Desmond O’Neill: HIP medicine

Des O Neill 2015In the last month I have had two wonderful musical experiences in Dublin, each causing me to reflect on one of the key challenges of medicine, that of getting to the core of what is troubling people who seek medical attention.

Each of the performances was from music ensembles who seek to perform music in a fashion that as closely as possible resembles what the composer would have heard at that the time. Tuning, instruments, and musical styles have changed over the years and what we now hear is substantially different from what listeners in the baroque and classical eras would have heard.

This is analogous to the many layers of technology, tests, and form filling that can hinder our ability to get to the core of what troubles people, and distract us from the key element of the diagnostic and therapeutic process: the history outlining the personal narrative.

In trying to develop an authentic approach to music, one of the challenges is that music performance is a transient experience, and it is difficult to describe what has happened afterwards. As Mendelssohn wrote, it is not that music is too imprecise for words, it is too precise.

The former music critic of the New Yorker, Andrew Porter, developed a helpful term, historically informed performance (HIP), to describe how efforts to recreate the wishes of the composer would always be imperfect but that didn’t mean that we shouldn’t strive in this direction.

And so, with careful attention to either original instruments or modern reproductions which can be radically different to modern versions, and through changes in style such as vibrato and phrasing, we have generally been accorded radical and fresh new experiences, rather like seeing an Old Master carefully restored.

And so it was with the Freiburg Baroque Orchestra reconceptualizing Mozart, notably through the use of a reproduction of an early form of the clarinet, the clarinet d’amour, very likely used in Mozart’s time. Without mechanical keys and with a wooden bell reminiscent of a saxophone, the instrument included a low stop played by pressing it against the performer’s knee! The plaintive and gentle sound was affecting and refreshing.

An even more sublime experience was the Bach B Minor Mass with the Bach Collegium Japan and their conductor Masaaki Suzuki. Their fantastic musicianship was expressed through wonderful period instruments which added a heady mix of gentleness (wooden flutes and reedy bassoons) and excitement (valveless trumpets and timpani played with wooden sticks) with period style singing and performance.

This search to get to the core truth and experience of the music, while recognizing that there will always be some speculation and imperfection, parallels the search in good medical practice to get to the core of what the patient is experiencing.

What the clinician should be seeking is what Oscar Wilde described in De Profundis: “What the artist is always looking for is the mode of existence in which soul and body are one and indivisible: in which the outward is expressive of the inward: in which form reveals.”

So our major challenge in medical environment where so much technology is available is to ensure that students and trainees do not get distracted from the central tenet of medicine, which is that 80% of diagnoses arise from taking a history.

Just as HIP musicians try to strip away the accumulated layers of style and changes in the structure and strength of instruments, so too the treating doctor needs in the first instance to listen carefully and proceed through the deceptively simple but sophisticated process that is the medical history.

Diagnostic tests should only be ordered or reviewed after this, but the processes in modern medicine are such that these may be available before the doctor sees the patient, and it is hugely important that the temptation to peek is resisted. Otherwise there is the danger of Procrustean error: Procrustes was the inn-keeper of mythology who had a bed of one size, and either stretched or trimmed the legs of those who did not fit. Seeing test results before taking the history can skew the process in a similar manner.

Protecting the centrality of the history and narrative in medical care is, and will be, a key challenge to medical care in an ever more complex system, but movements such as narrative medicine and the medical humanities provide some reassurance that medicine can stay “HIP.”

Desmond O’Neill is a geriatrician and an educator on the TCD Massive Open Online Course on ageing.