“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Saturday, May 26, 2007

Making beautiful music ...

"I have been impressed with the urgency of doing. Knowing is not enough; we must apply. Being willing is not enough; we must do.”
~ Leonardo da Vinci

Many people view medicine as an art and I am one of these people. Although, there is a lot science to back up much of what we do, there are many thing that we do that are not based on science; they are based on experience and intuition. I refer to this as an "emotional" issue. We are all products of our environment and training. We are influenced by those around us, both our educators and colleagues, as well as, our personal experiences outside of the field of medicine. Medicine is an art and surgery is like a symphony. The operating theater is the orchestra and the surgeon is the conductor.

What does it mean to be the conductor? The purpose of the conductor is to communicate real-time information to performers. The conductor is also responsible for the preparation and rehearsal of the orchestra, and for making interpretative decisions - such as whether a certain passage should be slow, fast, soft, loud, smooth, aggressive, and so on. There are no absolute rules on how to conduct correctly, and a wide variety of different conducting styles exist. As the conductor you must have an understanding of the basic elements of musical expression and the ability to communicate them effectively to an ensemble. A conductor communicates these decisions both verbally (in rehearsal) and during the performance using different movements, gestures, and facial expressions. It is the conductors role to communicate his/her interpretation of the music to the ensemble.

Many conductors have at least a basic understanding of all of the instruments and and that instruments role in the music being presented. The modern symphony orchestra consists of around 20 different musical instruments. There are four main groups: Strings (violin, viola, cello, bass, and harp), Woodwinds (flute, oboe, clarinet, bassoon) Brass (trumpet, horn, trombone, and tuba), and Percussion (including the piano). The conductor must have an understanding of each of these instruments and their importance to the music that is being interpreted. Their understanding of these instruments and their role in the musical piece are affected by their experience and previous instructors or conductors. This is why the same music will sound different when performed by different orchestras and conductors. Each conductor has developed his/her own style or flare; their understanding of the music is different because of their experiences. The outcomes are ultimately the same, but the approach may be different.

The operating theater is very similar to the orchestra. You have strings (residents/PA's), woodwinds (scrub nurse), brass (circulating nurse), and percussion (the instrumentation rep). It is the attending surgeons responsibility to assure that his interpretation of the procedure as s/he sees it is performed to his/her standards. The conductor (attending surgeon), who has been influenced by his her mentors, must communicate with his 1st violin (primary resident or PA) what he expects for a particular musical piece (procedure). S/he must speak with the percussion to assure that the proper instruments are present so that the tempo and flow of the procedure is consistent and unimpeded. The conductor must keep those woodwinds and brass from getting too loud and overpowering the strings. On occasion, the woodwinds many have their own solo (first assist) when the strings are unavailable. The more time the group have together, the better they all understand the particular nuances of the conductor and can anticipate his/her expectations for a particular piece.

In surgical residencies, the attending staff are training many future conductors. In the first few years, the residents are gaining knowledge of the basics of their craft. An understanding of the different musical instruments and how they can effect the musical interpretation. The residents learn from many master conductors. The resident's style is a combination of the many different influences of his/her residency training. The future conductor will read the techniques in a text book and have a basic understanding of how music can be played. They also see how the masters have conducted the particular musical pieces and will form their own style based on their interpretation. That is what makes this fascinating. The patient's presentation, your understanding of the basic science and your experience will determine how you will approach a patient and which techniques you may use to solve the problem.

It is an interesting thing to watch form as interns transform into chief residents and young attendings. In watching a chief resident conduct the operating theater, you can see the influences of the different conductors that they have trained under. Their use of different instruments in a procedure shows a preference to certain surgical techniques. At the end of the year, the chief residents begin to spread their wings and start to show their own interpretation of the different musical pieces. It is almost July and in the coming months there will be a number of new conductors out into the world. In the surgical residencies, we a getting a whole new group of bright eyed new students and losing a number of talented young conductors. My hope is that we have given them the necessary skills to produce beautiful music.

“The beginning of love is to let those we love be perfectly themselves, and not to twist them to fit our own image. Otherwise we love only the reflection of ourselves we find in them.”
~Thomas Merton


Midwife with a Knife said...

That is a PERFECT analogy. Spot on. Are you sure we're not twins separated at birth somewhere? ;)

Someonetc said...



i don't think we are twins, but i do think we have a strangely similar thought process. kinda weird, huh.