November 12, 2015

Orchestral Distress

Carl Ellenberger, MD

I suppose it is necessary to ask questions, as Peter Dobrin does,in this time of empty seats and unbalanced budgets. I had thought an orchestra's purpose was just to play music, but that was in an earlier time of sold-out subscriptions. Dobrin asks, "What is the job of this orchestra in this city in this day and age?" [re Philadelphia] His answer in part: "I'd get all the input I could and hold a public forum on the question...more money to program and market properly...." The orchestra awaits a consultant's report.

Dobrin sees the cause of the problem as “undercapitalization.” That prevents the orchestra from expanding and improving activities necessary to generate more revenue (and in Philadelphia from honoring salary commitments), a vicious cycle. This condition affects more than a few other orchestras and musical organizations (not including Gretna Music). 

It seems sensible to link that condition to a general diminished interest in classical music among our society. Sure, there is enough violence and misery in the world to distract any sensible person these days, but I don't see many empty seats in the stands for the Fall sports lineup (based on what I see as I pass by ESPN on the cable dial and one actual physical presence at a Virginia Tech football game last month--with >60,000 others). 

Attempts to treat the problem that tend to be short term, focused on the music and its players, and often called "thinking out of the box," have brought limited success:

1) Changing the music to appeal to a broader audience. Most 'crossover' and 'pops' concerts are unfortunate examples of a quest for 'relevance' and 'accessibility.'

2) Changing the concert: shorter duration, less intimidating ritual and formality, 
better 'communication' 

3) Taking concerts to more venues, conventional and unconventional.
4) Seeking a 'new image' by 'creative marketing'
5) Going digital: streaming and filming 
6) Avoiding the word, "classical"
Despite these efforts the recent words of conductor Jed Gaylin remain, in general, true: 
"We need to figure out ways for the potency of great music to reach audiences that admittedly bond, socialize, recreate, and rejuvenate with technologies unforeseen in the era when the symphony orchestra was born." 2
When I see our musicians connect that "potency" with literally every member of our audience again and again each season, my first thought is always, "Why aren't more people here seeking this same amazing spiritual connection?" Tickets are affordable, walk-ups welcome, pre-requisites not necessary. Some people I'm talking about are sitting on porches just a few houses away -- in a Chautauqua!!!

I would argue that classical music and concerts are very healthy (and 'relevant'), in large part because increasing numbers of children all over the world manage to discover they want to play. The current abundance of good musicians, and resulting stiff competition, is why orchestras, and smaller ensembles, have been improving for decades, at least over my lifetime. 

I can only conclude that changes in the "wider cultural environment which surrounds classical music" 3 have not increased the number of listeners, and patrons, apace with the number of players. 

David J. Skorton, MD, cardiologist, and new Secretary of the Smithsonian, dug up what I think is one root of the problem: "As long as we consider the arts as a frill and as intrinsically less important than learning to code a computer, we're going to systematically disinvest. In school, when something's gotta go, it's art and music." (WSJ, Oct 24)  In contrast, investment in sports -- in schools and beyond -- seems to be increasing as we continue becoming a "shouting culture."4 

As in good medical practice, it's important to explore causes, including the environmental ones, before prescribing treatment. I buy tickets for the Cleveland Orchestra when I am East and LA Phil when West because I think they're worth $89 and $127 respectively. I don't similarly value mid-range seats for the Cleveland Browns ($269), but obviously not enough people's values align with mine. 

Why do I value an orchestra? The answer, I think, goes way back. My earliest memories include my mother playing the piano and my father blowing his old trumpet, both instruments untouched since their school years. Now it's clear; they resurrected those skills just for my (and my sister's) benefit! Neither played well but how was I to know? They also played records; my mother liked Somewhere Over the Rainbow, my father loved Schubert. Absent similar parental guidance you might find 3rd graders today blasting JZ's Big Pimpin out of their ear buds. Adult participation is clearly desireable.5

When I was in the third grade, after-school home piano lessons interrupted my play, but I learned, in 15 minutes of gently encouraged daily practice, how to make notes printed on pages into tunes, rhythm, and harmony, my first second language, easy to learn at age 8. After that math and Latin classes came easier. 

Using my new language skills, I could solo with the plastic 'flutophone' band by the end of the 4th grade. When I finally picked up a real flute, reading and figuring came easy and I enjoyed being excused from class to play in the small orchestra. In succeeding years the school bands were even more fun (except the marching part). The gentle parental encouragement became pride and admiration.

Sensitive developmental periods for the brain to acquire skills, like sensorimotor musical skills and aesthetic taste, come and go before age 9 or 10 (March 5, 2013). We have to learn certain skills while we can. If kids participate only in sports during those years, their future may take them in different directions, eventually to stadiums rather than concert halls. Though only a handful of my friends continued playing instruments after high school (more than continued football), enough of them learned to value the cost of symphony tickets and support their symphony. And sing in church.

My parents got as much of a thrill hearing me in school orchestras as other parents get from seeing their sons 'suit up' for the team. There is a risk, of course, that adults hearing only an average school ensemble will decide they don't like 'classical' because they have never heard it played well. But some parents clearly do get inspired; there are few performances more exciting than a really good orchestra of kids who amaze you by how well they play The Firebird.

Summer music camp at Interlochen brought me the confidence that I could compete successfully with good players and learn a large slice of the repertoire sealed my fate as a musician and lover of music.

In medical science single case studies like mine don't prove much but can be educational. I think my example may help explain why at least some of the symphony audience are in their seats, and suggest that the decline of music in schools is one reason for their dwindling numbers.

Imagine the impact of a good orchestral brass quintet or string quartet visiting a third grade classroom! Maybe not on all kids, but enough of them. Dobrin too advises the Philadelphians to conceive of 
"programs that reach every public school student, regularly, in a serious way."


1. Peter Dobrin: The Philadelphia Orchestra needs to rethink its future

2. Jed Gaylin: Being Relevant -- Who Cares?

3. Philip Clark: What’s wrong with the classical concert experience in the 21st century?
. . . And perhaps it’s the wider cultural environment which surrounds classical music that has a problem.

In a culture increasingly obsessed with ephemeral celebrity, fed by a spin drier of rehashed PR trivia presented as ‘news’, where sport is the new religion, where Saturday night fluff like Strictly Come Dancing is analysed seriously and given acres of press coverage, then a cultural landscape invested in supporting all that activity damn well ought to have a problem with classical music – with its difficultly, with its emotional ambiguity, with its allusiveness, with its celebration of individuality, with its refusal to conform, with its ability to move our emotions beyond something that can be controlled and manipulated into turning a profit.

. . . the real reasons that students quit is often beyond their own understanding.  It is up to teachers and parents to create “magical moments” during the year for students to want to continue on their instrument, especially during the early years of study, in order for the child to be successful and stay with their craft.

October 13, 2015

The Bard Comes to Reading

I attended a concert by Friends of Chamber Music in Reading PA. The artists were "The Bard Conservatory Ensemble."

The Conservatory is 10 years old and “guided by the principle that musicians should be broadly educated in the liberal arts and sciences to achieve their greatest potential. All undergraduates complete two degrees over a five-year period, a bachelor of music and a bachelor of arts in a field other than music."  I have always admired the President of Bard, Leon Botstein, the longest-serving college president (since age 28, now he nears 70), a renaissance man who is an inspiring scholar, educator, and esteemed orchestra conductor.

Robert Martin, the cellist in the ensemble (and 11-year veteran of the Sequoia Quartet), is Director of the conservatory, artistic director of the Bard Music Festival1 and Vice President for Academic Affairs of Bard College. He studied at the Curtis Institute with Leonard Rose and Orlando Cole and graduated from Haverford College. I knew Bob during the one year he was principal cellist of the New Haven Symphony while earning a Ph.D. at Yale, when I, a medical student, played in the orchestra. We both remember performing behind Van Cliburn, Perlman (age 17), Rubinstein (age 75), Rostropovich and many other superstars accessible to New Haven from New York. (My memory wants me to think I got perfectly all the flute licks in the Rococo Variations, but...)

The Reading concert was well-played by an ensemble that included two Bard faculty (Martin and Marka Gustavsson, viola) and 3 undergraduates: the pianist and two violinists. What a great opportunity for undergraduates to spend their Fall Break on tour with seasoned professionals! The ensemble could keep up with any of the ones at Curtis and many of those we have programmed over our 40 years.

The hall in Reading—“WCR Center for the Arts”—is a European-style chamber music hall downtown, converted from a decayed old building into what it is by $400,000 and a lot of "loving hands." It is rectangular in pale green pastel with 15 comfortable 9-chair rows on a wooden floor. A small proscenium and elevated stage at one end comfortably accommodated a piano quintet and could hold a Spohr Nonet without piano. A Strauss Serenade for 13 Winds might be a bit tight. The ceiling is flat and about 30 ft high. They have no special audio, video, or lighting—just like it would have been in Brahms' time. Only about 75 of the audience chairs were occupied for the Brahms Piano Quintet, Beethoven String Trio and a group of Bartok Violin Duets. 

I imagine a hall of wood with similar dimensions in the Gretna woods. There are lots of these at other summer festivals, called "sheds," "shells," etc. Climate control, offices, practice rooms, etc could be added in later stages, resources permitting.

My friend Tom Souders, a retired ophthalmologist, 'inherited' the “Friends” from his father who began it 63 years ago. Tom, a violinist, is now “Manager” and there is a board and an Executive Director, Shari Gleason-Mayrhofer2 and a website.3 

The parking situation was odd. When trying to shoe-horn into a short space on the street, I noticed a jolly toothless balded-headed individual leaning on the meter. He greeted me as I emerged from the car and assured me that parking on Sunday is free. (It would have been about $.75 on other days.) He delivered a short discourse on parking in Reading and, as I started away, politely asked if I could please spare $.75. I obliged and told him to take good care of my car as he started toward the next empty space on the block. A member of the audience recalled a similar experience in Senegal when he had to select from a crowd of children who competed to provide parking services.

1. The Bard Festival each summer "was created with the intention of finding ways to present the history of music in innovative ways to contemporary audiences. Each year the festival selects a single composer to be its main focus and presents performances in tandem with presentations on biographical details on the subject and links to the worlds of literature, painting, theater, philosophy, and politics that would have influenced the life and works of the featured composer." Bard Conservatory 

2. email Friends of Chamber Music

October 5, 2015

Mahler in Cleveland

by Carl Ellenberger, MD

The Cleveland Orchestra, Mahler 3, Severance Hall, Franz Welser-Möst: my equivalent to meeting the Pope. We drove 12 turnpike hours round trip through the margins of Hurricane Joaquin, and upon arrival in Cleveland endured 30-mph winds, arctic temperatures, and "Lot Full" parking. I recognized some of the potholes I learned to avoid when I lived there 30 years ago. 

Plunging into the traffic and crowds in University Circle I suspected that very few others were heading to Severance Hall for what I believed could be a concert of a lifetime. Most probably have never set foot in one of the world's greatest temples of music. Those suspicions were confirmed by the empty seats in every section of the hall. We easily obtained prime center seats in the third row of the dress circle for $89. 

The dark lobby spaces and narrow halls seemed old and a little shabby--the lower level a bit like the bowels of Penn Station--but better than Carnegie Hall. We wanted a glass of wine at a small booth before curtain time but the server had no cork screw. At least there were no long queues like there are in Walt Disney Hall. When we asked an elderly usher, still mystified by her bar-code scanner, for directions to the "Concert Preview," she directed us to the room where Renée Fleming was finishing a master class. We finally found the preview upstairs and eventually even a glass of wine.

When we finally entered the hall, it was indeed like walking through the pearly gates. It remains the most perfect concert hall I have ever been in, perfectly-sized, comfortable, with acoustics that seem to defy the laws of physics. In every seat you can hear every note perfectly balanced as if you were sitting on the conductor's podium. Only the sound of oboe players inserting earplugs before trombone eruptions failed to reach the audience. More than 200 performers didn't seem at all crowded.

Trombonist, Massimo La Rosa, was a star of the first movement. "Robust" would be an understatement. When he was acknowledged by conductor Welser-Möst during a long standing ovation, the cheers from the audience could have drowned out a stadium full of Browns fans after a touchdown. That's not to detract from the entirety of the performance, which was a magnificent and memorable experience--maybe "transformative" is the accolade du jour, and it must have been for some of the 50 members of the Children's Chorus. It was for me when I first heard this orchestra in this hall with George Szell as a child in the late 1940's. (Thanks, Mom and Dad.)

Kelley O'Connor's rich mellifluous, O Mensch! Gib acht! filled the hall and the orchestra playing would have brought Mahler to tears. I can't imagine even the most rabid tea-party congressman not being humbled--OK, maybe slightly moved--by such a powerful result of human collaboration. Too bad the Pope missed it.

After the concert, the Severance Restaurant provided a comfortable place to unwind and relax with a glass of Sancerre and a lovely charcuterie after 95 intense minutes of music. While some of the players were probably relaxing up the street in a Little Italy trattoria, we conversed at the bar with a close friend and student of John Mack, the orchestra's former principal oboist and Dean of Oboes in America. As I have been, Mack's friend was a neuroscience imager, albeit micro while I was macro. Go figure.

September 22, 2015

Truth about Vaccines

The candidates have done their best to spread fear and falsehood to serve small political gains, an unfortunate tactic that could eventually account for thousands of deaths.

The truth, written by Michael Specter in The New Yorker and bolstered by what little authority I have as a physician, thus might be worth repeating:
It is sad to have to write this, when it should be clear by now, but here it is: vaccines are the most successful medical intervention in the history of humanity. They have prevented millions of deaths. They are a triumph of human ingenuity and of our desire to alleviate suffering. 
There are not too many. They are not administered too soon. They do not cause autism or allergies or cancer. The only thing “too bunched up” about vaccines, as a matter of fact, are the falsehoods and deliberate misconceptions spread by demagogues and then endorsed by people like Carson and Paul, both of whom should—and almost certainly do—know better.

By the way, for anyone interested in autism, a common and misunderstood condition, NeuroTribes; the Legacy of Autism and the Future of Neurodiversity by Steve Silberman is fascinating reading. 

September 8, 2015

The Gretna Shooting

I'm trying to sort out my feelings on the day after a tragic event in Mt. Gretna. 

I didn't know Stacey, an attractive 46-year-old single mother of two teenaged boys. She owned and operated the "Gretna Emporium" and was there every morning of the summer, setting out onto the porch a wide array of statues, yard art, plants, toys, flags, and gifts to tempt the crowds heading for ice cream or just wandering around this distinctive community, many probably on their first visit, astounded by its fairy-tale cottages, majestic trees, or strains of Janáček's music wafting from the Playhouse. 

Stacey joined in Gretna life, especially children's lives as a volunteer for the children's part of the Annual Art Show. She and Chuck, proprietor of the next-door "Jigger Shop" Ice Cream Parlor exchanged morning greetings almost daily as they prepared their businesses for opening. I'm sure some in our audiences have wandered into both of them before or after concerts in the Playhouse about 100 yards up the hill.

Stacey and a boyfriend were seen last summer at real estate Open Houses. They seemed like a "nice loving couple." Because both lived in far eastern sections of Lebanon County, perhaps they were thinking of marrying or living together in a Gretna cottage closer to Stacey's business. 

In December the boyfriend was convicted of domestic violence -- "he beat her up" a neighbor said -- and jailed. Stacey filed a 3-year "Protection from Abuse." Court sentencing was scheduled for tomorrow. 

As I drove back yesterday to Gretna from taking musicians to the train station in Elizabethtown, police cars streaked past toward Gretna, ending up at the Jigger Shop. We soon learned that as Stacey and Chuck were opening their businesses for the last day of the season, a man parked his car beside the Emporium and got out with a 357 magnum. Seeing him coming Stacey ran for help toward the Jigger Shop, only to by followed and shot in the side of her head. After she fell the man shot her again point blank in the face. 

Chuck on the Jigger Shop deck, a mere 10 feet away, shouted to his workers, some of them teenagers, to "get down" and then to run for cover out the back door. As the man headed for another door of the Jigger Shop, Chuck locked it, exited the back, called 911, and watched from cover as the man sat down on a bench. Eventually he arose, pointed the gun at his temple, and pulled the trigger. The ex-boyfriend eventually died at the Medical Center.

Scene of the crime: Emporium straight ahead, Jigger Shop to left. Stacey was shot in front of the bench to the right. The shooter tried to enter the Jigger Shop, then sat on the bench for a minute or two, then stood and shot himself in the right temple.

Since events like this happen up to 80 times each day somewhere in the US, this one probably won't get much more coverage. Just another unfortunate consequence of the 'freedom' we enjoy to "exercise our Second-amendment rights." Indeed, a small price to pay for that freedom, or, as they say around here, "You'll have this." Or we will hear, "We need to do better in treating the mentally ill, locking up criminals, and enforcing the law."

The elephant in the room, however, is the serious infestation of guns in our society, far more serious than in most other countries. If dozens of people died in the US each day from virulent salmonella in Big Macs, you can be sure authorities would take all possible measures to end that, aggressively and immediately. We acted after smoking was revealed as a cause of cancer. We further curtailed our freedom by mandating seat belts, greatly reducing deaths and injury. We require drivers' tests before granting a license.

Gun violence too is a public health problem. The reality that "more guns = more homicides" has been proven beyond any doubt. The idea that the clumsily-written Second Amendment assures individual possession of guns would have been laughable to any pre-NRA Supreme Court. 

In this case I can't imagine any human behavior more selfish or any means to the same end more cowardly than the use of a gun.

Adam Gopnik wrote recently in The New Yorker,
On gun violence and how to end it, the facts are all in, the evidence is clear, the truth there for all who care to know it—indeed, a global consensus is in place, which, in disbelief and now in disgust, the planet waits for us to join. Those who fight against gun control, actively or passively, with a shrug of helplessness, are dooming more kids to horrible deaths and more parents to unspeakable grief just as surely as are those who fight against pediatric medicine or childhood vaccination. It’s really, and inarguably, just as simple as that.

August 16, 2015

"Headache Associated with Sexual Activity"

With an orgasm comes a thunderclap in the head, a crashing headache. That could scare you out of your wits! What to do? It's too late to "ask your doctor if you are healthy enough for sexual activity," as the gratuitous sotto voce Viagra marketing slogan implores.

The surprising number of Mt. Gretna residents who have consulted me for this symptom has led me to consider several hypotheses: the ~1,600 denizens of this community have, 1) more headaches than average, 2) more accessible neurologists per capita than average (~1/1600, formerly 2/1600), or, my favorite, 3) more orgasms than average.

Ample experience shows that cerebral aneurysms can rupture under stress of sexual intercourse. More than just famous people like Nelson Rockefeller have died of brain hemorrhage or heart attack in such circumstances, in what has been called la mort d'amour, a mode of exit even more romantic than a motorcycle accident in Rome.

But the good news is that the vast majority of such headaches, also pompously called "orgasmic cephalgia," "sex headache," and, most unromantically, "headache associated with sexual activity," are indeed benign, more frightening than symptomatic of serious conditions. Though medical science has not found their cause (or the cause of migraine for that matter), experience teaches us several other things: headaches that coincide with orgasm are infrequent, both among populations and even among those unfortunate enough to have had them on occasion. They usually last minutes to hours, occasionally a few days, and are more often reported by people who have had a life-long migraine tendency, especially if it comes with exertion, and by men. They tend to eventually disappear after a small number of appearances.

So, if your headache totally subsides in hours, there is probably little cause for alarm. As headache-free weeks and months pass, the headache is even less likely to be serious.

No systematic trials guide treatment. Not surprisingly, the usual over-the-counter pain remedies rarely help, though claims have been made for most of them. Only if such headaches linger or happen with increasing frequency do you need to call your doctor and anticipate an MRI. Of course, the "worst headache" of your life, under any circumstances, especially if associated with other symptoms like vomiting--or if you are someone for whom headache is a very rare experience--should get you to the Emergency room.

For more information see, Neurology 2003;61;796-800. For a general overview of migraine read Oliver Sacks' Migraine, revised and expanded in 1992. Sacks believes migraine is a "spiritual" condition. He describes the case of an aspiring priest for whom migraine with orgasm seemed to be penance for the indiscretion of his sexual contacts. Note that better migraine treatment, the triptan family of drugs, has been developed since that writing.

August 11, 2015

A Summer to Love

Hold me, love me
Hold me, love me
I ain't got nothing but love, babe
Eight days a week

So goes one stanza by John Lennon and Paul McCartney that we heard Sunday night when the Matthew Parrish group and Joanna Pascale performed selections from the McCartney Songbook. The concert ended our 40th Anniversary 8-day celebratory week. Love was all around our six concerts that followed the 31st Annual Tour of Gretna Homes, our annual fundraiser that helped make the week possible. 

I can't imagine a more perfect 40th Anniversary celebration. By being excluded from rehearsals I had no idea of the surprise planned for me as an expression of love from the entire Gretna Music family, engineered by Carl and Suzanne: the Mahler Adagietto that opened the concert last Saturday. Mahler sent the manuscript as a love letter to his wife. After that I was too overwhelmed to play many of the notes in the Bach-Stokowski Prelude that followed—I hope few people noticed—but recovered in time for the Serenade, another expression of love by Howard Hanson who wrote it to propose marriage to Peggy. She must have liked it—as most everyone who heard it Saturday said they did. (Insider joke: "That program had Carl Kane written all over it.")

The orchestra and conductor were amazing. All were indeed my family for the duration, enjoying wonderful weather, Gretna ‘charm,’ good food and wine, and hospitality in Gretna and Elizabethtown while rehearsing and practicing up to 8 hours a day under the affable and firm capable direction of Ronny Feldman of the Boston Symphony, Boston Pops, and Tanglewood—and a former mentor of Carl Kane. The joy of hearing our efforts getting better and better in rehearsals made them into play, not work. I have rarely played in such a happy orchestra with such pleasure. New friendships were made and the Gretna Music family adopted new members.

As George Szell said in Cleveland, we started rehearsing at the point where other orchestras finish, with a group that included members of the Philadelphia Orchestra and Momenta and Wister Quartets, and more. For the opening Sunday concert they were joined by Lise de la Salle on her way from the Chicago Symphony to Germany's Moritzburg Festival in a magnificent Jeunehomme Concerto that would have knocked the socks off Mozart. Frank Kowalsky played the Copland Clarinet Concerto in a way that the composer (and dedicatee Benny Goodman) could only have dreamed of. (Frank recalled playing in “The President’s Own” Marine Band with Gretna’s own trombonist Jimmy Erdman!) 

The Philadelphia Orchestra's Assistant Concertmaster, Nancy Bean, and their Principal Cellist, Lloyd Smith, led the orchestra and smaller groups with solid experienced playing. Nancy’s Duo Parisienne with harpist Anne Sullivan played an exquisite program for an onstage audience after a delicious Sunday brunch. The night before Anne played the Mozart Flute and Harp Concerto at the tempos they should be and your humble servant was able to keep up after a lot of practice enabled finally by retirement from his medical career (or perhaps a suspension of normal ennui). We gave Allen Krantz’s new cadenzas a proper sendoff. At the elegant 18th C. Cornwall Inn we played a Haydn Symphony (in a frugal arrangement), a Vivaldi Lute Concerto, Eine Kleine Nachtmusik, and two sexy Piazzolla tangos. Then players and listeners enjoyed wine and dinner.

Veteran musical comedian and PBS and New York Chautauqua regular, Mark Russell, had the Friday audience in stitches for 90 minutes then repaired to a Gretna porch for a late dinner and to regale guests with more stories. 

The dedication of every single musician was inspiring to witness. After weeks of individual preparation and 6-hour rehearsals, their first activity when arriving back at their hosts was to practice for an hour or two. Every one of them is hoping to do it again next summer. With Ronny on the podium.

Gretna Music ‘made budget’ with ticket sales and sponsorships (thanks, Tom Carmany, for sponsoring me). That increased the chances that we can make similar 8-day weeks a feature of future summers.

During those 8 days most Gretna denizens were lounging on their porches or on the decks of the Jigger Shop or HideAway, while the usual hordes of summer visitors ambled around the streets goggling at the cottages or headed for ice cream, mini-golf, or the lake. On rare occasions one or two, by accident passing the open back of the Playhouse, might have turned their eyes from their conversation or the quaint surroundings to peer into the hall. Maybe a few even slightly slowed their pace for an instant. I wondered whether it would have been any different if a reincarnated Mozart had been sitting at the piano or Mahler was conducting.

July 13, 2015

Note to My Health Care Proxy

I read Advanced Dementia in a recent issue of The New England Journal of Medicine. Lots of data from many patients about this inevitably progressive, memory-robbing, life-ending condition, mostly in the form of Alzheimer's Disease but also in less common forms. It now afflicts 5 million persons in the US, a number expected to increase to 14 million by 2050. We can't predict when dementia will end a life. That depends on when and which complications come, most commonly as eating problems and infections, especially pneumonia. Medications are costly and ineffective.
Treatment decisions for patients...should be guided by the goals of care; providers [new name for doctors and nurses] and patients' health care proxies [persons you entrust to speak for you after you no longer can] must share in the decision making. After the provider has explained the clinical issue to the health care proxy...the proxy should then articulate the goal or level of care that aligns with the patient's preferences, such as treatments that promote comfort only....
If I ever should suffer the misfortune of this condition, my goal of care will indeed be comfort, even before my Alzheimer's becomes advanced. We talk about the "healing" power of music but maybe should talk instead about its "comforting" power. After all, music can temporarily restore a Parkinsonian patient's ability to walk (to the beat) or speak (by singing) or help Alzheimer patients access memories (like a "can opener" according to music therapist Gretta Sculthorpe), but it can't heal a wound or restore failed kidney function.

In Musicophilia Oliver Sacks remarks, therapy in people with dementia...seeks to address the emotions, cognitive powers, thoughts, and memories, the surviving "self"...and to enlarge...existence....  
Music has no side effects like tranquilizers that calm at the expense of blunting further any remaining trace of self and sensibility.

Despite evidence that musical taste deteriorates as dementia progresses -- suspect dementia if you start to prefer pop music -- I don't think I'll be comforted by Somewhere over the rainbow, or by singing my high school "fight song." My proxy had better play Leon Fleisher's recording of Brahms' arrangement of Bach's Chaconne--or equivalent--through my headphones as I recline with a chilled glass of L'effet papillon. (from

May 28, 2015

Looking Back and Forward

'Tis the season. For reunions -- I'm attending my 50th Yale Medical School reunion this weekend. I would gladly go to medical school there again. It was where I developed a strong foundation for a medical and neuroscience career that included curiosity, a thirst for reading and writing, and a respect for listening, especially to patients. 

And what other medical school would have allowed me to play rehearsals and concerts several nights every week for four years? Bach cantatas and chamber music at the Yale School of Music and orchestral music in the New Haven Symphony and several other nearby regional orchestras, some conducted by Leonard Bernstein's conducting fellows with soloists like Arthur Rubinstein, Benny Goodman, and Mstislav Rostropovich.

At the time I couldn't avoid anxiety over being distracted from my medical studies. Now I am convinced it was exactly what I should have done--for my sanity then and for my life afterwards. I hope music protected me from the dehumanization that medical schools (Yale excepted) are so good at instilling in students. Nowhere else could I have had a better medical education. Now retired from medicine, I can still play music.

'Tis the season also for Commencement speeches. A brilliant one at Washington University by the film maker, Ken Burns, is my favorite so far this year. "Wash U" is where cynicism set in after the Army and the Vietnam War interrupted my happy University of Virginia postgraduate education. Burns explains that feeling -- I still feel it -- and offers good therapy, such as replacing cynicism by its "old fashioned antidote, skepticism."

Excerpts from Burns' finale don't capture the full essence of the address:
Remember: Black lives matter. All lives matter. 
Reject fundamentalism wherever it raises its ugly head. It's not civilized. Choose to live in the Bedford Falls of "It's a Wonderful Life," not its oppressive opposite, Pottersville... 
Don't confuse monetary success with excellence. The poet Robert Penn Warren once warned me that "careerism is death"... 
Listen to jazz. A lot. It is our music. 
Read. The book is still the greatest manmade machine of all -- not the car, not the TV, not the computer or the smartphone. 
Do not allow our social media to segregate us into ever smaller tribes and clans, fiercely and sometimes appropriately loyal to our group, but also capable of metastasizing into profound distrust of the other... 
Convince your government that the real threat, as Lincoln knew, comes from within. Governments always forget that, too. Do not let your government outsource honesty, transparency or candor. Do not let your government outsource democracy... 
Insist that we support science and the arts, especially the arts. They have nothing to do with the actual defense of the country -- they just make the country worth defending...

May 12, 2015

ON THE MOVE by Oliver Sacks

by Carl Ellenberger, MD

Who else would write this?
"It is the function of medication, or surgery, or appropriate physiological procedures, to rectify mechanism--the mechanism, the mechanisms, which are so deranged in these patients. It is the function of scientific medicine to rectify the 'It.' It is the function of art, of living contact, of existential medicine, to call upon the latent will, the agent, the 'I,' to call out its commanding and coordinating powers, so that it may regain its hegemony and rule once again--for the final rule, the ruler, is not a measuring rod or clock, but the rule and measure of the personal 'I.' These two forms of medicine must be joined, must co-inhere, as body and soul."   
...from Awakenings

Like medical care, medical writing usually focuses on diseases: incidence, causes, manifestations -- "the mechanisms" -- and treatment. Oliver Sacks focuses instead on the stories of the victims of neurologic disease, on finding the "personal 'I.'" A pill or a shot or surgery may be necessary but rarely can totally heal. None of those methods can cure, for example, patients with MS, Alzheimer's, or Parkinson's, so knowing who they are can be important in helping them improve their time on earth. Alas, in my view, medicine has been heading mostly in the opposite direction during Dr. Sacks' and my careers, a reality that becomes evident soon after On The Move begins.

I admire Oliver Sacks, author of Awakenings, The Man Who Mistook his Wife for a Hat, Migraine, other books and articles in The New York Review of Books, Granta, The New Yorker, and The New York Times, where his recent Op-Ed (Feb 19) revealed his current battle with a lethal melanoma. 

Throughout his career some of his colleagues, probably mostly those who practice, teach, or 'investigate' in conventional ways, have dismissed Dr. Sacks' voluminous, detailed, and often inspired descriptions of his selected patients or other "subjects" (including himself in disguise), gathered over many hours of intense and repeated observation, as little more than material for his many writings, well-crafted as they are, but don't offer much to his patients. Sacks has, however, more than anyone, revealed to the public what Neurologists do, or at least should do, in addition to adjusting 'the mechanism' by ordering MRI's and EEG's, and prescribing medication.

Sacks is an avid musician and probably plays Beethoven sonatas on the grand piano in his apartment. He's also a biker, lifter, hiker, swimmer, surfer, albeit a clumsy participant at best in most of these endeavors, according to his account. And he does't hesitate to reveal his own demons.

Here's one of his music-related stories:

A producer was filming, in their hospital, the patients with post-encephalitic Parkinsonism (an excerpt), the characters in Awakenings. (The book was also made into a longer film starring Robert Di Niro). He asked, "Where is Kitty?" the music therapist.
"It was quite unusual in those days to have a music therapist--the effects of music, if any, were considered no more than marginal--but Kitty...knew that patients of all sorts could respond strongly to music and that even the postencephalitics, although often incapable of initiating movements voluntarily, could respond to a beat involuntarily, as we all do." 
David Leventhal of the Mark Morris Dance Company has taken that phenomenon to a new level; his efforts displayed in a new film, Capturing Grace, will soon be released. Then, in a footnote, Sacks relates: 
"By 1978, Kitty had decided to retire; we thought she had reached the usual retirement age of sixty-five, but she was, we learned, in her nineties, though astonishingly youthful and vivacious (could music have kept her young?)"
Little 'hard' evidence could be mustered to answer that question, Dr. Sacks' neurology colleagues would hasten to assert. But they don't get it. In On the Move, an amazing story teller reveals his own amazing life.