Megan Griffin explores how the listening skills gained as a professional musician have benefited her practice as a medical doctor.
I used to be a musician, but I stopped performing during medical school. Even so, I somehow talk mostly about music when I meet people. It is not surprising, since it was my life for 20 years whereas medicine has been for a mere four. However, I often struggle to find words to express my experience with music; perhaps this is why I was drawn to it in the first place, since I did not need to use words if the music could speak for itself. Yet now I find myself trying to speak and write about music and how much it has influenced not only my life, but also my experience in medicine. This became ever more apparent as I started learning how to interview patients, which encompasses many different aspects of medicine including knowledge, critical thinking, deductive reasoning, conversation skills and listening. Overwhelmed by the process, I was struck by how much the patient interview felt like playing chamber music. While I looked forward to gaining the skills outlined for me in our Practice of Medicine syllabus, I considered that my focus on listening was stemming from my musical background.
I have experienced moments of intense and deep listening that are indescribable in words, but I keep putting forth meagre attempts. There was the time I performed a Beethoven string quartet with an incredible group of musicians, and the way we connected felt like we might be sharing a brain (or a soul?). Even now listening to the recording, I am brought back to that powerful moment and overcome with the feeling of being “in it”. It is what I wish I could replicate for everyone, the feeling that inspired my deep dive into how we listen and how we can do better. If only I could give everyone this gift, of sitting in a group feeling everyone’s mind solely focused on listening, yet still achieving the difficult task of playing an instrument. I believe that with this experience our conversations and, more to my specific interest, our treatment of the patient interview could be improved. I wondered if there was a way to use my experience in music to help other medical students, to help them think deeply about listening. Chamber music and patient interviewing depend on having background knowledge and specific techniques, but also rely on listening skills. It has been noted for both subjects that there is difficulty in teaching these skills, so they utilize real-world experience to overcome this difficulty. I have the benefit of being trained in both worlds, which showed me the challenges of the topic. Communication and listening skills are not often taught in a class; instead, they are learned through practice.
In “The Medical Interview”, Mack Lipkin describes an essential part of the medical interview being the task of communicating interest, respect, support and empathy. While techniques can be listed, applying them as appropriate responses to a patient require practice and careful thought. Physicians cannot know how patients will express themselves, and without truly listening the patient-doctor relationship can be only marginally successful. Ways of observing listening have been explored, such as the Active Listening Observation Scale, which evaluated practitioners’ interactions and resulted in an itemized list including things like “shows not to be distracted” and “listens attentively”. However, the art of listening is inherently difficult to teach: tools like the Observation Scale are focused on checking boxes, missing a deeper understanding. Although many artforms could be used to increase listening awareness, my personal experience during patient interviews was influenced greatly by chamber music, and I wondered 1) if my musician colleagues think about listening the same way and 2) how other physicians think about and develop their listening skills. I interviewed five physicians and five musicians with the same questions, to see if the connections I had experienced occurred in both fields and to explore how we might use chamber music to better our listening skills.
Without having yet formally analysed the results, what I have learned is fascinating. However, it comes with caveats about the messy nature of this “qualitative research”. First, the physicians I interviewed were chosen because they have been my examples of how to talk with patients, and I greatly respect their practice. This led to an obvious bias I naively did not realize beforehand: these physicians have spent significant time thinking about how they listen. Second, musicians often have the luxury of time. Rehearsals are diagnostic, as the players solve problems of expression, but this comes back to listening. As one musician simply put, “listening is life”. In medicine, with increasing demands to see more patients and complete documentation, the diagnostic intent of a patient encounter is usually just that—a diagnosis, based largely on medical knowledge and critical thinking skills.
When participants were asked if they ever had training on how to listen, answers varied. However, everyone reported informal ways they had learned or practiced listening. One physician mentioned having conversations during long car rides, when there was little opportunity for distractions, helped hone her listening skills and improve her practice in chaotic listening situations. Musicians noted the importance of listening to self-recordings. In recordings they were able to pick out moments where they were not listening while playing, as meta as that sounds. One physician recommended listening to recorded patient interviews (acknowledging HIPAA), saying that each conversationalist node that could have gone a different direction can teach us about our listening. No one mentioned a class where they were taught how to listen, emphasizing the difficult nature of the subject.
Another question posed was about identifying things that get in the way of listening, where the computer was often mentioned by physicians. Frequently mentioned in both groups was mood and alertness, which can also be thought of as wellness. How can you expect to listen intently in a rehearsal when you are in physical pain, or truly listen when it is your 24th hour of a shift? Music professionals are sometimes asked to extend rehearsals or perform for minimal pay for self-promotion or to contribute to a cause. This stems from the idea that musicians are doing what they love for a living, so they should be appreciative and honoured to do it. Wellness in medicine is also a longstanding discussion given duty hours and burnout but was recently newsworthy. During the COVID crisis, many medical residents requested hazard pay, which one institution denied saying that the request was “not becoming of a compassionate and caring physician”. In both careers people often feel a sense of destiny and duty, yet this should not mean sacrificing needs and wellness. This digresses from the topic of listening to a separate soapbox, so I leave this thought: if we don’t have wellness, we don’t have mental capacity to listen, which impacts the outcome of our work whether that is a Carnegie Hall performance or patient care.
Back to listening: there is a moment where one realizes they are not actually listening. They are thinking about what was said five minutes ago, about the upcoming difficult part of music or about the next question they should ask. Both groups had tangible tips, such as writing a note to remove the worry that you might forget your thought (I once had a conductor said “amateurs remember, professionals write it down”). What came up most frequently was the practice of meditation. One physician described it as a hypnotic state, setting up for each patient encounter such that listening had the intense focus of hypnosis. Others compared it to moments of meditation when you realize how many thoughts you have, and you lose your centre. Even more difficult in both music and medicine is the knowledge and skill level which needs to be attained before it feels like we can begin to focus on listening. The physical difficulty of a musical phrase can overpower the best listeners, similar to the gear-turning sense of determining a difficult diagnosis while your patient continues telling their story. One “solution” to the problem is practice; the more we practice the physical difficulties of our instrument or learn to recognize diagnostic clues quickly, the easier it is to focus on listening. But we never fully master medical knowledge or musical technique and discussing with people who I consider experts in both fields, I realized that one of the ways they improved their overall practice was by developing their listening skills.
There is more to this connection, but I also think this is the starting point: we need to emphasize the importance of developing our listening skills early in medical training, exploring different ways of learning so students find what works for them. It would be interesting to design a scenario where medical students could focus only on listening, without worrying about the checklist of questions or three differential diagnoses. It is imperative that every physician take the time to think about listening—the experiences in their life that have taught them how, the ways they can continue to improve, and the importance it has in developing all the skills needed to be an excellent, caring and intelligent physician.
*****
Megan Griffin in an internal medicine resident at the University of Washington in Seattle. She recently graduated from NYU School of Medicine after previously attending The Juilliard School for viola performance, where she received her bachelor and master of music degrees.
References:
Fassaert T, van Dulmen S, Schellevis F, Bensing J. Active listening in medical consultations: Development of the Active Listening Observation Scale (ALOS-global). Patient Educ Couns. 2007. doi:10.1016/j.pec.2007.06.011
Hlavinka, E., 2020. NYU Leadership Gaslights Residents Over Hazard Pay. Medpagetoday.com. 2020. Available at: <https://www.medpagetoday.com/infectiousdisease/covid19/86126>
Lipkin M, Putnam SM, Lazare A. The Medical Interview : Clinical Care, Education, and Research. Springer-Verlag; 1995.
