February 7, 2024
The overlap between medicine and musicality is long-standing and well-known. Doctors of all types have excelled at playing musical instruments. For example, famed physician and Nobel Peace Prize winner Albert Schweitzer, MD (1875–1965), worked as a professional organist before attending medical school.1 Theodor Billroth, MD (1829–1894), known as the father of modern abdominal surgery, was an amateur pianist and among the first to research scientific aspects of musicality.2
But what does a pervasive love of music mean for surgeons’ work in the OR? What insights do surgeon-musicians have to offer those whose musical experience extends no farther than hitting play on a stereo? In this article, four surgeon-musicians—Claudius Conrad, MD, PhD, FACS, Jeffrey B. Matthews, MD, FACS, Daniel Shoskes, MD, MSc, FRCS(C), and Joseph A. Dearani, MD, FACS—share their insights.
If anyone knows about music in the OR, it’s Dr. Conrad. After training as a pianist at a conservatory in his native Munich, Germany, he completed both a doctorate in the philosophy of music and a medical degree. He focuses clinically on minimally invasive liver and pancreas cancer surgery in Boston, Massachusetts.
Dr. Conrad also maintains a robust research portfolio on “many domains related to music in clinical medicine,” as he put it, briefly listing studies on the impact of music on patients undergoing surgery, the well-being of patients’ relatives, surgical performance of surgeons with varying experience levels, and team dynamics in the OR.
This comprehensive overview gives Dr. Conrad insight into what surgeons may gain through integrating music. In conversation, those findings flow together with observations from his many years of playing music.
His study3 examined the molecular means by which music may impact the human stress response: “What we found was an interesting inverse correlation between growth hormone and interleukin 6. Growth hormone at that time was considered to be a stress hormone, and it was later found that cells of inflammation have growth hormone receptors on the surface, so that when growth hormone binds with interleukin 6, it is less secreted. So, when you listen to music, your brain will secrete growth hormone that then binds with cells of inflammation, and interleukin 6 is less secreted. That’s the pathway.”
The same general finding—more music, less stress—has consistently shown up in the results of his studies and in his own life and work. As a part of a team attempting challenging and sometimes wholly new surgeries, Dr. Conrad sometimes finds himself needing methods to cope with tremendous stress. “I want to do the best for my patients. So, I not only employ some of the mental mechanisms that I learned to deal with the anxiety of being on stage, but I try to practice the piano more,” he said. “There’s no question that even at this stage of being a relatively senior surgeon, the more I practice the piano, the more relaxed I am. I will use the weekend to practice more to be ready on Monday for a big surgery.”
He also said that practicing sensitizes his fingers to feedback from the patient’s tissues during surgery, explaining the hyperawareness is simply about being relaxed enough to focus on this sensory input, “The more relaxed you are, the entire body leading up to your fingers, the better you will be as a pianist and the better you will be as a surgeon.”
For Daniel Shoskes, MD, MSc, FRCS(C), the connection between music and surgery is less molecular and more metaphorical.
A kidney transplant surgeon by training, Dr. Shoskes transitioned to surgical practice in urology at the Cleveland Clinic in Ohio, and more recently took a position as vice-president of global medical affairs at Pacific Edge Diagnostics, a company focused on bladder cancer diagnostics.
Dr. Shoskes played music in his youth, set it aside while becoming established as a surgeon, and then returned to it. This involved a shift from the cello and guitar of his earlier years to the lute, a stringed instrument with a short neck and a rounded back that was once played worldwide. Since his early 40s, he has played “music from the Renaissance to the Baroque,” a period from the 13th to the 18th centuries.
“I’ve been professional adjacent, in that I have performed with some professional orchestras,” as well as creating four albums, consulting on films, and offering prodigious output via his YouTube channel, Dr. Shoskes said.
For him, improvisation is a key to both music and surgery. “I would have to say that the musical event most similar to a complex surgery is playing continuo, which is primarily in Baroque music, when you’re accompanying a singer or an opera or in the orchestra,” he said, further explaining that only a single bass line and some indications of harmony are planned, with all other elements improvised live by the musicians.
The result is total commitment. “You’re constantly listening. The singer may do a particular ornament, and then you might imitate that over the bass line that you’re playing, or the singer may jump to the third verse instead of the second verse, and you have to adjust to that. So, you’re simultaneously controlling both your hands and reading the music and listening to multiple other musicians and responding to them,” an experience that occupies the mind and body so fully in the present that everything else simply falls away.
The same feeling arises during a complex surgery, particularly “when you know something does not go as planned,” he said. “That’s when you slow your breathing and really become focused. I would say that those skills, when things go wrong in music, that’s like when things are tense in the operating room. That is probably the skill that is most complementary to surgery.”
Dr. Dearani, director of pediatric and adult congenital heart surgery at the Mayo Clinic in Rochester, Minnesota, is a saxophonist, trained in part at the New England Conservatory of Music. He currently plays in a jazz combo called TakeTwo & Friends4 and a charity-focused band of pediatric cardiology clinicians called the Baby Blue Sound Collective,5 as well as maintaining daily music practice that aids in work-life balance and stress management. “I play 4:30 to 5:30 in the morning before I come to work. During the pandemic…I felt like music, to some degree, saved me a little bit.”
He discussed the relationship between musical improvisation and surgery in a 2021 article in The Journal of Thoracic and Cardiovascular Surgery.6 Dr. Dearani wrote that in jazz improvisation as with a Baroque continuo, elements such as harmony are nonnegotiable and the musician has autonomy to otherwise interpret and embellish the score. “This requires intense acuity in communication,” through each musician listening and responding to the notes the other musicians play.6
When players are skilled, excellence can result. “Great jazz performances occur when whole-system thinking is embraced by everyone involved,” including “cross-functional relationships, real-time sharing of firsthand knowledge, highly attuned skills of listening, and in-the-moment design thinking.”6
He posited that the same elements may apply to cardiothoracic surgery. Some procedures (e.g., valve replacement) are highly predictable, with little need and few opportunities for modification. Others, such as corrections for Ebstein anomaly, are far more variable. For these operations to succeed, the surgical team must have skills similar to those required for jazz improvisations: the basic surgical plan—a factor analogous to the nonnegotiable harmony of a song—plus solid technical skills, good communication and teamwork, awareness of each patient’s unique anatomy and pathology, and readiness for all potential mid-procedure changes.
While others revamp their musical skills for surgical purposes, Dr. Matthews, a Harvard-educated surgeon with a practice focused on the pancreas, uses music itself to aid his work in the OR. For 17 years, he has been the chair of surgery and Dallas B. Phemister Distinguished Service Professor of Surgery at The University of Chicago in Illinois.
Alongside his thriving career, Dr. Matthews is a self-described “drooling fanatic” for rock music. His background includes learning to play guitar as a teenager, becoming a punk rocker and radio disc jockey at Harvard in his undergraduate years, and transitioning into a blues and jazz fan later in life. As Dr. Shoskes did (and many other musically inclined surgeons do), he set music aside for years as his career advanced. “When I was in my 40s, I kind of decided, with the encouragement of my wife and kids, to get more seriously back into it again,” he said.
Gradually, he moved from intensive practice to writing his own songs, finally landing at recording albums with a team he described as a Grammy-winning producer, a drummer formerly employed by Paul McCartney, a guitarist who toured with David Bowie and played on John Lennon’s Double Fantasy, and other rockers with similarly illustrious CVs. The songs they record together are available on Spotify and elsewhere. “I don’t have any illusions about the talent level I bring to the table,” Dr. Matthews humbly noted, “but it’s a lot of fun to do.”
While he is impressed with the resumes of his musician colleagues, he said, they are impressed with his surgical achievements. And the connections between music and surgery don’t stop at mutual respect. For Dr. Matthews, music is important in the OR—where the purpose involves targeting attention. “Music helps with my flow,” he said.
Flow in the psychological sense is a term first defined by psychologist Mihaly Csikszentmihalyi, PhD. It is an intense state of concentration in which a person becomes so fully devoted to the task at hand that self-consciousness, awareness of time, and even a focus on one’s own physical needs temporarily vanish. The original impulse to study the phenomenon arose, Dr. Csikszentmihalyi once said, when he realized that artists, including musicians, often had the experience of becoming totally lost in their work.7
A mental state not fully under personal control, flow occurs when the amount of information a person receives is at or near, but not over, their maximum capacity. Through his research, Dr. Csikszentmihalyi eventually pinpointed this at 110 bits of information per second (in comparison, understanding a conversation takes approximately 60 bits per second).7
The Yerkes-Dodson law,8 first defined in 1908 by Robert Yerkes and John Dodson, captures an empirical relationship between physiological or psychological arousal and performance. To wit, increased stimulation improves performance up to a point, after which excessive arousal causes performance to decline. The key to sustaining a state of flow—and thereby maximizing performance—is to perfect the rate of input and the arousal it creates.
The goal of music in the OR, then, is to fine-tune arousal to the right level. In describing immersive operations as akin to an intensive experience of musical improvisation, Drs. Shoskes and Dearani are perhaps nodding to the concept of flow—in that case, flow achieved by maximal absorption in two different kinds of challenging situations.
For other, more routine operative experiences, Dr. Matthews described music itself as a topping-up of the information rate. He noted that it involved adding easily accommodated sound (“It’s sort of about filling in the spaces in the atmosphere”) and covering up extraneous noises (“I find it really distracting to hear people’s conversations around me. So, for me, having the music on allows that to go away”).
Dr. Matthews’s approach is common; most surgeons, including Drs. Conrad and Shoskes, listen to music in the OR. Dr. Dearani noted that music can reduce tension in the surgical theater: “This feeling that making the room completely silent translates into people being more focused—I’m not sure that’s the case. That’s not the case for me, I know.”
But Dr. Matthews’s experience hints that the choice of songs playing in the surgical theater often needs to be precise. Getting it right is no small matter; all the interviewees, as well as the literature on music in surgery,9 agree that there is no guarantee music will aid an operation.
It is a finding that Dr. Conrad could verify through his own research. “I would say you should think about the role of music in the operating room like a drug. There are positive effects, but there can be side effects, and you have to be very strategic in the dosing of your music,” he said.
That includes the volume, which should be neither blasting loud nor whisper quiet; beat frequency, which should be slow to moderate; and shifts in tone and emotional intensity, which should be limited.
Dosage does not necessarily dictate genre, however. Here, tastes can vary. In the OR, Dr. Matthews tends to prefer the genre he plays himself, rock. Dr. Dearani said he has kept the same carefully curated mix of songs by James Taylor, Carole King, and Stan Getz for 25 years. Meanwhile, Dr. Conrad has examined the question of which genre of music is best and strongly favors classical music. As a result, he has created an entire album, Healing Hands, tailored for use in the OR and freely available online.
When referring to the lute music he plays, Dr. Shoskes noted, “My music is good background music,” but specified this was true for “only the people who have no connection with the music I perform,” an audience that of course excludes himself. Knowing the nuances of Renaissance and Baroque music means he taps into the music’s emotional depths, an experience too complex to handle mid-surgery.
“Pop music doesn’t engage me emotionally and intellectually the way this other stuff does,” he said, and this means the procedure itself can be his central focus. In the OR, where flow and the need to improvise can be essential, the only “best” music may be the kind that achieves this exact result.
Whatever one’s involvement with music, it is clearly inextricable from the lives of many surgeons.
Indeed, surgeons’ inquiries into music in surgery go nearly as far back as surgery itself. In addition to the 19th-century inquiries of Dr. Billroth, a 1914 JAMA article, “Phonograph in Operating-Room,”10 raised the option of playing music “for calming and distracting patients.”
That early modern work added to a tradition already more than a millennium old. The medically trained Turco-Persian philosopher Al-Farabi (who, like Dr. Shoskes, played the lute), considered music a form of therapy in his treatise Meaning of the Intellect, written around AD 925, and compared learning music to learning medicine in his Kitab al-Musiqa al-Kabir (Grand Book on Music).1
The centrality of music to human lives is unlikely to abate, too. Dr. Matthews said his lifelong love of music has “deep, deep psychological roots,” a statement less particular to him than a description of nearly all of humanity.11
Music can be uniquely powerful for humans—whether surgeons or anyone else. Dr. Conrad mused, “People go to a concert and have this ecstatic or out-of-body experience that people rarely have from looking at a painting or listening to poetry. And what is it from? It’s nothing. It’s nothing we ingest. It’s just molecules in space that change their frequency. This is unbelievable, right?”
M. Sophia Newman is the Medical Writer and Speechwriter in the ACS Division of Integrated Communications in Chicago, IL.