Jazz and the ‘Art’ of Medicine: Improvisation in the Medical Encounter

In his essay, "Jazz and the 'Art' of Medicine: Improvisation in the Medical Encounter", Paul Haidet provides a wonderful exploration of the parallels between jazz and the physician-patient relationship. The author provides an insightful comparison of a “master musician” and a “master clinician”. Perhaps the most valuable contribution of this article is the artful description of the nuances that distinguish mastery from competence. Competence can be demonstrated through the effective use of communication skills, such as agenda setting, active listening, empathy, and participative decision-making. Communication skills are the foundation of an effective relationship between provider and patient. Observers can reliably and objectively rate communication skills. However, as family medicine educators and researchers we have had difficulty defining the elusive interpersonal skills that are subjectively valued by patients and may be the distinguishing traits of master clinicians. In contrast to communication skills, interpersonal skills are much more subtle and contextual. They are experienced by the receiver of communication (the patient) but may not be apparent to an observer. The three concepts identified by Haidet (building space into one’s communication, developing one’s voice, and achieving ensemble: accommodating to the others’ style) are well-described examples of interpersonal skills. His use of jazz as a metaphor for the physician- patient relationship provides the context for effectively relating his ideas to the reader. Haidet’s jazz metaphor and should strike a chord, or at least a familiar melody, for students of the physician-patient relationship.

Competing interests:   None declared

Aristotle said humanity’s greatest intellectual power was our ability to make metaphors. Einstein told us imagination was more important than knowledge. Paul Haidet combines these thoughts and imagines a metaphor to lead us toward better teacher understanding in medical education: jazz improvisation as a lens to explore patient-physician communication.

Using Miles, ‘Trane, and The Bill Evans Trio, Haidet orchestrates a rich explanation of the issues medical students need to explore while on their way to becoming physicians. More than an explanation, the metaphor offers the reader a clear image of what these skills will sound like in practice. This is very important, for too many in our field believe that skills of this type are innate and cannot be taught. Haidet disagrees (and so do I). His metaphor and descriptions of how jazz musicians go about “gaining familiarity with jazz scales and chord structures, mastering an instrument, apprenticing in the real world, and learning the repertoire” of the field equates with the training of medical students who must accomplish similar feats of understanding the patients with whom they work.

Several times in the essay Haidet stresses the importance of dignifying the patient in the communication process. That is done, he shows, not by taking the lead, but rather by finding the right space and voice for the collaborative relationship that is the patient-physician ensemble. Our students must experience that patients come with tremendous knowledge about their health, and only through a shared, narrative environment will physicians discern the felt nature of the condition that brought them together. Seeing the world as a jazz musician can help in that goal.

I especially like the thought: “It takes listening aligned toward understanding, not just the collection of factual data.” Understanding, from an educational perspective, comes when intuitive thoughts and beliefs are transformed. Haidet’s essay points to several ideas that need transforming in medical education, even our growing misuse of the concept of evidence based medicine.

As he clearly states, no algorithm can reduce the complexity of human health care. Rather it will always be the relationship that develops between the patient and physician that brings understanding to the ear of both. Situating that understanding in a metaphor of jazz improvisation is an exquisite statement of proper purpose, expanding both the pedagogy and practice of medicine simultaneously.

Competing interests:   None declared

When I was invited to comment on Dr. Haidet’s article about the similarities between jazz improv and family medicine, I had just finished reading a chapter in a book about negotiation. The book (Fisher, Ury, & Patton, 1999) emphasized the importance of active and responsive listening when attempting to communicate effectively with another individual. Specifically, the authors recommended that the listener periodically repeat back the speaker’s main points in order to show the speaker that he or she is understood. Additionally, when speakers appear to be motivated to discuss a topic on their mind, allowing them to do so without interruption is beneficial not only for the clarity of the discussion, but also for the speaker’s ability to relax and feel understood. These listening techniques are not only relevant with regards to negotiation, but are important skills to implement in any situation where effective communication is essential, such as meetings between physicians and their patients.

Effective communication is similarly important in the art of jazz improvisation, as I learned during my years as a saxophonist in jazz ensembles. When soloing, the band leads me in the right direction and facilitates my soloing by providing a steady beat and background chords. Although their presence is noticeable, it does not interfere with my soloing, but accompanies my notes and melodies with supportive sounds. The band allows me to “say” what I want and to express myself in the way I choose. That the band plays a background role to soloists, however, does not diminish its importance. The band also helps soloists to stay focused and to keep their commentary (the notes and melodies they play) headed in a relevant direction.

Although in his article Haidet writes that the doctor plays a role of improvisation, in some ways the doctor also plays the role of the band in the background that supports the patient’s solo. When patients describe their problems, the doctor should listen actively and provide supportive direction but should avoid interfering with patients’ descriptions of their problems. The doctor, like a band, guides the patients (soloists) to prevent them from exploring irrelevant tangents that do not mesh with the overall goal of health (or good music) promotion. Allowing patients to feel at ease within the comforting background of the doctor’s guidance permits patients to express themselves freely, and it allows the doctor to understand patients’ problems within the context of their unique circumstances.

References

Fisher R, Ury W, Patton B. Getting to Yes: Negotiating an Agreement Without Giving in. (2nd ed.) London: Random House; 1999.

Competing interests:   None declared

Improvisation is one of the key dimensions of reflective practice, which we in our rural residency program call the "seventh competency." We have even added this seventh competency to the six required of us by the ACGME and have integrated it into our system of evaluation and professional development.

We have devised ways of encouraging improvisation and "reflection-in- action" in our students and residents, and in weekly sessions of "Clinical Jazz" residents, faculty, and visiting students practice what this essay promotes. Each of us brings our own voice to a weekly case-based discussion focused upon the doctor-patient relationship, which we see as the core of clinical practice. Together, from our diverse perspectives and life experiences yet sharing a common basis in family medicine, we through collective "reflection- on-action" achieve a kind of ensemble, arriving at a clinical pearl or pearls for practice and publishing "Notes from Clinical Jazz."

We've not yet been able to measure and prove our success to others, but I am encouraged by this essay and other articles in this issue of the Annals to persist in what we are doing. The most important outcomes are not the most easily measured. I look forward to others' comments and suggestions as to how to best teach and demonstrate the essential nature of this skill in exemplary practice.

Competing interests:   None declared