Space Between Two Notes: Dissonance in Healthcare Encounters by Makowski

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  • Discussion with audience – what is their view of dissonance? Conflict? Can we come to a common understanding?Discomfort in ourselves? In the other? In both?Words, settings, witnessing suffering… Feelings are what define this… “Dying” “will die” “Cancer” “Spread” – how do they feel compared with “metatastasized” “treat”
  • Exercise on what have you done well? Seen done well? Delivery of news, etc. Diads – dialogues. Experiencing counsel.
  • Describe types of encounters… Like the discus thrower, the cake eater… (Kelly’s patient), the patient who wanted to go home.
  • Click clip from DVD player first if possible video clip 4
  • What would have happened if it were just the last stanza? Without the dissonance?
  • This time, turn back to the diad – tell a different story. This time, share a story of a tough incident: witnessed or experienced. Something you feel ok sharing here, now. Remember, listener, your role: to hold these words in complete confidence, to listen, to watch. Don’t touch. Try not to give too many non-verbal cues. Simply watch. Notice what comes up inside of you and in the person before you. Be aware. Be present. When done speaking, simply say, “I have spoken.” After, listener, respond with, “I have heard.” Then change the role.
  • Nurse who feared the morphine…Physician who feared stopping the IV antibiotics…Clinician who changed the goals of care… confusing all…


  • 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
    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
    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,
    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
    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…
    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
    Cassell EJ. AAHPM annual meeting 2009.
    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.
    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)