Saturday, September 20, 2014

High Touch: The Course in Compassion

Rebuilding a Curriculum of Caring for Healthcare

Embedding a foundational "toolkit" of  compassion in our present and future physicians will be  essential for  patient-physician communication and physician satisfaction. This essay was initially written as a project paper for the Harvard University Advanced Leadership Initiative in which I was a 2013 Fellow.

"May I see in all who suffer only the fellow human being" 
                                                             Maimonides                                                 
The Problem

Healthcare is broken and doctors are burning out.

That is the current mantra. Healthcare has gotten too expensive and impersonal, and there is inconsistent access to that care. Doctors are increasingly stressed and do not seem as engaged. Patients complain that their doctors are too busy and no longer listen. They ask, “Who will take care of me as a person and not just as a bunch of x-rays and lab test results?” I trust my doctor, but why does she seem so distracted and disengaged.” With all the technological advances of the last several decades, with genomics and PET scans, MRIs and super-subspecialists for every conceivable body part, what in the world is happening to the very doctors who care for us?  We have all this “High Tech,” but, where is the “High Touch?”  Is being a physician no longer a calling?  Has it become just another job?  Have patients become commodities? Why has doctoring gone astray?   

Gaps

The American system of medicine has become organized largely as a disease-management system, and not as a health-care system, with diagnoses and treatments now reduced to an impersonal set of numerical codes. The concept of “caring” is no longer central to a discussion of “health care.” Patients are being viewed by their health care providers more as the sum of their diagnostic testing, or as the "I-patient," to use the term coined by Abraham Verghese M.D. of Stanford University, which is to say, the "virtual" patient, seen by the physician more through the lens of that physician’s pda, laptop or computer screen, and not as the real, live, hurting individual in front of them.

Of course, this is an oversimplification. There are legions of dedicated doctors who are serving an ever larger and aging population, and who do so with empathy.  But we as a society have indeed reached a watershed moment, a saturation point on many fronts. We now live ever more hectic and hurried lives, with hardly a moment to stop and reflect. With increasing demands on our time and resources, we have become more anxious, are getting less sleep, and are making poorer dietary choices. The cumulative effect of this leads to illness. However, when we get sick, we still want help, and we have come to expect that help to be prompt and caring. Yet, even when we do find that help, it seems to have become curiously robotic and disengaged.

It is crucial for the health care profession – now a health care system, comprised of collaborative teams of physicians, nurses, PAs, social workers, ethicists, and even economists – to remain focused, engaged, vibrant, and committed to caring. We cannot have it any other way. We cannot be a healthy society, with healthy citizens contributing to the success and happiness of that society, without an engaged health care team. We need to (re)-train physicians for a lifetime of caring, so that they continually demonstrate empathy in their work, and so that they themselves remain energized and happy in their careers, as this will improve patient outcomes over time.



Physicians cannot heal without caring, and they cannot care without first being informed by a core set of ideals that will carry through their training and into their professional careers.  Medical schools are set up to train physicians, and at many of them, there is already an awareness of these problems which I have outlined, and some initiatives are in place. But the system, engrained and with its own cultures and rituals and focused on disease management, has lost sight of its ideals, the ideals embodied in the Hippocratic Oath.
 

Solutions


: Frameworks in Medical Humanities


We must re-embed a pathway of caring in our health care providers and transfer a lifelong set of skills that will inform them throughout their careers, certainly in the physicians who still lead the health care team. What is needed is an overarching and cohesive rubric, which I have entitled The Course in Compassion: A Curriculum of Caring (The Course). These skills can be identified, quantified and measured, and will populate The Course.  The Course will be divided into modules, and taught using an accepted paradigm in most medical schools, the Problem-Based Learning (PBL) format. Six core modules, which are termed “Frameworks in Medical Humanities,” would be taught over the four years of medical school in weekly two-hour sessions:


                Sensory experience                      Motor task



           Dance and Movement                  Motion Research



           Music Appreciation                      Rhythm/Melody-Making

                                     

           Narrative & Reflective writing       Diary-Keeping



           Mindfulness and Spirituality          Yoga/Meditation 

                                                                          

           Art & Aesthetic Appreciation        Drawing/Sketching



           Empathy Training & Acting          Care-Giving





Stakeholders



Patients, physicians and physicians-in-training (medical students and house officers), medical school administrators, curriculum designers, The Association of American Medical Colleges, state licensing boards, and insurance companies – each of these entities is a stakeholder with a say in physician education. Adopting The Course will require hours of time to teach its principles, hours that will have to be taken in part from existing core disciplines as anatomy, biochemistry, pathology, physiology and microbiology, as well as from time already assigned to the medical students for hospital wards and outpatient clinics. Conversations will need to occur at many levels to allow stakeholders to “buy-in” to The Course as a foundational aspect of medical education.



However, The Course does not have to be built “from scratch.”  There exist a number of programs which have pilot projects aligned with my vision and ideas. A number of medical schools, (Harvard, Yale, Weill Cornell, Johns Hopkins, Stanford, UCSF, and Columbia, inter alia), offer courses which champion aspects of The Course. These existing initiatives are already testing the “proof of principle” of The Course. They are virtually all elective (that is, they are not required to graduate), but they exist. Therefore, it is not necessary to “reinvent the wheel” to populate the syllabus of The Course. Rather, The Course would be populated with “best practices” from existing efforts in addition to new initiatives I would add that have not yet been created or tested.

As Harvard Business School Professor Rosabeth Moss Kanter has written, change is often a result of Big Vision and Small Steps.” The Big Vision is creating and curating The Course in Compassion: A Curriculum of Caring (The Course). The small, essential and crucial steps are to pilot a series of medical humanities courses in all six modules, and, utilizing longitudinal data analysis, create metrics to measure patient outcomes and satisfaction over time, and physician satisfaction through their careers.

 
Impact
 
“It is far more important to know what person the disease has than what disease the person has.”  
                                                             Hippocrates                                  
 
Medical humanism is a core set of ideals that should be taught from college through medical school, internship and residency, and that should continue to inform a physician through their career. Medical humanism serves as a beacon and lodestone for how physicians listen, respond and care for their patients, as well as providing a road map for the well-being of a physician’s own mind and body over the course of their professional lives. The Course in Compassion will be a foundational paradigm around which physicians can be better engaged, and more motivated and passionate about providing care. Patients will achieve better outcomes, and physicians and their healthcare teams will enjoy longer and more fulfilling careers. This is an initiative which can no longer be fragmented, ad hoc and elective. The Course must become the epicenter of medical education and professional practice.

©   Vincent P. de Luise MD FACS

Tuesday, August 19, 2014

Undying Love, Murder, Plot, Dinner - A Magical " Magic Flute" Evening in Middlebury

Connecticut Magazine:Arts & Entertainment

Undying Love, Murder Plot, (Dinner)—A Magic (Flute) Evening in Middlebury

The role of Pamina in Die Zauberflote (The Magic Flute)
 will be sung by soprano Rebecca Palmer


Evening ascends toward its loveliest moments of the year as August slides down the back of high summer toward September. The heat of piercing days begins to abate, the light grows gentler and more diffuse, hinting of autumn, and yet a feeling remains that idylls are still allowed and pressures may be discounted.
It’s the perfect time to go out—for day trips, walks in the woods, visits to museums, and long, lingering dinners. In culture-rich Connecticut, all of that can be very satisfying, like perfect chamber music.
If you dare to turn up the volume, a terrific opportunity awaits August 23rd, in Middlebury, to experience some of the state’s unsung cultural amenities at a level that is a little more, well, operatic.
The full experience features dinner and drinks in a singular venue, a lovely walk to one of the state’s prettiest private school campuses, and then—with the dessert course served during intermission—a performance of the legendary tale (set in a mythical kingdom) of two sets of lovers seeking redemptive unions. Along the way to an ultimately happy ending there’s enslavement and a murder plot.

The event is a fully-staged (and costumed) production, with orchestra, of Mozart's “sublime and delightful last opera, "Die Zauberflote (“The Magic Flute”) K.V. 620.
                                                                                                           The opera is being presented by the Connecticut Lyric Opera Summer Institute, and the Connecticut Virtuosi Orchestra, in collaboration with the Woodbury - based Connecticut Summer Opera Foundation (CSOF), which is sponsoring and promoting the event.

This production of “The Magic Flute” is the capstone of the CLO summer program for aspiring singers, held at Tunxis Community College in Farmington. It begins at 7:30 p.m. in the theater at The Westover School (1237 Whittemore Road in Middlebury.) Tickets are $40; $20 for senior citizens and students. Tickets will be available at the door, but those planning ahead can also send checks, payable to CSOF to: CSOF, P.O. Box 112,  Woodbury CT 06798. (Tickets will be held at the door.)

Apart from the opportunity to see a fully-staged opera presented by a professional company (the last in Connecticut), what makes this event special is the larger experience being offered.
Guests are invited to begin the evening at 5:30 p.m. with a two-course  "Evening at the Opera dinner" at the nearby The Café at Whittemore Crossing, (right, the kitchen) a unique venue located in the same Shingle-style manse Middlebury Consignment and The Shoppes at Whittemore Crossing. The cost, excluding tax and alcohol, is just $29.99. (Call the café directly for reservations and menu options, at 203-528-0130 , and  see the details and register online.)

After dinner, guests will leave their cars at Whittemore Crossing and enjoy a slice of the evening by walking the short distance to Westover (which has very limited parking). And dessert comes as the course served during intermission at the opera.
Emily Hughes will sing the role of Papagena in
CLO's performance of Mozart's Die Zauberflote (The Magic Flute)
Altogether it’s a richly different and stimulating evening out that’s also a bargain (especially in the world of professional opera presentations).

All of those attributes are offered thanks, in large part, to Dr. Vincent de Luise, MD, president of the Connecticut Summer Opera Foundation, founded in 2012 to to provide valuable performance experience to up-and-coming conservatory-trained singers, and to bring opera to young adults, exposing the next generation of concert-goers to the art form. (The other principal members are Carole Winer-Sorensen of The Country Loft special events venue and French antiques shop, Karen Reddington-Hughes of Abrash Galleries antique rugs and Maria Jablon.).

“Our mission and our passion is opera, and vocal music, and promoting it in Litchfield County,”
Dr. de Luise says in a phone conversation about the “The Magic Flute” production.
Having attended a Master Class event Aug. 9 at Westover that featured some of the singers performing in “The Magic Flute,” Dr. de Luise can attest to how high the quality will be. (At the Master Class “superstar soprano” Jurate Svedaite , artistic co-director of the CLO’s summer institute, and Maestro Adrian Sylveen, artistic director and conductor of CLO and conductor of the Connecticut Virtuosi Orchestra, offered “a wonderful glimpse into the creative process of making vocal music!") 
Soprano Jurate Svedaite co-drects the CLO Summer Institute
Just as students performers will be featured in “The Magic Flute,”  the orchestra that evening will consist of roughly half professional musicians and half students. “I think ‘The Magic Flute’ is a perfect summer choice,” Dr. de Luise says, "in part because it can be viewed on so many different levels, and is an opera easily enjoyed by children."
In one way, it’s “the straightforward story of a prince and a princess and their undying love and devotion to each other, in the face of the usual, various and sundry forces of darkness and operatic mortal dangers, who come through these travails unscathed,” Dr. De Luise writes in “Mozart's Magical Mystery Tour de Force: Unraveling the Threads of Die Zauberflöte,” an essay written for the program book of an Opera Company of Brooklyn's concert performance.

CLO Artistic Director Adrian Sylveen
Dr. de Luise adds, “Die Zauberflöte" can be viewed as nothing more than another delightful opera by a great composer, this particular one quite approachable by both children and adults, a charming musical fairy tale that is replete with hummable tunes, a certifiable hero and  heroine, comical characters, a story line that is easy to follow, with  exciting moments and a happy ending, in which truth, morality, personal integrity, love and fidelity  win out.”
Ah, but those thoughts are just the overture to Dr. de Luise’s much deeper essay, which goes on to plumb the depth’s of “The Magic Flute’s” “allusions that exist on a deeper and more introspective plane … ,” with none “more foundational than the Masonic symbols that serve as  leitmotifs and recurrent threads throughout the opera.”
Digging even deeper, Dr. de Luise asks, “Could Die Zauberflöte also have contained  a hidden political agenda?” (Read his essay to discover the answer.)
On whatever level you choose to enjoy “The Magic Flute,” don’t miss this rare opportunity to enjoy a magical evening amid the late-summer beauty of the Litchfield Hills, with dinner and a substantive “cultural entree”—and also, of course, with generous spicing from love, plotting, dark deeds and a quest like none other.
See the website of Facebook page of the Connecticut Summer Opera Foundation to connect with the Aug. 23 performance.
To attend dinner at The Cafe at Whittemore Crossing, call 203-528-0130 for reservations and menu options, or go online.
The CSOF is a fully-volunteer 501(c)3 nonprofit arts organization. Anyone with a passion for opera and classical music who is interested in joining the team may call Dr. de Luise directly at 203-232-9028.

Reader Comments

Friday, July 25, 2014

"Searles' Folly" : The story behind Block Island's Mansion House


Vincent P. de Luise MD

White Hall, aka The "Mansion House"   Summer, 1890  (BI Historical Society).




".... A stately pile of oriental splendor....whose noble dome glistens in the sunlight on the southern slope of the Corrugated Bluffs of the Neck...." (1) 

Just as Nantucket, Martha's Vineyard and the other so-called "Outer Lands" in the North Atlantic have their own interesting stories with iconic and memorable protagonists, so too does Block Island have its share of fascinating tales and eccentric, larger-than-life characters. Conjure, if you will, an individual who was at once an interior designer, an architect, and the inheritor of one of America's greatest fortunes, and you have Mr. Edward Searles, centimillionaire, dreamer, visionary, and builder of one of Block Island's most singular and unusual edifices.

Edward Frances Searles (1841-1920)

Edward Frances Searles was born in Methuen, Massachusetts on the Fourth of July, 1841, about the most auspicious and lucky a birthdate one can possibly have. From a young age, Searles was drawn to the arts. He was highly musical and became an accomplished organist and pianist. His aesthetic talents led to a position in 1869 with the prestigious Boston firm, Paul & Co., where he quickly rose to being one of their leading interior designers. In 1871, he was asked to join the nationally renowned New York City design firm Herter Brothers. Herter was at that time advising the Vanderbilts on the outfitting of their newly built Fifth Avenue mansions,  and Searles soon found himself working on the furnishing of the homes of the rich and the famous. 

In 1881 Searles was sent out to San Francisco by Herter Brothers to assist a certain Mrs. Mary Francis (nee Sherwood) Hopkins in the decoration of a new home that she just recently had had built for herself. This Mrs. Francis Hopkins just happened to be THE Mrs. Hopkins,  the widow of Mark Hopkins (1813-1878), the San Francisco railroad magnate, who was one  of  the four founders   (along with Leland Stanford, Collis Huntington and Charles Crocker) of the Central Pacific Railroad. 

As one of the "Big Four" railroad czars, Mark Hopkins had become one of the wealthiest people in the United States, and his wife, Mrs. Mary Frances Sherwood Hopkins was referred to more than once as "the richest woman in America."  Curiously, or not, Mark Hopkins and Mary Frances Sherwood were also first cousins, he a Congregationalist and she a Presbyterian. Evidently, she got her way a lot: they married in a Presbyterian church.
Mark Hopkins
(1813-1878)
Hopkins was famous for his thriftiness. It was said that he could "squeeze 106 cents out of every dollar." He was happy to live modestly, in a cottage, while building the railroad company. Despite his reluctance, Mrs. Hopkins, again getting her way, had convinced him to build an enormous and ornate mansion on top of Nob Hill, to this day a patrician and rarefied location in San Francisco with sweeping views of the bridges and the Bay. The site is still the location of a grand building (the mansion itself survived the 1906 Earthquake but was destroyed in the Great Fire that immediately succeeded it), reborn into what is now the elegant Mark Hopkins Hotel.
The Mark Hopkins Mansion, c. 1880, on the
 southeast corner of Nob Hill, San Francisco


Mark Hopkins never saw the mansion completed. He died in 1878. Mark and Mary Hopkins did not have any children of their own, but along the way, Mary had adopted her housekeeper's son, Timothy Nolan, who took the surname Hopkins.

So it came to pass that Mrs. Hopkins needed help in furnishing her ornate and magnificent new manse atop Nob Hill, and found a kindred spirit in the the arts and design inyoung, handsome in the talented Edward Searles.

Evidently, Mrs. Hopkins was quite pleased with Mr. Searles' work in San Francisco, because shortly thereafter she helped him secure a second commission, for the building and interior design of another of her baronial homes, this time a monumental stone palace in her birthplace of Great Barrington, Massachusetts.

Begun in April 1885, and completed in October, 1887, the mansion was called Kellogg Terrace (and now has been reincarnated as the Dewey Academy for Boys). Kellogg Terrace remains one of America's great masterpieces of Gothic and neo-Renaissance architecture Notice the strong similarity in architectural style between the Mark Hopkins Mansion (see above) and Kellogg Terrace (see below), though the Hopkins mansion was of rusticated wood (wood that was beveled, painted and then sandblasted to resemble stone), while Kellogg Terrace was hewn completely from stone.

Kellogg Terrace, Great Barrington, MA,
completed in 1910.
(Now the Dewey Academy for Boys)
The close and constant companionship between Mr Searles and Mrs Hopkins in San Francisco and in the Kellogg Terrace project led to a more intimate friendship, which blossomed into a May-September romance (Mrs. Hopkins was twenty-two years Searles' elder, and thus one of the earlier cougars on record). Of course, there ensued the usual gossip, and this on both coasts, about their unusual relationship, and the ulterior motives of each.

While Searles was finishing the interiors of the Kellogg Terrace, he heard from a friend about a lovely and relatively underdeveloped island off the coast of Rhode Island called Block Island. Searles and Mary Hopkins visited the Island in the summer of 1887, and, on the spot, bought several large parcels of land on the northern part of Block Island's Corn Neck, totaling sixty-five acres, extending from the Great Salt Pond to the Atlantic. It was there, at the far end of Crescent Beach, that Searles planned to build what he would call his "dream house," the opulent mansion that he would later christen "White Hall."

Back on the mainland, in Great Barrington, on November 7, 1887, more magic occurred: the perpetual bachelor Edward Francis Searles, 47, married the wealthy widow, the 68-year old Mary Frances Sherwood Hopkins. The newlyweds then took a six-month honeymoon, which was more a  'Grand Tour' of Europe on the highest level.

Upon their return, Mary executed a codicil to her will, excluding her adopted son Timothy from any and all claims, and leaving all her earthly possessions upon her death to her new husband, Edward Frances Searles. Her exact words in the codicil were: “The omission to provide in this will for my adopted son, Timothy Hopkins, is intentional, and not occasioned by accident or mistake.” (1)

Searles then really went to work on Kellogg Terrace, adding a host of ornate, baroque additions to the palazzo, including a giant nave on its west side which was planned as the music hall, outfitting it with one of the largest pipe organs ever built in a private residence in the United States. 

Searles went back to Block Island in 1888 and enlisted a colleague from prior projects, the supremely talented and prolific church architect Henry Vaughn, to design and build Searles' Block Island dream house White Hall.

It was Vaughn who had brought English Gothic style over to the United States from England, popularizing it on these shores as  the Gothic Revival ecclesiastical architectural style. Vaughn's reputation was burnished as he was the principal architect of the National Cathedral in Washington, D.C., and drew the plans for parts of the Cathedral of St. John the Divine in New York City, and Christ Church, in New Haven.

The architect Henry Vaughn (1845-1917) in 1907

Vaughn's concept was to construct Searles' White Hall in the English Mannerist tradition, with two gigantic, identical and bilaterally symmetrical wings, mirror images separated from each other by a massive three-story central hall, complete with a grand staircase that bisected the building and ran up to a third floor belvedere. Rumor began to circulate that Mr. and Mrs. Searles, let alone having very different and individual tastes, were perhaps growing apart, because of the very obvious "His and Hers" wings in their Island home.

There was an abundance of custom-made features of White Hall, many of which were among the newest inventions for every creature comfort. Beyond the mahogany railings and cedar closets for the valet rooms, along with individual bathrooms, perhaps the most elegant touch was in crafting the capitals of the exterior columns. Vaughn fancifully chose to use all three of the canonical orders of classical architectural style in their design: Doric on the first floor, Ionian on the second, and Corinthian on the third. It was a brilliant conceit and another example of Vaughn's exquisite taste and exceptional talent, which Searles would utilize again in later projects.


White Hall, the Searles Mansion on Block Island.
It was nicknamed the "Mansion House" shortly after 
its completion in 18890. Note the cupola on top.
White Hall was begun in the summer of 1888 and finished in 1890. At the beginning, it appeared as this majestic jewel of an edifice with a magnificent dome gazing down on a spectacular beach, one of the most beautiful stretches of shoreline on the east coast of the United States.  Block Island resident and historian Martha Ball elegiacally relates what the author of an 1890s guidebook of the Island had gushed about White Hall:

“The most magnificent of these (summer cottages), and indeed, one of the finest in the world, is the elegant mansion of Mr. Edward F. Searles of Methuen, Mass., who has here exhausted all the resources at command of almost fabulous wealth in the erection of a stately pile of oriental splendor. Every stranger approaching the Island asks about the imposing structure, whose noble dome glistens in the sunlight on the southern slope of the Corrugated Bluffs of the Neck.” (2)

The structure was so big and of such a bright white color of rusticated wood resembling stone, that it could be seen from miles away by ships passing across the mouth of Long Island Sound, eventually even appearing as a "point of interest" on nautical maps of the time. The maps identified the site as "white ho' flat-top," i.e., "white house with a flat top, the "flat top" monicker being given it because Searles had the domed cupola removed after it was damaged in a violent storm during the first winter after it was built. 

To the Island's residents, White Hall, with its monumentality and  opulence, and surrounded as it was by the simple and natural beauty of Block Island, began to seem out of place; it soon became an object of both amazement and ridicule. There were those who called it "Searles' Folly" (perhaps recalling the alliterative "Seward's Folly," although Alaska would prove to be anything but a folly). The enormous edifice, only episodically occupied by either Mr. or Mrs. Searle, earned the nickname, the "Mansion House," and the part of Crescent Beach that it overlooked was referred to as  "Mansion Beach."

Not only did Mr. Searles have Vaughn build the grand White Hall building to overlook Crescent Beach, he also had him build a not-so miniature version of it as a Bath House, right on the beach, an exact replica of White Hall right down to the Corinthian columns of the third floor and the cupola above it !

The Bath House below White Hall (The Mansion House), connected to it by a boardwalk.
The Bath Hath was also built for Mr. Searles by Henry Vaughn, as an exact
but smaller replica of White Hall,  on the north end of Crescent Beach ("Mansion Beach").
After Mrs. Hopkins Searles' death in 1891, Mr. Searles inherited her vast real estate holdings in San Francisco, New York City, and Great Barrington and Methuen in Massachusetts, and a trove of cash; the real estate alone was valued at that time at almost 50 million dollars (almost a billion dollars today). Searles rarely visited the Mansion House after his wife's passing, but he did pay to continue its upkeep. And yes, there was a law suit. Timothy Nolan Hopkins, Mary Hopkins' adopted son, sued to get some of her estate. Edward Searles gave Timothy about 4 million dollars in settlement.

However, it was the cash inheritance from Mrs. Hopkins Searles, over 20 million dollars (the equivalent today of over 400 million dollars), that allowed Mr Searles' even freer reign to design and build several other extravagant and extraordinary properties: to wit, the two fantastic castles he conjured and then actualized with Henry Vaughn:  Pine Lodge, in Searles' birthplace of  Methuen, Massachusetts, in 1910, and Stanton Harcourt Castle, a few miles up the road, in Windham, New Hampshire, in 1915, where Searles found the property and estate taxes to be less onerous.


Mr. Searles'  Stanton Harcourt Castle,
Windham, New Hampshire, built by Mr. Searles
and his architect Henry Vaughan  in 1915
Edward Searles passed away on August 6th, 1920. There were no heirs. From then on, the Mansion House lay largely abandoned, becoming the episodic location of unofficial drinking parties and dances during and after prohibition. The town of New Shoreham, Block Island's official seat, bought the property in 1929, and then sold it a few years later to a certain Oliver P. Rose, who didn't do much with the building.

The Mansion House changed hands a few times after that but no substantive improvements were made by any of its owners, until the summer of 1956, when a Westport lawyer named Ernest Pollien, who had been buying and selling Block Island properties for several years, purchased the building and its surrounding acreage and made a credible attempt at rehabilitating and refinishing it as a holiday retreat. 

White Hall (The Mansion House) c. 1955,
as seen from the Northeast.
(The Block Island Historical Society)

The Mansion House continued on for a while longer, an aging and forgotten dowager on a magnificent piece of beachfront property, and then, one night in April 1963, it mysteriously burned to the ground. Arson was suspected, but no one has ever been implicated.

White Hall (The Mansion House) as seen from Crescent Beach.
The cupola was removed after being hit by lightning.
The building mysteriously burned to the ground in 1963.
Today, all that remains of the once-imposing Mansion House, Searles' White Hall, are parts of the two brick pillars where the entrance had been and a bit of the foundation.This past winter and spring, a group of hard-working Block Islanders from the Highway department has been meticulously uncovering the foundation, removing masses of trailing ivy and exposing the beautiful round stone and brickwork beneath, bringing us even closer to Mr. Searles' wondrous and mystical  "dream house," White Hall.  (2)

Yet, there is a more lasting legacy. The grounds on which the Mansion House once proudly stood contain enduring meaning to both visitors and Island residents, because that is the spot where anyone who arrives early enough on any beautiful day on "the Block" parks their bike, car or SUV and walks down to, where else, Mansion Beach !  

In imagining the once-glorious and imposing Mansion House, all that it was, and now that it is gone, one is reminded of the end of Shelley's poem, Ozymandias:


"Nothing beside remains. Round the decay
  Of  that colossal wreck, boundless and bare.
The lone and level sands stretch far away."

Edward Searles' White Hall, the Mansion House, may indeed have been his folly, but it was also his unique vision and dream, and in many ways, it lives on today to grace the beautiful shores of everyone's delight, Mansion Beach, on Rhode Island's jewel, Block Island. (3)   
Sic transit gloria mundi.
 
Copyright 2014 Vincent P. de Luise MD

1. Cross, John, Whispering Pines: Stranger than Fiction, Bowdoin Daily Sun, Dec. 2011

2. Ball, Martha, Island Notes, Memories of the Mansion House, Block Island Times, February 24, 2014.

3. de Luise, V. A Block Island Reverie: Thirty years of journeys, trips and vacations to Rhode Island's Jewel. http://amusicalvision.blogspot.com/2011/12/manisses-block-island-reverie-thirty.html

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