Space between two notes:Dissonance in healthcare encounters

Suzana Makowski, MD MMM FACPAssistant Professor of Medicine

Palliative CareUMass Medical School, UMass Memorial Healthcare

My life is not this steeply sloping hour In which you see me hurrying. Much stands behind me; I stand before it like a tree; (and you look like a tree there, for a moment) I stand before it like a tree;I am only one of my many mouths,and at that, the one that would be still the soonest.(By this time the person you ran into is backingoff down the corridor. Then you follow them, and you say,)I am the rest between two notes, which are somehow always in discordbecause Death's note wants to climb over—but in the dark interval, reconciled,they stay there, trembling,

And the song goes on, beautiful.

(from Selected Poems of Rainer Maria Rilke (Translated by Robert Bly)

DissonanceLet me explain dissonance. Dissonance can be described as

notes whose frequencies are less than "harmonious” to our ears.

For instance, playing notes that are one half-step apart (open first-string E played with the fourth fret of the second string, a D#) is considered dissonant by most people. Playing notes that are a major seventh interval apart, 11 frets, is also considered to be quite dissonant; for instance, play the open second string (B) together with the 6th fret of the first string (A#).

However, dissonance is a requisite part of most music that we hear, providing it with "tension" that leads to "release. "Without it, we end up with music that tends to command little attention.

- Mark Hanson

Dissonance

How are we taught?

• Official teachings• Unofficial teachings

• Patient encounters• Colleagues• Interdisciplinary interactions

The physician-patient encounter

Bad News in the ERThe serious young doctor started the story at the beginning.“Your son was at a concert when he collapsed.”Can I see him? “An ambulance was called. EMTs started CPR.”Where is he? “They tried to revive him, but got no response.”Please... “They brought him here. We worked a long time.”Oh God. “We didn’t want to give up. He was so young.”I searched the doctor for sorrow found a stoic earnestness. He

ended with an apology.“I’m so sorry,” he said, as if he’d hurt my feelings, as if I could forgive

him.Alchemy of Grief – Emily FerraraFirst published in Family Medicine

I have spoken… I have heard

Difficult encounters• The meaning of distress is as important as the

symptoms themselves. – Eric Cassell• Curiosity: – with where this is coming from,– how despair will manifest, and – how/whether resolve will follow.

“There is only one way to understand the other person’s story, and that is by being curious. Instead of asking yourself, ‘How can they think that?!’ ask yourself, “I wonder what information they have that I don’t?’… Certainty locks us out of their story, curiosity leads us in.” (page 37 – Difficult Conversations)

Lessons from Mahler and Brahms

Dissonance - Resolution• Reflection on listening to Dr. O’Reilly speak of

Mahler and when you listened to Brahm’s:– Act of listening– What happened in the piece?– What did you experience?

“Something about Music directly links us to the Eternal, the Divine, the Spiritual. […] It’s the sense of awe that is awakened in us at moments in life when something helps us get in touch with the fact that the material world is just the smallest part of the wonder of it all. So I think healing has to do with slowing down, coming into the present, listening, accepting, forgiving, entering into community with, and healing is prevented by the opposites of those things.” - Balfour Mount, MD

“Good listening requires an open and honest curiosity about the other person, and a willingness and ability to keep the spotlight on them. Buried emotions draw the spotlight back to us...Our listening ability often increases remarkably once we have expressed our own strong feelings.” (page 90 - Difficult Conversations)

Outside the patient’s room…

Other physicians,Nurses, social workers,Administrators…

How do these principles apply?

Ladder of Inference – Peter SengeFifth Discipline Fieldbook, 1994

“We all have different stories about the world because we each take in different information and then interpret this information in our own unique ways. In difficult conversations, too often we trade only conclusions back and forth, without stepping down to where most of the real action is: the information and interpretations that lead each of us to see the world as we do.” (page 31 Difficult Conversations)

Dissonance and Empathy

• What is our role?– To be honest– To lend strength and alleviate suffering

• How do we not burn out?– Exquisite empathy– Self-awareness practice– Solitude

Kearney MK, Weininger RB, Vachon ML, Harrison RL, Mount BM. Self-care of physicians caring for patients at the end of life: "Being connected... a key to my survival". JAMA 2009 Mar 18;301(11):1155-64, E1.

The Prerequisite to Practice:It’s more than “self-care”

• Mindfulness practices/compassion practice: meditation, music…

• Story-telling• Narratives• Medical Humanities• Solitude, reflection

Study (Lutz, Davidson) showed that long-term meditators on compassion’s response to vicarious suffering surprising.

On Breaking Bad Newsafter William Carlos Williams

Nourish the subtle body between “I” doctor, and “Thou” patient.

Tend not to the news—for lackof what is found there (men die

every day)—but to what is found between. The unarticulated

fear, sadness palpable in the deepening dark, broken by touch, eyes brimming

hollyhocks, double-blossomed whiteand multiple magentas take breath

give life, subtle body, what is foundis nourished, is all we have. Lean in.

By Emily Ferrara – used by permission. Not in print.

Some Resources• http://www.upaya.org/bwd/• http://litmed.med.nyu.edu/Main?action=new• http://www.umassmed.edu/Content.aspx?id=41252• http://pallimed.org • Cassell EJ. AAHPM annual meeting 2009.

http://www.aahpm.org/education/09conf/09highlights.html#nature • Ferrara E. The alchemy of grief : alchimia del dolore, traduzione di sabine pascarelli. 1st ed. New York, NY:

Bordighera Press; 2007.• Goleman D. Emotional intelligence. Bantam 10th anniversary hardcover ed. New York: Bantam Books; 2006. • Kearney MK, Weininger RB, Vachon ML, Harrison RL, Mount BM. Self-care of physicians caring for patients

at the end of life: "Being connected... a key to my survival". JAMA2009 Mar 18;301(11):1155-64, E1. • Lutz A, et al. Regulation of the Neural Circuitry of Emotion by Compassion Meditation: Effects of Meditative

Expertise. PLoS ONE; 2008. http://psyphz.psych.wisc.edu/web/pubs/2008/LutzRegulationPLoSONE.pdf• Martensen RL. A life worth living : a doctor's reflections on illness in a high-tech era. 1st ed. New York:

Farrar, Straus and Giroux; 2008.• Nepo M. The exquisite risk : daring to live an authentic life. 1st ed. New York: Harmony Books; 2005.• Stone D, Patton B, Heen S. Difficult conversations : how to discuss what matters most. New York, N.Y.: Viking;

1999.• Drazen RY. A Wayfarer's Journey: Listening to Mahler (movie)