1. Space between two notes:Dissonance in healthcare encounters Suzana Makowski, MD MMM FACP Assistant Professor of Medicine Palliative Care UMass Medical School, UMass Memorial Healthcare

2. My life is not this steeply sloping hour In which you see me hurrying. Much stands behind me; I stand before it like a tree; (and you look like a tree there, for a moment) I stand before it like a tree; I am only one of my many mouths, and at that, the one that would be still the soonest. (By this time the person you ran into is backing off down the corridor. Then you follow them, and you say,) I am the rest between two notes, which are somehow always in discord because Death's note wants to climb over— but in the dark interval, reconciled, they stay there, trembling, And the song goes on, beautiful. (from Selected Poems of Rainer Maria Rilke (Translated by Robert Bly)

3. Dissonance Let me explain dissonance. Dissonance can be described as notes whose frequencies are less than "harmonious” to our ears. For instance, playing notes that are one half-step apart (open first-string E played with the fourth fret of the second string, a D#) is considered dissonant by most people. Playing notes that are a major seventh interval apart, 11 frets, is also considered to be quite dissonant; for instance, play the open second string (B) together with the 6th fret of the first string (A#). However, dissonance is a requisite part of most music that we hear, providing it with "tension" that leads to "release. "Without it, we end up with music that tends to command little attention. - Mark Hanson

4. Dissonance

5. How are we taught? Official teachings Unofficial teachings Patient encounters Colleagues Interdisciplinary interactions

6. The physician-patient encounter Bad News in the ER The serious young doctor started the story at the beginning. “Your son was at a concert when he collapsed.” Can I see him? “An ambulance was called. EMTs started CPR.” Where is he? “They tried to revive him, but got no response.” Please... “They brought him here. We worked a long time.” Oh God. “We didn’t want to give up. He was so young.” I searched the doctor for sorrow found a stoic earnestness. He ended with an apology. “I’m so sorry,” he said, as if he’d hurt my feelings, as if I could forgive him. Alchemy of Grief – Emily Ferrara First published in Family Medicine

7. I have spoken… I have heard

8. Difficult encounters The meaning of distress is as important as the symptoms themselves. – Eric Cassell Curiosity: with where this is coming from, how despair will manifest, and how/whether resolve will follow. “There is only one way to understand the other person’s story, and that is by being curious. Instead of asking yourself, ‘How can they think that?!’ ask yourself, “I wonder what information they have that I don’t?’… Certainty locks us out of their story, curiosity leads us in.” (page 37 – Difficult Conversations)

9. Lessons from Mahler and Brahms

10. Dissonance - Resolution Reflection on listening to Dr. O’Reilly speak of Mahler and when you listened to Brahm’s: Act of listening What happened in the piece? What did you experience? “Something about Music directly links us to the Eternal, the Divine, the Spiritual. […] It’s the sense of awe that is awakened in us at moments in life when something helps us get in touch with the fact that the material world is just the smallest part of the wonder of it all. So I think healing has to do with slowing down, coming into the present, listening, accepting, forgiving, entering into community with, and healing is prevented by the opposites of those things.” - Balfour Mount, MD

11. “Good listening requires an open and honest curiosity about the other person, and a willingness and ability to keep the spotlight on them. Buried emotions draw the spotlight back to us...Our listening ability often increases remarkably once we have expressed our own strong feelings.” (page 90 - Difficult Conversations)

12. Outside the patient’s room… Other physicians, Nurses, social workers, Administrators… How do these principles apply?

13. Ladder of Inference – Peter Senge Fifth Discipline Fieldbook, 1994 “We all have different stories about the world because we each take in different information and then interpret this information in our own unique ways. In difficult conversations, too often we trade only conclusions back and forth, without stepping down to where most of the real action is: the information and interpretations that lead each of us to see the world as we do.” (page 31 Difficult Conversations)

14. Dissonance and Empathy What is our role? To be honest To lend strength and alleviate suffering How do we not burn out? Exquisite empathy Self-awareness practice Solitude Kearney MK, Weininger RB, Vachon ML, Harrison RL, Mount BM. Self-care of physicians caring for patients at the end of life: "Being connected... a key to my survival". JAMA 2009 Mar 18;301(11):1155-64, E1.

15. The Prerequisite to Practice:It’s more than “self-care” Mindfulness practices/compassion practice: meditation, music… Story-telling Narratives Medical Humanities Solitude, reflection Study (Lutz, Davidson) showed that long-term meditators on compassion’s response to vicarious suffering surprising.

16. On Breaking Bad News after William Carlos Williams Nourish the subtle body between “I” doctor, and “Thou” patient. Tend not to the news—for lack of what is found there (men die every day)—but to what is found between. The unarticulated fear, sadness palpable in the deepening dark, broken by touch, eyes brimming hollyhocks, double-blossomed white and multiple magentas take breath give life, subtle body, what is found is nourished, is all we have. Lean in. By Emily Ferrara – used by permission. Not in print.

17. Some Resources http://www.upaya.org/bwd/ http://litmed.med.nyu.edu/Main?action=new http://www.umassmed.edu/Content.aspx?id=41252 http://pallimed.org Cassell EJ. AAHPM annual meeting 2009. http://www.aahpm.org/education/09conf/09highlights.html#nature Ferrara E. The alchemy of grief : alchimia del dolore, traduzionedisabinepascarelli. 1st ed. New York, NY: Bordighera Press; 2007. Goleman D. Emotional intelligence. Bantam 10th anniversary hardcover ed. New York: Bantam Books; 2006. Kearney MK, Weininger RB, Vachon ML, Harrison RL, Mount BM. Self-care of physicians caring for patients at the end of life: "Being connected... a key to my survival". JAMA2009 Mar 18;301(11):1155-64, E1. Lutz A, et al. Regulation of the Neural Circuitry of Emotion by Compassion Meditation: Effects of Meditative Expertise. PLoS ONE; 2008. http://psyphz.psych.wisc.edu/web/pubs/2008/LutzRegulationPLoSONE.pdf Martensen RL. A life worth living : a doctor's reflections on illness in a high-tech era. 1st ed. New York: Farrar, Straus and Giroux; 2008. Nepo M. The exquisite risk : daring to live an authentic life. 1st ed. New York: Harmony Books; 2005. Stone D, Patton B, Heen S. Difficult conversations : how to discuss what matters most. New York, N.Y.: Viking; 1999. Drazen RY. A Wayfarer's Journey: Listening to Mahler (movie)