Monday, June 23, 2014

"Mozart's Effect on Us" : A twenty year meta-analysis of the Mozart effect

The “Mozart effect”: A review and twenty-year meta-analysis of research in an aspect of music and cognition ©   
by Vincent P. de Luise MD FACS

Assistant Professor of Ophthalmology, Yale University School of Medicine
Fellow, Advanced Leadership Initiative, Harvard University
Music and Medicine Initiative, Weill Cornell Medical College

(I wrote this as a term paper for the course, The Psychology Of Music, taught at Harvard University in the spring of 2013 by Professor Peter Cariani).

  
W. Mozart, by Joseph Lange
The 1789 enlargement of the 1782 original
Salzburg Mozarteum
I. Introduction
For over half a century, cognitive neuroscientists have explored whether there is a direct connection and causal relationship between listening to music and enhancement of cognitive ability. Reducing this reasoned inquiry to its more simplistic, “sound bite” form, does music make one “smarter?”  Can listening to music, especially certain genres of music, or perhaps the music of certain composers, lead to greater mental capacities of memory and intellect? Is music hard-wired in the human brain and in turn, does music hard-wire the brain?  Or, is this “music-mind stuff” just hype, nothing more than anecdotal and uncontrolled pseudoscience, a pernicious and persistent neuromyth, a  marketing ploy rather than hard science. This paper reviews the context surrounding one aspect of the question: does listening specifically to the music of Wolfgang Mozart improve cognitive ability over listening to other types of music or silence, evaluates the published research, and draws conclusions on the validity and utility of the findings. 

II .  Overture 
Early researchers thought that there might actually exist a “music box” in the brain somewhat analogous to the so-called  “language box” of Noam Chomsky, that music and language might be subserved by similar neural networks, and that entraining these networks could lead to improved cognition. Further inquiries into the field of the psychology and neurology of music arose out of findings in structural neurology.  
Mountcastle, in 1957, was the first to posit that the cerebral cortex has a columnar organization, with the trion as the basic structural unit.(1) A trion is an idealized mini- column of neurons with three levels of firing activity. (1)  Between 1988 and 1990, Leng et al examined histological sections of temporal lobe auditory cortex with Cajal staining technique, and discovered that the neuroanatomy of the auditory system has a columnar architecture similar to the trionic neural architecture hypothesized by Mountcastle, and akin to that of the visual system as first described by Hubel and Wiesel. (2)   Leng hypothesized that this vertical stacking of auditory neurons predisposes them to fire in certain patterns and rhythms, that these patterns of firing were quasi-stable, and that this was a logical and mathematical outcome of the columnar cortical architecture, representing a form of “basic exchange of mental activity.” (2)  They then used computer modeling and computational symmetries to create a one-to-one correspondence between these neuronal firing patterns and discrete musical pitches, and found that the output, rather than being random noise or unorganized sound, which is what one might intuitively expect, actually sounded more like actual music, organized sound with the  "flavor,” to use their term,  of new age music, “Eastern” music, or music of the early Baroque (2). 
Leng hypothesized that if brain activity can sound like music, could it also be possible to begin to understand the neural activity by working in reverse and observing how the brain responds to music? (2, 3) Might patterns in music somehow stimulate the brain by activating similar firing patterns of nerve clusters? (2, 3).
Around that time, a different line of research was ongoing in Paris which would eventually align with Leng's research.

Alfred Tomatis M.D. was a French-born otolaryngologist who in the late 1980s founded the specialty of “audiopsychophonology.” His thesis was that “the voice cannot produce what the ear cannot hear.” (4) Using Gregorian plainchant and several of Mozart’s five violin concerti, Tomatis used his technique to treat patients who could not properly vocalize, declaim on theatrical stages or sing in concert halls.  Thomatis’ concept of “auditory processing integration” retrained the voices of, inter alii, Maria Callas, Gordon Sumner (Sting), Gerard Depardieu and Benjamin Luxon, resuscitating and re-energizing their professional careers. Tomatis reported on his findings in 1991, stating that there was “a Mozart effect” to explain the improvement in these patients.(4) This was the first time the term “Mozart effect” had been used. Tomatis did not proceed to copyright the term.
 
III.  Prelude 
Frances Rauscher, Gordon Shaw and Ky, in the department of psychology at the University of California, Irvine, published a one-page paper in the October 14, 1993 issue of the prestigious journal Nature, entitled, "Music and Spatial Task Performance." (5) 

They found that short-term listening to the complete first movement and the first three minutes of the second movement (10 total minutes) of the Mozart two- piano sonata in D (K.V. 448/375a) led to a short-term improvement (8-9 points, for about 15 minutes) in spatial-temporal tasks on a Stanford-Binet Test (paper folding/ cutting), over the same group tested after sitting in silence and then after listening to “relaxation music.” (5)  The Rauscher team did not give this finding a name or a monicker, nor did they extrapolate their findings to state that Mozart’s music improved any other aspect of cognition.  

IV. Sonata 
What is so special about the two-piano sonata in D (K.V. 448) of Wolfgang Mozart that it was chosen for the Rauscher study? In September 2012, in preparation for some remarks on the “Mozart effect” that I presented at an October 2012 music and medicine symposium at Weill Cornell Medical College in New York City, I was able to interview  Professor Frances Rauscher about this topic. Professor Rauscher, who is now at the University of Wisconsin-Madison as an emeritus professor of psychology, told me that when she and her team were organizing the Nature study at UCI in 1993, she had asked  a musicologist at her institution for a piece of music that was relatively upbeat, had some repetition and was melodically relatively straightforward, and that this was the  piece chosen. “We used the first movement of the Mozart 2-piano sonata because it has very few musical motives that interweave in various forms throughout the movement; that it was a 2-piano sonata helped reinforce the symmetry in the music.” 

I went on to ask her why they used not only the first movement, marked allegro con spirito, but also the andante second movement. Her response was, “we included a portion of the second movement as a sort of cool down period.” (Frances Rauscher, personal communications, 9/12/2012)  
I thought this was fascinating, in that the Mozart selection the researchers chose was purposely not of one tempo, because they wanted music that was both fast and slow. 

The first movement of the 2-piano sonata is in D, is largely comprised of tonic and dominant chords, and  has six distinct repetitive motifs. The two pianos not only echo each other, but often play the same melody in octaves. I asked Professor Rauscher about this seeming overkill, and she said they purposely wanted some musical redundancy to emphasize certain melodic themes as that would potentially engrain better.  
                                           *  *  *
In 1996, Don Campbell, a professional musician, successfully petitioned the United states Copyright and Trademark Office to obtain a copyright for the term “The Mozart Effect” (note the capitalization of both “Mozart” and “Effect”)  and subsequently published a 1997 book entitled, The Mozart Effect: Tapping the Power of Music to Heal the Body, Strengthen the Spirit and Unlock the Creative Spirit. (6) 

Campbell followed that up with another book, The Mozart Effect for Children, along with dozens of related cassettes, CDs and related workbooks. In his 1996 book, Campbell defined “The Mozart Effect” as "an inclusive term signifying the transformational powers of music in health, education, and well-being. It represents the general use of music to reduce stress, depression, or anxiety; induce relaxation or sleep; activate the body; and improve memory or awareness.”  (6)  
Campbell went on to claim that “innovative and experimental uses of music and sound can improve listening disorders, dyslexia, attention deficit disorder, autism and other mental and physical disorders and other diseases.” (6) 
The response to the Campbell books was overwhelmingly positive. If Youtube had existed then, it could have been said that the books and the term “The Mozart Effect”  had gone  "viral".  The "Mozart Effect" was so popular as a concept that it became a political call- to-arms for the arts, reaching, among other places, the Georgia state legislature, when in 1998 then governor Zell Miller apportioned funds to buy every child born in Georgia either a tape cassette or CD of classical music. (7)   
At the same time that Campbell was reaping profits and notoriety from the cottage industry he spawned popularizing the notion of some kind of “Mozart Effect,” the  Rauscher study was being subjected to an enormous amount of scrutiny, most of it negative.         


V. Theme and Variations 
On 3/1/13, I performed a Medline search of all titles containing the terms “Mozart effect,” or “Mozart + spatial,” or “Mozart + cognition.”  A total of 107 distinct articles were retrieved and analyzed as to:  peer-review, accepted methodology, controlled trial, and rigor of data analysis. Most of the articles were reviews of other works, hypotheses, single case studies, anecdotal opinion, or did not meet all of the four critera; of the 107 articles, only six qualified for the meta-analysis 
A 1994 study by Stough et al from Auckland, New Zealand, failed to find any relationship between the Mozart sonata and spatial reasoning. The researchers employed Raven’s Advanced Progressive Matrices, an accepted tool for analyzing spatial reasoning, whereas the Rauscher group used Stanford-Binet testing. This study, while meeting the four inclusion criteria, could not be definitely analyzed given the different testing methodologies. (8) 
In 1995, a group from SUNY Albany replicated the Rauscher study and increased the study group to 114 subjects, with a slight older mean age than the college students in the Rauscher study (SUNY mean age 27.3 vs Rauscher mean age 20.8). The SUNY group found no increase in spatial-temporal reasoning, and no correlation to higher scores and any type of classical music preference. (9) 
A study by Steele et al, the so-called Appalachian Study, also found no correlation between the music of Mozart and increased spatial-task performance. Steele’s conclusions were that “any cognitive improvement was transient” and more likely represented a “practicing’ effect and a familiarity with the paper-cutting test on multiple trials to different pre-treatment stimuli (10). 
However, two separate studies by Rideout et al, one employing EEG data and both reproducing the methodology of the 1993 Rauscher study, confirmed the findings of a temporary increase in spatial-task performance scores in the groups “pre-treated” with Mozart’s music. (13, 14) 
Rauscher and Shaw responded to the spate of studies, some of which confirmed, but most of which refuted their 1993 findings, by repeating a “Mozart effect “ study on laboratory rats, confirming that rats pre-treated with Mozart, learned to navigate a T- maze significantly better than rats exposed to minimalist music or silence, and that this increase was retained for several months. Rauscher went on to state that the inconsistent results of the “Mozart effect” in those other studies was a result of those studies ,utilizing diverse subjects and different methodological designs, such as musically disparate compositions, listening conditions, and measures. Rauscher also went on to reiterate that her 1993 study specifically identified its limitations: that the effect was small and transient. (12) 

VI. Coda
By 1999, six years after the Rauscher study, the scientific community had pronounced the Mozart effect anecdotal and non-reproducible. Two articles in Nature, both entitled “Prelude or Requiem for the Mozart effect?,” one by Kevin Steele and coworkers, and the other by Christopher Chabris, came to the same conclusion: that the results of the “Mozart effect” were transient, and that there was no difference in spatial-temporal skills after being pretreated, in their studies, with Mozart’s two-piano sonata, the minimalist music of Philip Glass or silence. (15, 16) Chabris maintained that “this (Mozart) effect, if indeed there is one, is much more readily explained by established principles of neuropsychology, in this case, an effect on mood or arousal, than by some new model about columnar organization of neurons and neuron firing patterns" (16)
This could have been the coda and the end of the interesting saga of the “Mozart effect.” However, in the last decade, more quantitative and rigorous lines of inquiry have been followed, examining specific circumstances in using Mozart’s music, and music similar to the music of Mozart: epilepsy in some studies, and cardiovascular health in others. These new avenues of research have reopened the related inquiry of whether there is a biological underpinning to the Mozart effect.
Epileptic patients who listened to the music of Mozart, and the music of two other composers whose style resembles that of Mozart (Johann Christian Bach and Johann Sebastian Bach), had a statistically significant reduction in the frequency of epileptiform activity, in comparison to the same patients when they listened to the music of 58 other composers, including the works of Beethoven, Chopin, Brahms and Stravinsky. Ref    The authors, John Hughes and John Fino of the University of Illinois, examined 81 musical selections of Mozart, 67 selections of J.C. Bach, 67 of J.S. Bach, 39 of Chopin, as well as 148 from 55 other composers. The compositions were computer analyzed to search for any distinctive aspect and to determine if there was a dominant periodicity.  Long-term periodicity (mean = 10-60 sec, median = 30 sec) was found most often in the music of Mozart and the two Bachs, which was significantly more often than the works of the other composers. Long-term periodicity was found to be absent in the control music that had no effect on epileptic activity in previous studies. Short-term periodicities were not significantly different between the music of Mozart and the two Bachs versus the music of the other composers. However, at least one distinctive aspect of the music of Mozart and the two Bachs, specifically, their long-term melodic periodicity, may resonate within the cerebral cortex and also may relate to brain coding.”  (17)  Thus, the “Mozart effect” could also be termed the “J.S. Bach effect” or the “J.C. Bach effect."
More recent evidence for the efficacy of Mozart’s music on epileptiform frequency has confirmed the Hughes and Fino data. In a 2011 series of experiments by Lin et al from the Graduate Institute of Medicine in Taiwan, the researchers looked at long-term listening of Mozart’s two-piano sonata KV 448 and epileptiform activity in children, and found that there was a significant reduction in activity in the group “treated” with Mozart’s music. (18)
Trappe looked at the effect of the music of Mozart, Beethoven,Verdi and heavy metal played by several groups, on heart rate and heart rate variability, and found that the music of these composers, but not heavy metal music, lowered heart rate and reduced the variability of heart rhythm. (19)

VII. Summary and Conclusion
What conclusions can be drawn from analyzing the data of these disparate findings? 
1. If there is anything that could be called a “Mozart effect,” it is transient and it is specific to spatial-temporal reasoning. 2. The Mozart effect cannot be extrapolated to other cognitive abilities nor cognitive enhancement over longer periods of time. 

3. There is not just a “Mozart effect.” There is also a “J.C. Bach effect”, a “J.S. Bach effect”, and likely, an “effect” by other composers in classical and popular genres, whose melodic themes happen to “align” with the periodicities of certain neuronal network activity. 
4. At the same time as the Mozart effect appears trivial and anecdotal, it does seem that certain types of music with certain specific rhythms and periodicity, create an arousal effect, and it is this arousal that creates the temporary enhancement in cognitive capacity. Whether or not this effect is a consequence of  the “aligning neurons" is unknown. This hypothesis needs further research.
5. Studies examining Mozart’s music and epileptiform discharge, and Mozart's music and heart rate and heart rhythm regularity, have found a positive and direct correlation with Mozart's music more than silence, random noise, and the music of other composers.
6. Despite the ambiguous interpretation of some of the findings, the arc and trajectory of the “Mozart effect” has been salutary, calling attention to the beauty of certain genres of music, and their positive effect in lowering disorganized brain activity (epileptiform discharge), and decreasing stress, blood pressure and heart rate. 

In a world increasingly fraught with stress, anger and anxiety, the use of music, especially Mozart's music, as pleasure and as therapy, has been one of the bright spots, centering all of us in a world of consummate and felicitous harmony.


References 
1. Edelman G,  Mountcastle V, The Mindful Brain: Cortical organization and the group selective theory of higher brain function, (1978) Cambridge, MIT Press 
2. Leng, X  Shaw G, and Wright, E., Coding of music and the trion model of cortex, Music Perception (1990) 8: 49

3. Lerch, D, The Mozart effect: A closer look  http://lrs.ed.uiuc.edu/students/lerch1/edpsy/mozart_effect.html
4. Tomatis, A, Pourquois Mozart?  (1991) Paris, Hatchette Diffusion Books
5. Rauscher, F, Shaw G, and Key, Music and spatial task performance, Nature (1993) 365: 611
6. Campbell, D., The Mozart Effect: Tapping the Power of Music to Heal the Body, Strengthen the Mind and Unlock the Creative Spirit, (1996) New York, Avon Books
7. Sack, K, Georgia’s governor seeks musical start for babies, New York Times (January 15, 1998), section A, pg. 12
8. Stough C,  et al,  Music and IQ Tests, The Psychologist  (1994) 7:253                            
9. Newman J et al, An experimental Test of "The Mozart Effect": Does listening to his music improve spatial ability? Perceptual and Motor Skills (1995) 81: 1379
10.  Steele K, et al, The mystery of the Mozart effect: Failure to replicate. Psychol. Sci. (1999) 10: 366
11. Rauscher FD, Shaw G,  Perception and Motor Skills (1998) 86, 835
12. Rauscher F, et al, Improved maze learning through early music exposure in rats, Neurol. Research, 1998 
13. Rideout B, Laubach M (1996) EEG correlates of enhanced spatial performance following exposure to music. Perceptual and Motor Skills. 85: 427
14. Rideout B., Taylor J,  (1997) Enhanced spatial performance following 10 minutes exposure to music: a replication. Perceptual and Motor Skills, 85: 112
15. Steele, K., et al, Prelude or Requiem for the Mozart effect? Nature (1999) 400: 827
16. Chabris, C, Prelude or Requiem for the Mozart effect? Nature (1999) 400: 826
17. Hughes, J, and Fino, J. The Mozart effect: Distinctive aspects of the music as a clue to brain coding (2000)  J. Clin. Electroencephal. (2000): 31: 94
18. Lin L., et al, Mozart effect decreases epileptiform discharge in epilepsy, Epilep. Behav. (2011) 4: 420
19. Trappe H, The effects of music on the cardiovascular system and cardiac health, Heart (2010)  96: 1868 
© Vincent P. de Luise MD FACS  2013

Thursday, June 5, 2014

Teachable Moments, Learnable Moments: Medical Rounds as a Paradigm for Education

Mind, Brain, and Education                                         
Journal of Mind, Brain and Education Volume 8, Issue 1 March 2014, pp. 3-5.                                                             
Teachable Moments, Learnable Moments: Medical Rounds as a Paradigm for Education

Vincent P. de Luise MD, FACS  (1,2)
Corresponding author: 1. Harvard University 2. Yale University School of Medicine

ABSTRACT

The medical profession has for almost a century employed various types of “Rounds” as pedagogical tools to engage physicians, physicians-in-training, and their health care teams, in the clinical diagnosis and treatment of patients. This validated paradigm of medical rounds (MR) has recently been extended to the field of education, where it is being used as an effective strategy for administrators to better understand their own domain. There are four distinct types of MR which can be further analyzed to find commonalities and parallels with the domain of education. The four types of MR are (1) Morning Rounds, (2) Chart Rounds, (3) Grand Rounds, and (4) Ongoing Collaborations—each have unique pedagogical characteristics and serve different functions. They are, however, unified by common threads of dynamic and interpersonal interactions wherein teacher (physician) and learner (physician-in-training) share leathe now outmoded theory of the “empty vessel” and corroborate the concerning and fluidly exchange roles in the pedagogy. MR models supplant pt of the teaching brain. A formal analysis of MR underscores its ongoing utility in education both for its pedagogical innovations and for the Interactive and inherently human attributes that are required between teacher and learner for its efficacy.


Introduction

        Docendo discimus (“By teaching, we learn”)   Seneca (4 BCE-65 CE)

For almost a century, the medical profession has employed various types of “rounds” as pedagogical tools to engage physicians and physicians-in-training in the diagnosis and treatment of patients, and in the learning and teaching of medicine and surgery. The older, static notion of the physician “doctor” (Lat. doceo, docere = “to teach”) as teacher and the physician-in-training as the “empty-vessel” learner has been supplanted by Dynamic Systems Theory (DST) (complexity) models extended to education and brain development and the synchrony and synergy between teacher and learner and the teaching brain (Rodriguez, 2012). It has been discovered that, as a function of the interrelationship between teaching and learning, the development of the teaching brain occurs in spurts, with each cluster of spurts producing a new level of skill and understanding (Fischer et  al., 2007), a development that also occurs in medical rounds (MR). In recent years, the validated paradigm of MR has been extended to the field of education, where it is being used as an effective strategy for administrators to better understand their own domain (City, Elmore, Fiarman, & Teitel, 2009). Are there deeper insights that can be gleaned from an analysis of MR that can be extended to education? Are there parallels between the two disciplines that are foundational and that exemplify aspects of the teaching brain? Is it even possible to tease out those aspects of MR that are distinct from education, when MR is itself, in its essence, a consummate pedagogical exercise?
Answering these questions requires an analysis of the four types and functions of ME which can be translatable to education. Each of these types of MR represents a unique opportunity for teaching and learning, and provides insights into the teaching brain.

Morning Rounds (“Walking” Rounds)
Morning Rounds, the archetypal MR, are the daily episodes of teaching and learning that occur in virtually all hospital settings. An attending physician or hospitalist (hospitalists are physicians specialized in hospital-based medical care)—a more experienced physician or surgeon who has the ultimate medical responsibility for the team's patients—is accompanied by a group of physicians-in-training which includes interns (Post Graduate Year 1, PGY 1), residents (PGY 2–4), and medical students. Morning rounds is a community effort: it also includes nurses, social workers, pharmacists, and quality improvement specialists, all of whom play an ever-increasing role in patient care and resource utilization (Cooper & Elnicki, 2011).

The team “walks” the floor of the medical unit, surgical unit, or specific area of the patients for which they are responsible. The team goes to the bedside of each patient on that team's watch, where each patient represents a “classroom episode” of teaching and learning pedagogy. One of the physicians-in-training, usually the intern or resident, presents to the team that patient's history, laboratory testing and diagnostic imaging results, as well as a differential diagnosis of possible disease entities that could explain the patient's illness and reason for admission. At one time, these presentations had to be delivered from memory, to underscore to the physician-in-training that they had to have complete mastery of knowledge and understanding of the patient's condition before they could opine a treatment strategy. A discussion then ensues, often in the presence of the patient and in the form of a dialectic using the Socratic method, of the most likely diagnoses and best treatment options. If there are pertinent physical findings (e.g., a mass lesion, a heart murmur, a skin rash), the attending physician will identify and discuss them, ask permission of the patient to examine them, and then lead the physicians-in-training in the physical exam by palpation or auscultation of those physical findings as appropriate. This experiential, heuristic model of pedagogy inures not only to informing the physicians-in-training, but continually shapes and transforms the teacher's mind in response to the dialectic.
Within the Morning Rounds model, there are not only distinct differences between teacher and learner, but also, as a result of the fluidity of the dialectic at any given moment, the teacher may become the learner and the learner a teacher. As the attending physician teaches an aspect of the patient's condition, or describes a particular clinical sign or finding, the physicians-in-training also participate in the pedagogy by asking deeper questions about those findings. This fluidity has parallels to the concept of synchrony in the DST model of the teaching brain (Rodriguez, 2012). A recent study has found that physicians-in-training (medical students in this particular study) actually learn differently, depending upon who is doing the teaching. At times, medical students acquire and understand a topic more fully if the intern or resident is doing the teaching than if the attending physician is doing so (Bodnar, Fowler, & Saint, 2013).
The syllogism that the physician-in-training represents the student, that the attending physician/hospitalist is the teacher, and that the patient is the object of the “teachable moment”—comparable in the educational setting to a classroom learning experience such as a book chapter reading or a science experiment—is far too simplistic. The pedagogical episodes in Morning Rounds are both top-down and bottom-up, as the data that are initially presented to the team by the physicians-in-training are then evaluated and modified not only by the attending physician, but by the whole team. Thus, the dialectic in MR is not just dyadic but rather remarkably fluid; observations and inquiries by the physicians-in-training, and the changes in laboratory test and imaging results over the course of the patient's hospital stay, modify the original diagnostic hypothesis and, as a direct consequence, alter suppositions about therapy.

Afternoon Rounds (“Chart” Rounds)

This episode of learning/teaching usually occurs at the nurses' station, or in a private room or a quiet area, away from patients. In these episodes of learning/teaching, the attending physician, hospitalist, or resident usually leads a discussion of each patient's lab test results and imaging results obtained during the day (i.e., since the end of the Morning Rounds). The “on-call” intern and/or resident are present to ensure that they understand each patient's diagnosis and current status for their responsibilities on the evening shift, as the other physicians go off-duty.

“Grand” Rounds

Grand Rounds are a form of top-down pedagogy which almost invariably take place in an auditorium venue, away from the patient bedside. The venue is physically located in the teaching hospital itself, or at the medical school with which the teaching hospital is affiliated. With the dramatic changes in health care delivery that have occurred, the auditorium maybe at a distance from the teaching hospital. Tele-videoconferencing allows members of the patient care team associated with that Grand Rounds case to be present in real-time, even if physically distant from the teaching hospital at the time of the presentation, as well as allowing physicians and physicians-in-training from satellite locations to participate.
In Grand Rounds, the pedagogy is usually delivered by a physician from a podium to a receptive audience of physicians and physicians-in-training, one of the latter of whom begins by presenting a patient case. Following the presentation, a physician expert in that patient's illness, discusses the case, bringing in relevant peer-reviewed data and literature. There is then an open forum of questions, answers, and alternative opinions exchanged between the physician expert and the physicians and physician-in-training in the audience, providing another example of the fluidity of MR pedagogy.
Technology now allows the archiving of Grand Rounds presentations, which then make these pedagogical episodes available as online videos. These can be viewed by physicians and physicians-in-training at a later date, enabling them to improve their knowledge and patient care, while accreting to one of the core ideals of the Hippocratic Oath: Medical education should be transparent and open, and physicians should actively share their knowledge without compensation in order to improve patient care (http://classics.mit.edu/Hippocrates/hippooath.html).

Ongoing Collaboration

Ongoing collaborations between physicians and basic science researchers are a separate yet crucial aspect of the teaching hospital–medical school model. These daily, ongoing teaching/learning episodes are harder to quantify, but which could be classified as a form of rounds. In these episodes of pedagogy, often taking place within the cafeteria or lounge of a teaching hospital, physicians and researchers tackle ongoing scientific challenges. These informal “chat” sessions have become essential as incubators for the cross-fertilization and transfer of ideas, so much so that a number of medical schools have purposely built common spaces easily accessible to both researchers and physicians to convene and discuss topics of mutual interest and inquiry. A result of these interactions and chats is often the birthing of a scientific breakthrough.
While these four identifiable types of MR are distinguishable based on either geographic or temporal grounds, the overarching aspect that unites them is that each is characterized by both dyadic as well as more complex and fluid interactions between teacher and learner. These are the synchronous, synergistic, and mutually beneficial relationships within the process of MR that inform the teacher as much as they impart knowledge to the learner.
Educators in general tend to have autonomous ideas about educating. In the domain of medicine, there are numerous disparate teaching styles in different pedagogical venues, the top-down lecture format of Grand Rounds being a prominent example. However, these individual styles of pedagogy are all subsumed in the context and structure of MR.
Teaching systems can be stratified into those capable responses: instinctual, higher-order student-centered teaching, or using more complex teaching brain teaching. At this most complex level, exemplified by the various types of MR, the teacher and student engage in a synchronistic teaching flow that achieves an optimal teaching and learning experience (Kent, 2013; Rodriguez, 2013). MR activities are inherently synchronistic and demonstrate teaching flow in the dynamic and complex interchange of teacher as teacher/student and student as student/teacher (Rodriguez, 2012, 2013).
The teaching brain is not subordinate to the learning brain; rather, the two are in a dynamic cycle of synergy and synchrony with each other (Rodriguez, 2012). The ultimate measure of effective teaching is not to assess whether an individual has learned a specific piece of knowledge, but rather to evaluate whether the learner and teacher come closer together in thought and skill, that they should flow together successfully within each other's context (Rodriguez, 2013). MR are pedagogical episodes that exemplify this point. MR maintain physicians, physicians-in-training, and researchers in a constantly engaged and challenged environment, continually pushing them to refine their understanding of their patients' condition by being informed by the most recent medical knowledge that supports their diagnosis and care. In an increasingly technological world, with laptops and PDAs at once essential to education (as learning tools, not as teachers) but also serving as further barriers to direct human contact, MR remain the most human and enduring of pedagogical activities. At the core of all of these dynamic pedagogical episodes is the observation that MR hinge upon, indeed require, face-to-face interactions between physicians, physicians-in-training, researchers, and their teams, and conversely, without these critical human interactions, that would be little if any pedagogy (Yano, 2013) and suboptimal patient care.
MR are not just about learning; they are also very much about teaching and about the synergies and effective outcomes that result. Educators need to employ many of the strategies found in MR to enhance their own ability to diagnose the problems that occur in their areas of responsibility and expertise, and in a collaborative fashion find the most effective solutions. These teachable moments and learnable moments need to become as essential in education as they have been in medicine.

REFERENCES


Friday, May 9, 2014

A Mozartean and Proustian Madeleine: Vienna Nocturne


A Mozartean and Proustian Madeleine

Vienna Nocturne by Vivien Shotwell
A Story of Wolfgang Mozart and Nancy (Anna Selina) Storace
The Mark Twain House, Hartford, CT  May 8, 2014
A Review - Vincent de Luise MD


“Anna had seen many virtuosi play. Wolfgang Mozart surpassed them all. He exhaled, and so many breathing notes unfurled from his unhesitating hands. He played as she had always wished to sing—how she imagined she might sing if she were not so excitable and striving, but selfless and assured, bound to music alone.“-                                                
an excerpt from the novel, Vienna Nocturne, by Vivien Shotwell

I had the privilege and pleasure this evening of attending author and mezzo-soprano Vivien Shotwell's beguiling lecture and mini-recital at the historic Mark Twain House and Museum in Hartford. The evening featured Ms. Shotwell and her first novel, Vienna Nocturne, an elegant portrayal of life in Vienna in a time gone by, and of the relationship between Wolfgang Mozart and Anna Selina (Nancy Storace).
Ms. Shotwell's writing of Vienna Nocturne was catalyzed by her hearing Mozart's gorgeous concert aria, Ch'io mi scordi di te...non temer amato ben (KV 505), a love song which Mozart wrote for Ms. Storace, upon her departure from Vienna in 1787.
Ms. Shotwell spoke this evening with The Mark Twain House's director of communication Craig Hotchkiss about her childhood loving vocal music and opera, that Die Zauberflote was the first opera she saw , that she was drawn to a career as a vocalist while at Williams College under the mentorship there of bass-baritone Keith Kibler where she first sang Ch'io mi scordi di te, about her studies  at the famed Iowa Writer's Workshop where she received  her MFA, and about her time at Yale School of Music where she received her Masters in Vocal Performance under the legendary Doris Yarick-Cross.  Ms. Shotwell is also a 2009 Regional Finalist of the Metropolitan Opera National Council Auditions.
Ms. Shotwell has woven a lovely and elegiac story about life in the Vienna of the 1780s, about Nancy Storace and her initial struggles in London, Napoli and Venezia building a career as an operatic vocalist, and then of her being called to Vienna to sing, where at the age 21,she first meets the then 30-year old Mozart in 1786.

Both Storace and Mozart were prodigies as children, were both married to others at the time of their meeting in Vienna, and who then developed a very special friendship. 
The basic facts of the novel are true (but there is no evidence that Mozart and Nancy ever had an affair during their time together).  Nonetheless, a special kinetic energy existed between them.  Composers often conjure and create their genius Art when inspired by another artist, a Muse, if you will. I am thinking of Anton Stadler inspiring Mozart's foundational clarinet works, and Richard Muhlfeld doing the same for Brahms at the end of his life with his trinity of clarinet pieces.
Vienna Nocturne is an engaging and lyrical story, which Ms. Shotwell spins in "prose as spirited, timeless and touching as Mozart's greatest compositions" (per the book's liner notes).
A fascinating aspect of Ms. Shotwell's talk this evening was how her book, which has now been translated into ten languages, has been re-titled in each country's market !
Here in the US, it is entitled Vienna Nocturne. In Italy, it has been retitled L'amante di Mozart ("Mozart's lover"), in Germany the book is called Die Schule der Liebenden -("The School for Lovers" (taken evidently from the subtitle of Cosi - La scuola degli amanti), in Hungary, it is entitled Mozart's Muse, and in Turkey, one finds the book as  Vienna Waltz, (which is odd because the waltz hadn't really been invented yet).
 Actually, Ms. Shotwell wanted to entitle her book, Amato ben  ( My Beloved  - a title which I personally love, as it derives from two words from the second part of Ch'io mi scordi di te... non temer amato ben.) Her title was rejected in favor of Vienna Nocturne.
Ms. Shotwell, a tall and willowy mezzo, began the evening before her interview by warming up with the Habanera from Carmen, and then sang the ineffable lied Abendempfindung an Laura, KV 523 in a setting for mezzo soprano, sensitively accompanied by Kyle Swann of the Yale School of Music piano faculty.
Before Ms. Shotwell sang Abendempfindung, she told us of the tripartite nature of this sublime lied of Mozart, which talks about special friendships and the evanescence and impermanence of life, and what happens to friendships after one passes on. 

She mentioned Arleen Auger during the talk, and so here is the wondrous Ms. Auger in an indelible performance of Abendempfindung:
http://www.youtube.com/watch?v=sY3QktRielY
It was a delightful evening of Mozart, whose story and music is, for me, always a Proustian madeleine, opening up memories of the lives that I have led before, and the lives that I have yet to lead.
Ars longa,
Vincent de Luise M.D.

@ Vincent P. de Luise MD 2014
 
(The images below are of the Mark Twain House, the wonderful setting for the interview; Ms. Shotwell engagingly explaining her artistic arc and trajectory; Ms. Shotwell and myself right before the book signing; and two of the book covers of the novel. She signed my copy of her book - "Dear Vincent. So great to meet a Mozart expert -Thank you so much for your warmth and joy ! "   To which I would add, "Thank you, Ms. Shotwell, for giving us such a lovingly written reverie and timeless story about Mozart and his Muse."
An die Musik!
Vincent de Luise

@ Vincent P. de Luise MD 2014






Wednesday, April 30, 2014

The Eyes of Bach and Handel

This essay was originally written for the  internet website, Only Opera  (www.onlyopera.com)


George Frideric Handel and Johann Sebastian Bach were two towering figures of the Baroque. Coincidently, they shared the same birth year, 1685, were both born in Germany, and only a month apart. Handel’s Messiah is an operatic oratorio, like his operas Giulio Cesare, Rodelinda and Alcina. Johann Sebastian Bach’s b minor Mass is a grand and operatic work of depth, breadth, texture and complexity. But something else united these two Baroque masters. That other bond between these two musical giants was that they both suffered visual loss at the end of their lives, possibly cataracts, and both may have had eye surgery by the same charlatan surgeon who went by the name, The Chevalier John Taylor.
It is the following excerpt from the autobiography of the Chevalier John Taylor that has catalyzed this essay on Bach and Handel and their failing eyesight:

“I have, at Leipsick (Leipzig), seen a celebrated master of music, who had already arrived to his 88th year, and who received his sight by my hands; it is with this very man that the famous Handel was first educated, and with whom I once thought to have had the same success, having all circumstances in his favour, motions of the pupil, and light, &c, but upon drawing the curtain, we found the bottom defective, from a paralytic disorder.” (ref.1)

The “celebrated master of music” was, of course, Johann Sebastian Bach, who was likely 65 and not "in his 88th" year when Taylor met the composer. Handel was not educated by Bach. The two likely never met, although Bach tried several times, was very fond of Handel’s music, and copied some of it out. Taylor did treat Bach, but it is not as clear whether Taylor operated on Handel, although the last clause in the excerpt above makes this writer think that Taylor may have treated Handel, as we shall see.                                                 
                                                 *****
The Chevalier John Taylor was born in 1703, the son of a surgeon of the same name. He studied at St Thomas’ Hospital under Professor William Cheselden.  Taylor decided to specialize in eye diseases, and soon thereafter proclaimed himself an ophthalmiater(a neologism that Taylor  himself coined, to mean  an “eye physician”). He became the self-proclaimed oculist (ophthalmologist) to King George II and the pope. His motto was "in optics, expertissimus!"

The Chevalier John Taylor (1703-1772)
Taylor was an itinerant surgeon, and for the most part, despite his medical training, a charlatan.  He coined the expression, Qui visum visam dator He who gives sight, gives life.He jumbled this correctly written Latin motto into a grammatically garbled, “qui dat videre dat vivere,” and put the quote on the canvas side of his horse-drawn wagon, which was everywhere adorned  with painted eyes, and from which he would bring out the nostrums and elixirs of his charlatan trade and feign to cure the visually impaired.  
Taylor would go from town to town, treating the blind, and if he diagnosed that they had cataracts (a clouding of the crystalline lens with age), he would “couch” the cataracts from patients so afflicted. Then, he would skip town before the almost inevitable consequences of eye surgery at the time (bleeding and infection) came to pass. According to scholarship by Professor Richard Zegers of the University of Amsterdam, the Chevalier Taylor once confessed that when he started practicing in Switzerland after medical school, he “blinded hundreds of patients.” (ref.2) 
Cataract surgery in the 18th century was not the remarkable, world-wide success story that it is today. With incisions smaller than an eighth of an inch, modern-day cataract surgery is a triumph. Cataracts are removed by ultrasonically emulsifying them.  Through the same minute incision, a foldable plastic lens implant is unfolded in the eye to restore and improve eyesight. Cataract surgery is the most commonly performed of all surgeries and, using benefit-risk and outcome metrics, the most successful.
In Taylor’s era, however, there did not exist the finely detailed technology we have now. Back then, oculists waited for cataracts to become mature, or “ripe,” then went inside the eye (without anesthesia!), and, using a small, sharp hook or lance, pushed or depressed (“couched” ) the cataract into the the fluid in the back of the eye called the vitreous humour, and ideally, though not always, out of the pupillary axis, thus allowing light to re-enter. This was now unfocused light which got into the back of the eye and the retina. Thus, the patient still needed glasses (those strong, thick, “coke bottle” glasses) to restore some form of clear vision.
Johann Sebastian Bach (1685-1750)
Johann Sebastian Bach was born in Leipzig in 1685. He became a renowned composer of church and organ music, cantatas and concertos, composing over 1100 works. Apparently, Bach's only infirmity was his vision. 
Bach was said to have had “naturally bad vision… weakened by a lot of study.” (ref.2)
If Bach were nearsighted (myopic), which is likely, it was not very severe, as he was able to sit at the organ for extended periods of time over the course of years and read music without glasses. He also had very narrow eyelids, which has been noted in much of the vetted portraiture (see above).
Because of his failing eyesight, likely due to cataracts, Bach was introduced to the Chevalier John Taylor, who, in 1750, performed two operations on the composer. Bach may have experienced some improvement after the first operation, but it is evident from the newspaper articles of the day, which still exist, that after the second operation (and it is not clear if one or both eyes were operated upon in the second intervention), he became “completely” and bilaterally blind. The adverb “completely” is subject to interpretation, and “complete blindness" to a layperson is not the same thing as “complete” or "total" blindness is to an ophthalmologist. To an ophthalmologist, that would be no light perception.
A few days after the surgery, Bach was not only unable to see, but he became quite ill. He developed what was described as a hitziges Fieber ( a non-specififc term which translates as a “burning fever”). He lingered on for a few months and died on July 28, 1750 at 6:15 PM, at age 66. (ref. 2)
It has been postulated that Bach developed either an eye infection from the surgery, or an increase in intraocular (eye) pressure, and  a subsequent stroke. 
It is not clear that the eye surgery was directly causal to Bach’s demise. As Professor Zegers posits, Bach lived about four months after the eye operation, and an endophthalmitis (an infection of the inner tissues of the eye), if it had gone into the central nervous system to cause a septic meningitis, would not have taken four months to cause a fatal infection, but would have occurred much sooner. (ref.2)
                                               
Georg Frideric Handel (1685-1759)
Georg Frideric Handel was born in Halle, Germany in 1685. After a wondrous tour of Italy between 1705 and 1709, where he became informed by Italian operatic style, he thereafter settled in England, where he continued his employ under George I, who had preceded him to the island kingdom a few years earlier.
In 1751, at the age of 66, and after four decades of extraordinary success in opera and oratorio, Handel began noticing changes in his eyesight. There is no direct documentation that Handel was seen or cared for by the Chevalier John Taylor, apart from Taylor’s own writings (see above). 
It is difficult to know exactly what specific disorder may have caused Handel’s visual loss. Some scholars insist that Handel had cataracts, because there is evidence that he had these putative cataracts “couched” lanced, pushing them out of the central pupillary axis). 
According to the Chevalier Taylor, he performed these procedures on Handel on several occasions. If this is the case, then Handel’s medical history mimicked J.S. Bach’s. Fortunately for Handel, despite unsuccessful surgery to both eyes, he lived a few more years after the operations.
A closer reading of Handel’s personal correspondence makes it clear, however, that the visual loss he sustained was not only initially monocular, but binocular, and his loss of sight in each eye consecutively, was abrupt.
The rapid loss of sight implied in the correspondence implies that Handel may not have suffered from cataracts, since cataracts do not cause sudden visual loss. Therefore, despite the bombastic pronouncements and rodomontade by the Chevalier Taylor that Handel had "cataracts," it is more likely that he sustained a sudden loss of blood, or “stroke”, to the ophthalmic artery of each eye, from an entity called anterior ischemic optic neuropathy (AION).
In closely reading the excerpt from the Chevalier Taylor's diaries, that last clause gives a clue, ".....but upon drawing the curtain, we found the bottom defective, from a paralytic disorder."
"Upon drawing the curtain" is a metaphor to imply that, "upon removing the cataract" (if it existed), Taylor evidently did find that the "bottom" (or "fundus" the back of the eye, where the retina and optic nerve are) was defective,  "from a paralytic disorder." This could have meant the consequences of sudden blood loss or "stroke."
In those days, the concept of  a stroke to a target tissue or organ was not as clearly understood, although the brilliant English physician William Harvey had made great discoveries in that regard a century earlier, in his monumental Du Motu Cordis (On the Motion of the Heart) of 1628.
A sudden loss of blood ("stroke") of the ophthalmic artery, the major blood vessel serving the front or anterior part or head of the optic nerve, causes the tissue in that crucial location  to die (infarct) from lack of blood flow. AION can be associated with other systemic illnesses such as rheumatoid arthritis, and present with headaches, myalgias, arthralgias and anorexia.  Handel's age of 66 years at that time is consistent with case studies of AION, whereas it would be a bit young for someone to have significant visual loss from cataracts. 
It is also of note that AION is more common in those with Scandinavian or German heritage. Handel, born in Germany, fit this demographic risk factor as well. On August 5, 1752, The General Advertiser of London reported: “We hear that George-Frederick Handel, Esq., the celebrated Composer of Musick, was seized a few Days ago with a Paralytick Disorder of the Head, which has deprived him of Sight."
 Statue and Memorial of G.F. Handel  with
"I know my Redeemer Liveth" from Messiah
           by Louis Francois Roubilia         
   Westminister Abbey  unveiled in 1762)
After he lost his vision, Handel's general health inexorably declined through the last eight years of his life. He became more religious, more introspective, and retreated into a cocoon of solitude and silence. Although he still played the organ and acceded to conduct the occasional Messiah, Handel's overall compositional style changed. He went on to complete the oratorio Jephtha in 1752, but that was to be his last work in the genre.  Handel's days as a composer of opera were long past as well; his last opera, Deidamia, premiered in 1741. He died on April 14, 1759, at the age of 74, a justly famous and widely admired cultural icon, having never married. He was buried in Westminster Abbey. He left his estate to his niece, Johanna, and also, as per four separate codicils, to his friends, his servants and several charities.
Posterity has been a most grateful beneficiary of the works of both J.S. Bach and "Mr. Handel." Their rich musical creations are a trove extraordinary in quantity and quality. Despite their visual impairment, Bach and Handel retained a wondrous auditory capacity, through which they conjured and created a sublime musical legacy.

©2014 Vincent P. de Luise MD FACS

1. D.M. Jackson. Bach, Handel and the Chevalier John Taylor, Medical History, 12: 385-393, 1968.

2. R. Zegers, The Eyes of Johann Sebastian Bach, Archives of Ophthalmology, 123: 1427-1430, 2005.