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
• Brahm's meditation

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 By Emily Ferrara – used by permission.
after William Carlos Williams Not in print.
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.

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, traduzione di sabine pascarelli. 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)