Medicine is a learned profession, but clinical practice is above all a matter of performance, in the best and deepest sense of the word. Because music is, at its core, a pure distillate of real-time performance, musicians are in an excellent position to teach us about better ways to become and remain expert performers in health care and ways for our teachers and mentors to help us do that. Ten features of the professionalization of musicians offer us lessons on how the clinical practice of medicine might be learned, taught, and performed more effectively.
(Citação do resumo do artigo.)
“At least 10 aspects of the professionalization of musicians offer lessons on how health care practice might be learned, taught, and accomplished more effectively.”
Performance
“The lesson: Although medicine is inarguably a learned profession, clinical practice is above all a matter of performance, in the best and deepest sense of the word. However, the performance aspect of medicine has been overshadowed in the past 150 years by the irresistible pressure to master an enormous, complex, and ever-changing scientific knowledge base. Recognition of music’s laser-like focus on performance could help us regain a more appropriate balance in medicine between knowledge and performance (between knowing and knowing how).”
Coaching
“The lesson: Great teachers in music are coaches, not lecturers. Coaches watch, listen, and provide the feedback that closes the experiential learning cycle; that helps learners acquire the advanced professional skills of reflection-in-action and reflection-on-action that they need to become expert performers. It is not coincidence that Donald Schön observed teaching sessions in both medicine and music in his now-classic field studies of how practitioners in applied disciplines acquire their expertise. Although knowledge transfer will always be a basic element of medical education, lectures, readings, and discussions are enabling elements of experiential learning — means, rather than ends – and coaching at the highest level is the appropriate model for clinical teaching. Unfortunately, mastery of coaching in medicine is still not seriously taught, rewarded, or studied. It must be.”
Stardom
“The lesson: Few health professionals become international experts, which is just as well, because neither health care delivery nor medical education could function if they depended mostly on superstars. The small number of master clinicians who become exceptional teachers apparently do so by learning to step away partially from their performance role even while they are performing, which lets them help their students move back and forth between being actor and observer. We do not know how those teachers acquire that particular multitasking ability. We need to find out.”
Talent
“The lesson: Just as a person with a tin ear would be ill-advised to choose a career in music, a person who faints at the sight of blood or is uncomfortable when talking with people should probably steer clear of a medical career. But it is equally reasonable to expect that almost anyone with certain basic abilities (for example, a stable personality, lively curiosity, good problem-solving skills, a moderately hypertrophied work ethic, and a deep satisfaction in relieving other persons’ distress) can become a terrific physician without also needing the medical equivalent of perfect pitch or other similar gifts.”
Time
“The lesson: Medical school and residency together already involve at least the estimated 7 to 10 years of focused involvement and 10,000 hours of practice needed to go beyond deliberative rationality to the level of true professional expertise; surgeons may need substantially more time to master both the cognitive and technical aspects of their specialty. Because current medical training is riddled with inefficiencies and has become almost intolerably expensive, medical educators are now exploring accelerated systems for ‘training to competence’. Although such programs seem both rational and promising, they need to be approached with caution, lest we end up creating cohorts of prodigies rather than wise decision makers and mature healers. Growing up takes time.”
Art
“The lesson: Medicine is not just science, but a ’professional, science-using, inter-level interpretive activity taken for the care of a sick person’; it is, as is often said, both science and art. Unfortunately, the lesson from music is unclear here, because we know musical technique is teachable but do not understand the sources of musicality any more than we understand the sources of the personal strengths, limitations, or styles of health professionals. Exploring the nontechnical aspects of performance should be a serious research endeavor in both disciplines. (Neuroscience might even help.)”
Practice
“The lesson: If dedicated practice is an essential element in clinical teaching, the current clinical training system seems to come up short, although the increasing use of feedback from audio and videotapes, role-playing, and simulations are steps in the right direction. Extensive time in real-world clinical practice teaches many unique and important skills. Unfortunately, it may not fully protect against some worsening of patient outcomes, in part, perhaps, because over time clinicians’ diagnostic thinking tends increasingly to premature closure and may become less flexible.
As attractive as it might be in principle, taking substantial amounts of time away from real-time clinical care to rehearse being a better clinician is obviously not realistic. One potentially useful way out of this dilemma might be to find ways to make daily clinical work serve simultaneously as practice in both senses of the word: delivering care and refining the skills of delivering it. Could exercises, such as periodic (perhaps random) critical self-review of videotaped office visits or operative procedures, be of help here?”
Teamwork
“The lesson: Even more than musical performance, clinical practice is inherently a team activity, but doctors, in particular, continue to be socialized primarily as autonomous agents; serious, formal rehearsing in multidisciplinary groups is the exception. Peers often learn informally to function quite well as medical teams; the harder part is reconciling teamwork with the diversity in age, experience, power, and status of most working clinical groups. But unless the training and practice of all health professionals seriously comes to grip with these realities, medical care will continue to be shot through with unnecessary and disruptive cacophony.”
Repertoire
“The lesson: Developing a basic repertoire of practices and procedures in medicine is as important as achieving total fluidity in scales and arpeggios in music, but clinical practice at its highest level requires deviating from these repertoires in response to particular patients in particular contexts. Of note, the requisite skills for making the necessary adjustments and departures in medical interviews have much in common with the skills jazz musicians use in improvising: creating communicative space, developing a voice, and cultivating an ensemble.”
Specialization
“The lesson: The powerful drive to specialization in music suggests that specialization is an inherent quality of all highly demanding performance arts, a hypothesis supported by the seemingly endless emergence of medical subspecialties and sub-subspecialties as new technologies and biological developments emerge. A deeper understanding of what governs the choice of medical specialty could help adjust the mix of practitioners to the needs of the care system, particularly because the system seems to need a great many more conductors.”
Bibliografia:
Davidoff, F. Music Lessons: What Musicians Can Teach Doctors (and Other Health Professionals). Ann Intern Med. 2011;154:426-9.
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