European Journal of Cardio-thoracic Surgery 39 (2011) 1—5

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EACTS Presidential Address

The surgeon and the musician§

Pascal R. Vouhé *
Department of Pediatric Cardiac Surgery — University Paris Descartes and Sick Children Hospital, Paris, France

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‘Without music, life would be a mistake.’ Friederich 2. First movement: listening to music during surgery
Nietzsche (1844—1900) (medical employment of music)

There is a strong evidence that listening to music during

‘Everything is music. A painting, a landscape, a book, a
journey is worth only if its music can be heard.’
Jacques de Bourbon-Busset (1912—2001)
1. Prelude
These two quotations encapsulate my personal thinking
about music. I cannot imagine my life without listening to
music most of the time. Being both a surgeon and an amateur
musician, I have been, for a long time, intrigued by the
potential relations between medicine and music (Fig. 1).
Indeed there have been in history, many famous people
who were both musicians and physicians or surgeons [1]. Just
in the field of cardio-thoracic medicine, Leopold Joseph
Auenbrugger (1722—1809) and René Théophile Hyacinthe
Laënnec (1781—1826) provide brilliant examples; both were
composers and excellent musicians; the former described
chest percussion and the latter invented the stethoscope;
both were able to use their musical abilities to implement
their medical achievements.
In a recent paper, H.M. Evans described three potential
relations between medicine and music: (1) medical employ-
ment of music, (2) medical explanation of music and (3)
music as a metaphor for medicine [2]. I would like to follow
the same pathway to explore the potential relations between
surgery and music and to try to convince the readers that
surgery may also be music.
§
Presented at the 24th Annual Meeting of the European Association for
Cardio-thoracic Surgery, Geneva, Switzerland, September 11—15, 2010.
* Corresponding author. Address: Chirurgie Cardiaque Pédiatrique, Hôpital
Necker — Enfants Malades, 149 rue de Sèvres, 75015 Paris, France.
Tel.: +33 1 44 38 18 67; fax: +33 1 44 38 19 11.
E-mail address: pascal.vouhe@nck.aphp.fr.
and after surgery is beneficial to surgical patients [3—6].
Music has been shown to decrease pain, stress and anxiety
and to reduce the needs for analgesic and anesthetic drugs.
There are many surgical centers in which music is used as a
routine in the operating room as well as in the intensive care
unit.
Less attention has been paid to the potential effects of
music on the operating room staff. There is nevertheless
convincing evidence that music may be beneficial to surgical
teams as well.
In a recent study, physicians and nurses working in the
operating room in three different hospitals were interviewed
to evaluate the perception of the influence of music [7]. Most
of the participants (93%) reported to listen to music on a
regular basis outside the hospital and a majority (63%) on a
routine basis in the operating room. Most professionals (63%)
considered that music had a positive effect on staff
communication and nearly 80% claimed that music made
people calmer and/or more efficient.
Allen and Blascovich have studied the autonomic
responses and the intellectual performance of surgeons
during a standard laboratory psychological stressor [8]. Fifty
senior surgeons, who reported to listen to music regularly
during surgery, were asked to perform serial arithmetic tasks
under three different conditions: silence, investigator-
selected music (Pachelbel’s Canon in D) and self-selected
music. Autonomic reactivity (as assessed on heart rate,
systolic blood pressure and skin conductance) was signifi-
cantly reduced in the surgeon-selected music condition than
in the investigator-selected music condition, which in turn
was significantly less than in the no-music control condition.
Likewise, speed and accuracy of task performance were
significantly better in the surgeon-selected music condition
than in the experimenter-selected music condition, which
was also significantly better than the silence of the control
condition.
The effect of music on surgical performance has been
evaluated in a few studies, involving expert surgeons as well
as junior surgeons. In the first study, eight internationally

1010-7940/$ — see front matter # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.ejcts.2010.11.046
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P.R. Vouhé / European Journal of Cardio-thoracic Surgery 39 (2011) 1—5
Fig. 2. Hypothetical neurohumoral pathway of music action during the human
stress response (reproduced from Conrad C et al. Overture for growth hor-
mone: requiem for interleukin-6? Critical Care Medicine 2007;35:2709—13 with
kind permission of the publisher Lippincott Williams & Wilkins).
Fig. 1. The surgeon and the musician: Pascal Vouhé (left) and Roland Pidoux
(right). Roland Pidoux is Professor of cello at the Paris National Conservatory.
After Pascal Vouhé’s Presidential Address, Roland Pidoux captivated the audi-
ence with his performance of the J.S. Bach’s third Suite for cello solo.
recognized expert surgeons were randomized to perform
three simple tasks on a laparoscopic simulator [9]. The tasks
were performed under the four following conditions: silence,
mental loading (by mental arithmetic tasks), auditory stress
(by dichaotic music, a condition in which a different type of
music is heard through each ear), and auditory relaxation
(listening to classical music by Mozart). End-points of the
study were time to complete the task and its accuracy. All
experts performed the tasks more accurately while listening
to classical music; the effect on time until task completion
was more variable. A very similar study was conducted in a
large group of junior surgeons without laparoscopic experi-
ence [10]. Forty-five novice surgeons were randomly assigned
to three groups: silence, listening to activating music
(classical pieces known to evoke an activated mental
condition, such as Richard Wagner’s ‘Walkyrie’) and listening
to deactivating music (music known to arouse relaxing
emotions, such as Mozart’s piano sonatas). The participants
were asked to subjectively consider the music as pleasant or
unpleasant. The results suggested that the group listening to
activating music had the worst performance; however, there
was a trend toward improvement when participants con-
sidered the music pleasant rather than unpleasant. In a last
study, twelve experienced surgeons undertook complex
laparoscopic tasks on a simulator under three conditions:
silence, noise and music [11]. Speed and accuracy of
performance remained unchanged across the three condi-
tions, suggesting that the intense concentration required by
a complex task, allows experienced surgeons to effectively
‘block out’ noise as well as music.
The exact mechanism by which music might influence
human physiology and particularly reduce stress response
remains hypothetical. A recent study may shed some light on
this matter [12]. Ten critically-ill patients were randomized
into two groups: one group did not receive music whereas the
other group received relaxing music (slow movements from
the Mozart piano sonatas). In the group listening to classical
music, blood pressure was decreased and the need for
additional sedation was reduced; in this group, there was a
significant increase in serum levels of growth hormone and a
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concomitant decrease in serum levels of interleukin-6 and
stress hormones (epinephrine and dehydroepiandrosterone).
These results brought the authors to the following explana-
tion (Fig. 2). Listening to music may stimulate the
hypothalamic—pituitary axis and increase the release of
growth hormone by the pituitary gland. The stimulation of
the hypothalamic—pituitary axis while listening to music may
stem from the transfer effect; it has been reported that
listening to music can lead to an increased activation of brain
regions that are not directly involved in the process of
listening. Some studies have demonstrated that there is an
inverse correlation between growth hormone release and
interleukin-6 release from peripheral blood mononuclear
cells. Interleukin-6 is a potent activator of the adreno-
cortical and sympathoadrenal axes; a decrease in inter-
leukin-6 production may therefore lead to a decrease in
stress hormones release. These data were obtained using
Mozart’s music in critically-ill patients. Further studies are
necessary to investigate how listening to music influences
human physiology in healthy people.
To summarize the first relation between music and
surgery, this is a common observation that music influences
human physiology. Listening to music reduces the cardiovas-
cular responses to stress, provides relaxation and promotes
concentration. There is growing evidence that listening to
music improves manual performance and intellectual
efficiency. For all these reasons, listening to music during
surgery should be beneficial to surgeons and operative room
staff members. However, musical experience and sensibility
to music may vary considerably between individuals and,
therefore, the beneficial effects of listening to music during
surgery may vary accordingly.
3. Second movement: playing music and performing
surgery (medical explanation of music)
The development of modern techniques such as magnetic
resonance imaging (MRI) has made possible to obtain three-
dimensional high resolution images of the living brain.
Statistical approaches allow precise quantification of differ-
ent aspects of brain structure (morphometric MRI). The brain
of living musicians has been extensively studied and
[()TD$FIG] P.R. Vouhé / European Journal of Cardio-thoracic Surgery 39 (2011) 1—5
Fig. 3. Voxel-based morphometric studies have shown that musicians and non-
musicians have different brains (reprinted from Gaser C, Schlaug G. Brain
structures differ between musicians and non-musicians. J Neurosci
2003;23:9240—5 with kind permission of the publisher and the corresponding
author).
compared to the brain of non-musicians (Fig. 3). All these
studies have clearly established that musicians have
structural and functional brain specializations [13—15].
Playing a musical instrument is a complex activity which
requires many cognitive skills (e.g., the translation of
virtually perceived musical symbols into motor commands
with simultaneous auditory monitoring of output). Musical
performance involves several brain areas including the motor
and sensory cortex in the frontal and parietal lobes, the
auditory cortex in the temporal lobe, the anterior portion of
the corpus callosum between both hemispheres and the
cerebellum; accessory areas are involved as well in the
inferior frontal area (music reading), the inferior temporal
cortex (pitch) and the superior parietal area (rhythm).
Structural and functional modifications have been demon-
strated in all these brain regions, when comparing profes-
sional musicians with amateur musicians and non-musicians.
These specializations are often instrument- or effector-
specific and correlate with aspects of the training history
supporting the view that they are the result, rather than the
cause, of skill acquisition [16]. The changes are correlated
with the age at which musical practice has begun and to the
intensity of the practice. The musician brain constitutes a
model, ‘par excellence’, of neuroplasticity. The results
obtained in musicians suggest that structural brain differ-
ences in adult experts (whether musicians or expert in other
areas) are likely due to training-induced brain plasticity [17].
Dysfunctional plasticity in musicians, known as musician’s
dystonia, may even lead to deterioration of extensively
trained fine motor skills.
Some cerebral modifications noted in musicians may,
however, be innate. Some people are born with the ability to
identify a sound by its pitch, without any reference; this is
known as absolute pitch. Absolute pitch has been linked to
one specific structure in the human brain (left planum
temporale). It has been demonstrated that the left planum
temporale in musicians with absolute pitch is more devel-
oped than in musicians without absolute pitch. Discussion is
ongoing to determine whether this specific modification is
congenital or secondary to some form of functional plasticity
which is possible only during a critical period of brain
development.
3
Performing surgery is also a complex human activity
which involves many cerebral functions. It is interesting to
note that playing music and performing surgery have in
common several cognitive skills; this includes: great
accuracy in motor performance, integration of multimodal
sensory and motor information, coordination between eye
and hand, spatial visualization, intense concentration, low
reaction time, efficient mental rotation. It is therefore
reasonable to speculate that musicians and surgeons may
have in common some brain specializations and postulate
that experience in playing music may help in performing
surgery.
In a recent study, 30 novice medical students without
laparoscopic experience were asked to perform simple
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laparoscopic tasks on a simulator [18]. Some students
never played a musical instrument; some used to play but
were not playing anymore and the remaining was currently
playing routinely. The participants, who were currently
playing a musical instrument, performed the laparoscopic
tasks significantly faster than those who did not. The visuo-
spatial abilities used in laparoscopic performance may be
enhanced in individuals involved in playing a musical
instrument.
These data should be put together with other results
which show that learning during sensitive periods of
development does not only affect selectively the develop-
ment of particular skills, but can also influence the brain
response to new learning experiences. This so-called meta-
plasticity (‘learning to learn’) has been demonstrated in
recent studies. Professional pianists showed greater improve-
ment in tactile acuity, following fingertip stimulation [19].
From the surgical point of view, several studies have shown
that experience in playing video games is correlated with
improved surgical performance on skills simulators and in the
operative environment [20—22].
As a summary of the second relation between music and
surgery, it can be said that musicians have special brains and
that playing music and performing surgery have in common a
number of cognitive functions. One could also speculate that
surgeons have a special brain and that playing a musical
instrument may help them in enhancing their surgical
performance. This offers a large field for further research
and thought.
4. Third movement: music as a metaphor for surgery
An organizing metaphor has been defined by Burke as
follows: ‘a device for seeing something in terms of something
else; it brings out the thisness of a that, or the thatness of a
this’. The intellectual goal of an organizing metaphor is to
provide a detailed analysis of both terms of the comparison,
but the practical goal is to enlarge our understanding
productively.
My purpose is to show that a detailed analysis of music
performance may enlarge our vision of surgical practice. Most
human activities are based on a tripartite concept made of
the performer, the practice and the recipient. In music, the
triad includes the musician, the interpretation and the
listener; in surgery, it includes the surgeon, the operation and
the patient.
4 P.R. Vouhé / European Journal of Cardio-thoracic Surgery 39 (2011) 1—5
4.1. The performer: musician and surgeon
To achieve an optimal performance (musical or surgical),
the performer should be an expert. The question then arises
to know how to acquire expertise.
For many years, the prevalent accepted theory suggested
a single factor, deliberate practice, as the necessary
component for acquiring expertise in a given field [23].
Deliberate practice includes all the voluntary activities which
are designed specifically to improve performance. The
validity of this theory has been established for various
activities, including sports, music, chess, mathematics, and
even medical diagnosis. Deliberate practice should be
started as young as possible and carried out intensively for
a long period of time (at least 10 years). Intense deliberate
practice leads probably to domain-specific cognitive mod-
ifications, an example of neuroplasticity.
The deliberate practice theory has been improved, at
least in the musical domain, by the summation theory, as
proposed by Detterman and Ruthsatz [24]. In addition to high
motivation and intense deliberate practice which remain the
leading factors, expert musicians have a general intelligence
above the average population and domain-specific skills,
known as musical intelligence. Musical intelligence includes a
combination of technical and expressive abilities which are
mandatory for musical practice. Interestingly, specific tests
(such the Gordon’s Test of Music Audiation) have been
developed to evaluate musical aptitude and the potential to
learn in the musical domain. Expert musicians are bright
(high intelligence quotient), exceptionally talented
(enhanced domain-specific skills) and highly motivated
(intense deliberate practice).
I believe that these data can productively be applied to
the education of expert surgeons. In most European countries
there is currently a disturbing situation; bright young people
are not attracted by medical studies anymore, and bright
medical students are not attracted by a surgical career; this
situation must be changed and the brightest students should
be prompted to become surgeons. The most talented of them
should then be selected; it is therefore necessary to design
specific tests to evaluate the potential technical and
psychological abilities to perform surgery. Once selected,
young surgeons must be trained as early as possible,
intensively and efficiently (including animal laboratories,
simulators and clinical practice).
4.2. The practice: interpretation and operation
It is intriguing to note that, at least in the English
language, the same words are used to describe both
practices: a musical ‘performance’ is produced in a ‘theatre’
and a surgical procedure is ‘performed’ in an ‘operating
theatre’. However, the metaphor can be carried out much
further than this simple semantic analogy.
Most of the qualities developed by musicians during
performance, can be applied metaphorically to surgical
practice:
Concentration. Intense concentration is a basic require-
ment for both musical performance and difficult surgical
procedures.
Strictness. A strict respect of the musical score is
obviously mandatory. Similarly, the steps of a surgical
procedure must be followed strictly to provide a
satisfactory outcome.
Anticipation. A musician is reading the score many bars in
advance of what he or she is playing. A surgeon should also
prepare subsequent surgical steps well in advance.
Improvisation. Improvisation is the essence of jazz music.
Even in classical music, there is place for some
improvisation called rubato; this makes the expressive
differences in interpretation between several performers.
Improvisation in surgery is necessary to take care of any
unexpected operative event.
Virtuosity. Musical virtuosity includes several elements
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such as style, elegance, rhythm, spontaneity, rapidity or
risk-taking. The same words can be used to define surgical
virtuosity which makes a surgical operation safer and
quicker.
Ability to listen. A mandatory quality for a musician is the
ability to listen to other musicians. In a surgical team, the
surgeon should also be able to listen to the ideas and
concerns of all the other team members.
Capacity to create harmony. Harmony is the essence of
musical performance. This a common experience that an
efficient surgical team is constituted by a group of several
people, physicians and nurses, working in harmony.
I am convinced from personal experience, that developing
those qualities inherent to musical practice and adapting
them to surgery could improve surgical performance.
4.3. The recipient: listener and patient
The recipient, third element of the operative triad, is the
actual finality.
The finality of music is to arouse in the listener emotions of
all kinds. According to the external circumstances and the
music itself, these emotions could provide pleasure,
refreshment, consolation or fulfillment and, finally, restore
harmony and well-being [25]. As previously discussed, recent
studies begin to elucidate the physiologic mechanisms by
which listening to music may influence human physiology and
psychology.
The finality of surgery is, apparently, simple; it is to
restore normal anatomy or physiology. This is, actually, the
finality of surgical ‘science’, which is disease-centered and
based on procedures, techniques and evidence-based pro-
tocols. This is forgetting the humanistic dimension of
medicine (and surgery) which is medical humanism, often
called medical ‘art’ [26]. Humanism in medicine can be
defined as those aspects of patient care which, in addition to
restoring good health, include meeting patient’s needs for
harmony and well-being. It is centered on the patient as a
whole, not only on the disease. The finality of medical
humanism is therefore pretty much similar to that of music.
The core qualities of medical humanism are empathy and
compassion.
During the last century, medical science has obviously
been privileged and medical humanism devalued in favor of
techniques and procedures. However, it is increasingly
 P.R. Vouhé / European Journal of Cardio-thoracic Surgery 39 (2011) 1—5
recognized that an appropriate balance should be restored
and maintained between medical science and medical
humanism. Consequently, humanism should be an important
component in the curriculum of medical and surgical studies.
Arts (such as literature, poetry, painting or photography)
are commonly used to teach humanities. Music is used as
well. Music may even be the best suited art to teach
humanism and to evaluate humanistic qualities in students
and residents [27]. Music teaches how to listen, an essential
step in the learning of empathy and compassion. Music is a
universal language that everybody can use and understand.
Music is probably the most emotive art and the most
powerful in arousing human emotions. For all these reasons,
many educationalists think that music is the best suited art
to teach emotionally-based subjects such as humanities and
ethics.
To summarize, the organizing metaphor involving musical
performance and surgical practice may be very productive
and enlarge our vision of surgery. It may help in selecting and
training young surgeons, in improving surgical efficiency and,
most importantly, in restoring the patient as the center of
surgical practice.
5. Coda
As quoted as preamble to this address, Friederich
Nietzsche stated that ‘without music, life would be a
mistake’. My purpose has been to show that the relations
between music and surgery are multiple, intimate, diversi-
fied and fruitful.
At the risk of overdoing the metaphor, I would like to
paraphrase Nietzsche and suggest that ‘without music,
surgery may be a mistake’.
Acknowledgement
I wish to thank Professor Marc de Leval for his critical and
thoughtful review of the manuscript.
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