanted on your burger. “Every sound you make at the piano should be preceded by an ‘order’ you submit.” She firmly believed that any sound not preceded by an “order” was without intention and at risk of derailing an entire performance. Put another way, the revered twentieth century American pianist Van Cliburn once remarked in an interview that this value had been impressed on him by his mother who said, “Don’t play any faster than you can think it before you play it.” (Dubal 1997) For my patients, every word I utter is part of a strategy that includes an intention for that specific phrase and a mind to deal with the consequences.
Healthcare professionals may consider themselves quite good at building strategy and intentions, but in the bedside performance of clinical medicine, it is our ears that control the pace and color of our sound; they are constantly monitoring not only what sound we produce, but the room we cast sound into. During one masterclass, the instructor shouted to me on stage, halting my performance (a Haydn sonata, again, of course). My tempo was rushing and that essential integrity of pacing and color had rushed right out the door with it, unbeknownst to me sitting at the center of it all. “Throw your ear to the furthest back seat of the concert hall. That’s who you’re performing for.” In response to her demand I stared down at the keys, swallowed my pride, and imagined my right ear severing itself from my body, floating silently over the heads of my colleagues seated in the auditorium. My ear would come to rest at the back of the hall, peering at me on stage. This image continued to provide me with invaluable insight into the execution of my intended sounds and inform any necessary remediation.
So for my patient in the emergency department, I threw my ear across the room and channeled a strong intention to hear and be heard by my audience: a critically unwell man who, while fully lucid, was limited in his hearing though not in his comprehension of the situation (himself a retired general surgeon). By adapting my musical technique and leaning in at the bedside, carefully choosing the appropriate time to interject with a well-paced question or guiding comment while my ears observed the intended and unintended consequences, I felt I could scrub away his previous label of “poor historian” and absorb this man’s story, asking his family for clarification only when necessary.
It was difficult then, when the resident doctor channeled very different intentions. He stood by the bedside, and after a few failed attempts to direct questions at the patient below him, shifted his focus to the patient’s daughter, who took on the emotional labor of translating a conversation about end-of-life care to her father, while her own daughter wept in the background for her grandfather. I could feel my tongue press against the roof of my mouth as I watched our patient’s head turn from the resident to his daughter’s reddened face. Where in the room, if anywhere, did this resident’s ear come to rest? What might it have told him about the words that were coming from his mouth?
I am still not very good at playing in tempo. I find myself contradicting my best intentions in spite of myself. The difference is that I am now more aware of when a performance is slipping—when my tempos are rushing and my patient becomes confused. More importantly, I am aware of the power I have over my own communication and my unique abilities as an artist to have a positive impact on my patients.
- Dubal, David. 1997. Reflections from the Keyboard. New York: Schirmer Trade Books.
WILLEM BLOIS is a medical student at Dalhousie University in Halifax, Nova Scotia. His approach to medicine is influenced by a broad base of experiences ranging from dairy farming and an upbringing in rural Nova Scotia, to training in the performing arts and classical piano.