(Editor’s note:  This is part two of Dr. Holly’s Acceptance Address for the Distinguished Alumnus Award for 2012)

Lecture 2:  The Pen and the Stethoscope

The second lecture was The 2012 Ewing Halsell Distinguished Lecture, The Pen and The Stethoscope by Abraham Vergehese, MD, Professor of Medicine at Stanford and Founding Director of the Center for Medical Humanities and Ethics.  The relationship between Medicine and Literature is deep.  Particularly, when we remember that the “literature” of most lives is not published but is oral history and often is the dialogue of cinematography.  People love to talk and if you listen, they are telling “their story.”  Often the story is a short story about an event in their life, but sometimes it is grand tome of their entire life. 

Charles Dickens illustrated this for us as he put into the mouth of David Copperfield in the first paragraph of his novel, the words, “Whether I shall turn out to be the hero of my own life or whether that station will be held by anybody else, these pages must show.”   The reality is that not only is the course of healthcare determined by a person’s story; healthcare is often delivered by the sensitive, compassionate, attentive listening to another’s story.

Three years ago, I was making rounds one morning.  The nurses rushed to me on one ward and said, “You must not go into this room.  The patient has said that he will kill the next doctor who comes into the room.”  I asked, “Does he have a gun?”  They agreed that they thought he did not and I said, “Then let’s go see him.”  Two burly hospital employees had been summoned without my knowledge and they quickly followed me into the room.

As I stood at the foot of the patient’s bed, I greeted him and said, “May I listen to your lungs?”  He looked at me quizzically and said, “Yes.”  I examined him and then ask several questions.  I listened to “his story” for thirty minutes.  You must realize that I have a short attention span and this is very unusual for me, but I was prepared to spend the day if he talked that long.  While he did not use the words, he relayed his feelings of worthlessness and of isolation.  He had lost all personal autonomy.  He had no income, no family, no friends, no relationships, which supported or loved him.  And, the one place where he could regain significance was in the control over his body.  But, no one had ever asked him for permission to enter his personal space; so he lashed out in anger.

As I listened to him and his lament of powerlessness and hopelessness, I wondered how I could give him both power and hope.  I realized that one way would be to give him power over me and to give him the hope that he could contact someone about his needs. At the end of my visit, I gave him my cell phone number and told him to call me anytime he had a problem or any time he needed an appointment and couldn’t get it.

The result has been remarkable.  Today, he is one of my dearest friends.  He has never abused he privilege of calling me but calls me about many “non-traditional” health issues.  He was arrested and he called me.  Turns out, he was falsely accused as stated by an experienced police officer but a young officer pressed charges.  His attorney was incompetent and he was convicted.  If he could afford the probation fees he could avoid prison, but he had no money.  It would normal not occur to us that probation fees could be a healthcare expense, but in his case it was.  SETMA’s Foundation has paid and continues to pay his probation fees and he is healthier than he has been in his life.  This all started by listening to his story.  Everyone has a story and they are eager to tell it and it is an essential part of their healthcare.  It is not necessary to record it in the medical record but it is necessary to record it in your heart.

Lecture 3:  Music and Medicine: Beethoven

The third lecture was delivered by Richard Kogan, MD, Psychiatrist and concert Pianist, Artistic Director of Weill Cornell Music and Medicine Program.  What a treat and delight.  The Boston Globe wrote,  “Kogan has somehow managed to excel at the world’s two most demanding professions €“ music and medicine.”  On Friday evening, in the University’s Holly Auditorium, excel he did.

At the end of the presentation, I asked the question; “Do you think that the intersection of medicine and music includes the continuity between the physics of harmonics in music and the science of equilibrium and balance in medicine?”  How are these related? 

If you place a thousand tuning forks in a room and then you “sound” one by striking it, all of the tuning forks which are of the same frequency or a multiple of that frequency will begin to vibrate.  They will “sound together” This is the same principle of the orchestra, where many instruments, each of which create a different sound by a different method, together make a harmonious sound.  The Greek word symphonia is transliterated into English which addresses this concept and from which we get our word “symphony.”  In a composition, there may be dissonance or cacophony, or what is called a “fugue.”  Yet, out of this sound, which may seem chaotic, the composer will weave a resolution into a melodic and lovely crescendo.  The language of music is made up, like the language of discourse, of thesis, antitheses and ultimately a synthesis. 

In medicine, we find patients whose bodily systems have become disharmonious and/or chaotic.  Our goal is to restore the balance, the equilibrium, indeed, the harmony of the body.  Because music is a metaphor for medicine and medicine is a metaphor for music, treatment can often create a temporary “physical cacophony” in the life and body of the patient, which is resolved in the end by the healthful restoring of equilibrium and harmony.  In oncology, we give patients whose bodies are out of balance, a “fugue” of chemotherapy, with the hope and expectation that in the end balance will be restored.  In ancient religious literature, we find examples of music alone restoring mental balance and health.

Sound is produced by vibrations and music is a special sound.  Most musical instruments utilize a “sounding board,” such as in the piano, to sustain, clarify, and shape the sound of the strings struck by a “hammer.”  If you take a Swiss music box and hold it in your hand, it produces a pleasant sound, but if you place it on a wooden surface, the wood becomes a “sounding board,” which will project the rich sound throughout the house.  “Sounding forth” is the meaning of the Greek word execheo, in which you can see and hear the word “echo.”  In one document, execheo is translated “sounding board.”   Without the “sounding board,’ the piano forte sounds like a harpsichord but with the sounding board, the music is melodious and beautiful.

Each of the alumni are the “sounding board,” the “sounding forth,” the execheo of our professors and of our School of Medicine.  We “re-sound” the lives and message of our teachers through our lives, adding the harmony of our own lives to theirs.  Without us as the “sounding board,” the knowledge and skills of our professors are limited in scope and outreach.

As individually, we are the ‘echo” of our teachers, we collectively are the symphony of them.  It is as the student who felt worthless stated at the end of Glenn Holland’s career in the movie, Mr. Holand’s Opus.  Now the governor of the state. and a self-confident and accomplished woman, this once timid child said:

“Mr. Holland had a profound influence on my life and on a lot of lives I know. But I have a feeling that he considers a great part of his own life misspent. Rumor had it he was always working on this symphony of his. And this was going to make him famous, rich, probably both. But Mr. Holland isn't rich and he isn't famous, at least not outside of our little town. So it might be easy for him to think himself a failure. But he would be wrong, because I think that he's achieved a success far beyond riches and fame. Look around you. There is not a life in this room that you have not touched, and each of us is a better person because of you. We are your symphony Mr. Holland. We are the melodies and the notes of your opus. We are the music of your life.”

Harmony and equilibrium, whether in music or medicine, are the physicians’ or the musicians’ goals which are the same and often their methods overlap as well.  The following story tells you how the harmony and equilibrium €“ the health €“ was restored to a patient’s life without curing his disease.

In February, 2009, I saw a patient in the hospital for the first time.  He was angry, hostile, bitter and depressed.  It was impossible to coax him out of his mood. Nurses did not want to go into his room, he was so unpleasant..  I was seeing him for one of my partners and he was new to our practice.  He had no insurance and no job.  When he was ready to leave the hospital, I gave him an appointment to see me, even though he was not my patient.  

In his follow-up visit, his affect had not changed.   In that visit, I discovered the patient was only taking four of nine medications because of expense.  He could not afford gas to get the education he needed about his condition. He was genuinely disabled and could not work.  He was losing his eyesight and could not afford to see an ophthalmologist.  He did not know how to apply for disability.  His diabetes had never been treated to goal.

When he left that visit, he had:

1. An appointment to SETMA’s American Diabetes Association-approved diabetes self management education program.  The fees for the education program were waived. 
2. A gas card paid for my SETMA’s Foundation with which to pay for the fuel to get the education which is critical to his care. 
3. All of his medication as SETMA’s staff negotiated a reduced cost with the patient’s pharmacy and made it possible for the pharmacy to bill The SETMA Foundation. 
4. Assistance from SETMA’s Care Coordination Department in his application for Social Security disability. 
5. A visit that day with SETMA’s ophthalmologist who arranged a referral to an experimental eye-preservation program in Houston, which was free. 

Six weeks later, the patient returned for a follow-up visit.  He had something which I could not prescribe for him; he had hope.  He was smiling and happy.  Without anti-depressants, or sedatives, he was no longer depressed as he now believed there was life after being diagnosed with diabetes for ten years.  And, for the first time, his diabetes was treated to goal. I continued to see him. Eighteen months later, he was in for a scheduled visit; he was sad. I asked him what the problem was and he said that he was afraid that we would get tired of helping him.  He had applied for and had received disability but he would not be eligible for Medicare for two years.  In two years. without care, he would be blind, in kidney failure, or dead.  He asked if we would stop helping him.  I said, “Yes, we will.  Absolutely, the day after we go bankrupt.”  Melodramatic, yes, but true.  He smiled and relaxed. He now has Medicare; his diabetes is still controlled, and he is doing well. 

Healthcare providers have always been warned about “transference,” which essentially is an emotional bond which a patient develops with a provider and which a provider can also develop with a patient.  While there is a caution to be heeded here, in patient-centered medical home, there is an appropriate bond which develops between patients and providers.  This bond is a caring compassion which has appropriate boundaries but is essential for trust and hope to power a medical home partially funded by a Foundation.

Conclusion

I realize that my “instrument” which contributes to the symphony created by the alumni of our School of Medicine will someday be silenced.  And, as I often try to hear each of the instruments in the orchestra and cannot, sometimes the melody of our lives is absorbed by the whole so that we become anonymous contributors to the opus.  But whether recognized or not, until that time, the honor which you have bestowed upon me is received with the humility of knowing that many worthy recipients will never be so honored publicly  And that humility will engendered in me the diligence and discipline which is the result of knowing that I have received more than I deserve and that the cost of it to me was less than it is worth and that  though I should work diligently for the rest of my life, I shall never satisfy the “dept of love and gratitude” which I owe to you all.

I am deeply grateful for this weekend. I thank you and I wish God’s blessings upon you all.

James L. Holly, MD