Caduceus Newsletter: Fall 2012.11, Week of November 5
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Table of Contents:
1. Events coming up.
1. Events coming up.
· Friday, November 9, starting at 5:30 p.m.: Bowlathon for Hope North in Uganda (sponsored by Tri Beta).
2. ===AAMC STAT===, News from the Association of American Medical Colleges, October 29, 2012 edition.
3. Why Obama Would Be Good for Doctors: from Medscape.com
Why Obama Would Be Good for Doctors: http://www.medscape.com/viewarticle/773050?src=mp
Re-electing President Barack Obama and continuing his policies would be better for physicians because millions more Americans will have insurance and be able to pay for healthcare and preventive services, say many physicians who support Obama. Additionally, administrative costs and hassles of dealing with insurers will be reduced, and doctors will play a leading role in new delivery systems to improve care and reduce costs.
Many physician Obama supporters also believe that Obama's economic and tax policies are better for doctors overall -- even if some doctors have to pay higher income taxes -- because those policies will help build a society with a stronger middle class and fewer social problems. And they believe that he would protect public investments in medical research and public health while Mitt Romney's budget plan might slash such spending.
Physicians who back Obama base their support largely on his comprehensive healthcare reform law, the Affordable Care Act (ACA). Although some would have preferred a single-payer, Medicare-for-all model, they say that the ACA finally will move the nation forward in addressing the longstanding problems of lack of healthcare coverage and access, rising costs, quality-of-care gaps, and poorer population health than in other advanced countries.
Like it or not, they say, there's no way to ensure that Americans with preexisting medical conditions can get private insurance without the controversial ACA provision requiring nearly everyone to have insurance, just as there's no way to make insurance affordable to lower-income people without the ACA's subsidies.
"I firmly believe what's best for physicians is getting everyone insured," says Mario Motta, MD, a Salem, Massachusetts, cardiologist who's a member of the American Medical Association House of Delegates. "Whatever person or party gets us to universal healthcare, that's who I have to support because that's what's best in the long run." He believes that the ACA's private insurance expansion is the only way to avoid a "complete government takeover" of health insurance, which he opposes.
In contrast, Mitt Romney's proposals to repeal the ACA and deregulate health insurance would sharply increase the number of uninsured and put even greater financial pressure on physicians. A recent Commonwealth Fund study projects that the number of uninsured Americans under Romney's proposals would soar to 72 million by 2022, while dropping to 27 million under Obama's ACA law. Among nonelderly Americans, 22% would be uninsured in 2022 under Romney's plan, compared with 10% under Obama's law.
Many pro-Obama physicians were appalled at Romney's recent comments that uninsured Americans can always get care in the hospital emergency room and that "we don't have people that become ill, who die in their apartment because they don't have insurance."
"It's really hard to take care of patients when they can't afford their pills or their treatment plan; they delay care until they have to go to the ER, and they skip doctor visits," Dr. Motta says. "All of that is directly attributable to the fact that they don't have insurance. We've pretty much solved that in Massachusetts."
He leans toward Obama but appreciates the Massachusetts coverage expansion law that Romney as governor helped pass, which was the model for the ACA. He's greatly disappointed that Romney has distanced himself from the Massachusetts reform model.
"The president's health plan is certainly better for doctors than having 72 million people without health insurance," agrees Rep. Jim McDermott, MD (D-Wash), a psychiatrist who represents the Seattle area and is a longtime sponsor of Medicare-for-all legislation. "It makes it possible for another 30 million people to have insurance and get preventive care. Doctors don't want to just treat catastrophes; they want to help people be well. That's a major step forward. Romney's alternative is a disaster."
Controlling Costs vs Free Market
Doctors who back Obama believe that the president's regulated-market reform model stands a better chance of controlling costs and preserving smaller physician practices than Romney's deregulated, free-market approach. They note that under the current competitive system, large hospital systems and insurers already are squeezing out independent doctors. And they contend that healthcare can never be a normal market because people don't have enough information to shop for plans and providers, and sick people aren't in a position to shop around.
Obama's reform law establishes a regulated competition system for private insurers who, starting in 2014, will sell standardized benefit plans to individuals and small groups through new state health insurance exchanges. Insurers will have to accept all applicants regardless of preexisting conditions, with limited price variations based on age. In contrast, Romney wants to encourage more insurers to compete and offer a wide range of benefit packages, without having to meet state benefit mandates or accept applicants who haven't had continuous coverage.
"The insurance exchange is good for doctors because then you've got a couple of health plans people will buy, and that cuts down on doctors' back-office work," Dr. McDermott says. "It's a big drag on your office to have to take care of 25 different insurance firms and have all this paperwork. Doctors just want to take care of their patients and get paid."
Other Obama supporters note that the current free-market model is hurting independent doctors who lack bargaining leverage, with many opting to work for hospital systems and larger groups. "Left on its own, the market will kill small private practice, no matter what doctors want to believe," says Robert Berenson, MD, a general internist and health policy fellow at the Urban Institute in Washington, DC.
In contrast, he points to the Accountable Care Organization (ACO) demonstrations launched under the ACA, which lets groups of private physicians band together to streamline care for beneficiaries in traditional Medicare and share in any cost savings if they meet quality targets. Many ACOs have been started by physician-led groups without hospital involvement.
"The ACA set up tests of alternative payment approaches that put doctors back in control of their fate," Dr. Berenson says. "So I think the law provides promise of a better healthcare system in which doctors will have greater satisfaction in their practice."
Obama's approach to Medicare and Medicaid is also better for doctors, Obama supporters argue, because he will preserve the programs as guaranteed benefits, providing patients with certainty that they'll have access to care when they need it. In addition, his reform law enhanced Medicare's preventive and drug coverage and extended the solvency of the program. In contrast, Romney's Medicare voucher proposal means that people "don't know whether they'll have access to affordable care when they are old and sick," says Steve Kagen, MD, an Appleton, Wisconsin, allergist and former Democratic congressman who's proud of his vote for the ACA, which he calls the most important legislation in a century.
Similarly, he adds, Romney's Medicaid block grant plan would "allow states to turn their back on people in need. What kind of nation would we be if we turned our back on children who are ill? By not paying providers their overhead for taking care of people in need, you're turning your back on the community and on providers delivering lifesaving care."
Effect on Society Beyond Doctors
More broadly, physicians who support Obama feel that his economic policies are better for all Americans, and that's good for doctors. "As doctors, we're dependent on a successful middle class, and our best opportunity is expanding the middle class," Dr. Kagen says. "In my view, Obama has the best plan to expand the middle class, by investing in education, clean energy, and infrastructure. Then I'll do better."
Dr. Berenson adds that even though physicians might benefit financially from Romney's proposals to cut taxes for wealthier Americans, "they wouldn't be very happy with a society marked by increasing disparities between the rich and poor, more crime, and more demands on public funding for food and shelter. That's not a world I want to live in."
Regardless of their tax bills, he says that doctors' professional interests lie more with Obama and the Democrats because "at least Democrats are trying to do something about the obvious problems in the healthcare system, while I've seen no evidence that Romney and the Republicans have any views of what should happen. Romney passed a very good law in Massachusetts, he's proud of it, but he can't tell anyone because his party is so Neanderthal on the issue."
The bottom line is that doctors who back President Obama strongly prefer his focus on ensuring that all Americans have access to healthcare and a way to pay for it. "I assume doctors mostly go into the profession because they want the personal satisfaction of improving the health of the public," Dr. Berenson says. "The obvious benefit of Obama's law is that it sets up an environment where doctors can feel proud that they are working in the health system."
1. Collins SR, Guterman S, Nuzum R, Zezza MA, Garber T, Smith J; The Commonwealth Fund. Health care in the 2012 Presidential election: how the Obama and Romney plans stack up.http://www.commonwealthfund.org/Publications/Fund-Reports/2012/Oct/Health-Care-in-the-2012-Presidential-Election.aspx?page=all Accessed October 19, 2012.
Medscape Business of Medicine © 2012 WebMD, LLC
Cite this article: Why Obama Would Be Good for Doctors. Medscape. Oct 25, 2012.
4. Why Romney Would Be Good for Doctors: from Medscape.com
Why Romney Would Be Good for Doctors: http://www.medscape.com/viewarticle/773048?src=mp
Mitt Romney's healthcare approach would be better for America's physicians because it would unleash free-market forces to let doctors deliver quality healthcare, give consumers more private insurance choices, and drive down costs in both private and public insurance programs, say many conservative physicians.
Some physicians who favor Romney say that he will bring positive changes for physicians and the practice of medicine:
• Many physicians backing Romney ardently support his call for repealing President Obama's Affordable Care Act (ACA), which they see as destructive to US healthcare.
• Doctors like Romney's proposal to encourage individual ownership of health insurance by giving people an income tax deduction for premium payments.
• They favor his ideas for deregulating insurance by letting out-of-state insurers sell policies nationally without having to meet state benefits, and boosting high-deductible health plans by letting people pay premiums out of their tax-free health savings accounts.
• And they love that Romney wants to curb medical malpractice lawsuits and reduce defensive medicine by capping noneconomic damages.
These conservative doctors may represent the majority view of physicians. A randomized national survey of 3660 doctors in September 2012, conducted by healthcare staffing firm Jackson & Coker, headquartered in Alpharetta, Georgia, found that 55% of physicians said that they would vote for Romney while 36% would vote for Obama. Male doctors, who comprised 72% of respondents, were far more likely to support Romney, while female doctors, who comprised 28%, were evenly split between the 2 candidates. The percentage who said that the ACA should be repealed and replaced was 55%, with 40% saying that it should be implemented and improved.
Romney supporters admit to some reservations because as Governor of Massachusetts, Romney passed a state healthcare reform law that served as the model for the federal law. Still, supporters say that, on balance, he would be far better than Obama for doctors.
Indeed, some conservatives admit that their presidential vote on November 6 will be as much anti-Obama as pro-Romney. "We have to repeal that monstrous law [the ACA]," says Robert Sewell, MD, a solo practice surgeon in Southlake, Texas, who represents the American Society of General Surgeons in the American Medical Association (AMA) House of Delegates. "I have to take Gov. Romney at his word that, if elected, he would do that. In that case I'm a supporter of his."
Others are more ardent in their support for Romney. "Romney wants to restore the doctor-patient relationship and have healthcare decisions made by patients in conjunction with their doctor, not by a panel of government-appointed bureaucrats," says Scott Atlas, MD, a Stanford University neuroradiologist and Hoover Institution senior health policy fellow who is advising the Romney campaign.
"He focuses on improving private insurance options rather than shifting millions of people into government insurance. That's good, because doctors in general don't want to practice in an environment where their hands are tied in how to diagnose and treat patients," says Dr. Atlas.
They also much prefer Romney's positions on taxes, deregulation, and the economy. While Obama proposes to end the Bush tax cuts on family incomes over $250,000 and says that wealthier Americans should pay more, Romney proposes to keep the Bush tax cut for higher incomes, maintain the lower capital gains rate, reduce income tax rates by 20% across the board, and eliminate the estate tax.
"Rich people are already paying the vast majority of taxes," Dr. Sewell says. "Romney believes that the solution is to increase the number of people with jobs paying taxes. It should be a disgrace that 47% of people don't pay federal income taxes."
No Benefit From Redistributing Wealth
That's echoed by Jane Orient, MD, a Tucson general internist and executive director of the Association of American Physicians and Surgeons, which promotes the private practice of medicine. "Romney believes in free enterprise and he doesn't believe we can solve problems by redistributing wealth, which is what Obamacare is about. Obama believes we can make people better by taking from people who are successful. That's totally destructive to the economy."
Conservative physicians express confidence that Romney's approach would give doctors greater freedom to practice medicine in the way they think is best for patients. They believe Obama's healthcare law puts too much emphasis on trying to keep people healthy through preventive care at the expense of providing high-tech tests and treatments for sick people. They think that it favors primary care physicians over specialists. And they believe that it creates mechanisms that would tell doctors how to practice and limits access to state-of-the-art services.
"Obama's plan shifts spending priorities from specialty care to generalist care, and that's rolling back the clock to the 1950s and dumbing down healthcare," Dr. Atlas contends. "All doctors know that the key to healthcare improvement has been more and more specialist care and more access to technology and innovative drugs."
Dr. Orient says, "The Romney plan boils down to giving people more freedom and doing away with impediments put in place by intellectuals who think they know everything, and that if the federal government sets the rules then everything will be fine."
She believes that Romney's approach is better than Obama's from an overall clinical perspective. "If you put all of the resources into checking blood pressure and free contraceptives and telling patients not to smoke, it takes resources away from taking care of people who are old and sick."
Conservative doctors believe that Romney also would give doctors greater freedom to negotiate fees with insurers and patients and get out from under government-set prices, along the lines of Medicare private contracting legislation introduced by Republican lawmakers. That's because Romney says that he would encourage the growth of health insurance plans that put more financial responsibility on consumers, including high-deductible health savings account (HSA) plans.
"Romney's general attitude is that he's a free-market businessman and that if you bring free-market principles back to medicine, it will be good for everyone, including doctors and patients," Dr. Sewell says.
Dr. Orient argues that Romney's proposals would create a virtuous cycle that would help physicians in smaller practices remain independent. Giving consumers a tax deduction for buying individually owned insurance, allowing out-of-state sales of health insurance policies without state-mandated benefits, and encouraging high-deductible policies all would boost smaller insurers. In turn, independent doctors would have greater negotiating power with those insurers than with larger insurers. In contrast, she says, under Obamacare, independent doctors are "targeted for extinction."
Dr. Atlas argues that the greater competition between insurers will lower premiums and lead to more Americans having insurance -- even without the ACA's refundable tax credits to help people afford coverage, which he calls a "fantasy handout." Romney's plan "reduces prices; more people will have insurance, and that's good for doctors," he says.
Hopefully an Improvement in the Malpractice Madness
Even physicians leaning toward Obama say that Romney's approach toward medical liability is better for doctors. Romney has proposed a federal cap on noneconomic damages in malpractice lawsuits -- a change long sought by organized medicine -- along with alternative dispute resolution of malpractice cases.
"The Affordable Care Act falls way short of what's needed on medical liability. It just kicks the can down the road, and the problem needs to be fixed," says Mario Motta, MD, a Salem, Massachusetts, cardiologist and member of the AMA House of Delegates who generally supports Obama's healthcare policies.
Dr. Robert Sewell strongly favors Romney's damage cap proposal, which his state, Texas, passed in 2003. He says that the Texas cap has resulted in fewer "frivolous" lawsuits, a sharp decline in liability premiums, and an influx of doctors into the state -- though he acknowledges that it still hasn't reduced defensive medicine or overall healthcare costs. "What's driving up the cost of care is defensive medicine, but [the impact of the cap] hasn't filtered into the real world yet," he says.
Doctors who back Romney also say that their candidate's Medicare and Medicaid proposals would help doctors and patients by preserving the fiscal solvency of those programs. Romney wants to turn Medicare into a defined-contribution program in which seniors receive a fixed amount and pick either a private health plan or traditional Medicare. On Medicaid, he would give states a capped block grant and let them run the program with greater flexibility. Dr. Atlas believes that moving more Medicare patients into private health plans would boost payments to doctors and give patients better access to care. "Romney's plan would save Medicare and Medicaid," he says.
A Better Philosophical Fit
Overall, conservative physicians simply find Mitt Romney's philosophical approach a better fit with their own personal and professional worldview. They see themselves as independent physicians and entrepreneurs, and they prefer Romney's vision of expanding free-market medicine over President Obama's model of competition within a more regulated framework.
"I think Romney's platform is right: It's short and it's nonintrusive," Dr. Sewell says. In contrast, he believes that Obama's approach will "make us into employees of the government. I didn't go to medical school, do a surgical residency, and spend 30 years in practice to become a government employee. I'll retire before I allow that to happen."
1. Jackson & Coker. Physicians on the presidential election. September 2012.http://www.jacksoncoker.com/Documents/JCElectionSurveyAnalysis928.pdf Accessed October 16, 2012.
Medscape Business of Medicine © 2012 WebMD, LLC
Cite this article: Why Romney Would Be Good for Doctors. Medscape. Oct 25, 2012.
5. Mending the Brain Through Music – from mescape.com –
Mending the Brain Through Music
Research and clinical experience increasingly support music as medicine. Accessing and manipulating our musical minds can benefit numerous psychiatric, developmental, and neurologic conditions, often more effectively than traditional therapies. Dr. Concetta M. Tomaino, along with noted neurologist and author Dr. Oliver Sacks, cofounded the Institute for Music and Neurologic Function to study the effects of music on the brain and neurologic illness in particular. In light of increasing interest in music therapy and accumulating data supporting the approach, Medscape spoke with Dr. Tomaino about how the brain perceives music and the role of the Beatles in treating neurologic disease.
Medscape: Thanks for speaking with us today, Dr. Tomaino. The Institute for Music and Neurologic Function has been integral to our understanding of how the brain processes music, and how music can be used as therapy in certain neurologic conditions. Can you give us some background on the Institute and discuss your role and work there?
Dr. Tomaino: The Institute was incorporated in 1995 to bridge the worlds of neuroscience and clinical music therapy. It grew out of the work of both myself and Dr. Oliver Sacks, with support from CenterLight Health System (formerly Beth Abraham Family of Health Services).
I'm a music therapist by training, with a master's degree and doctorate in music therapy but also with a strong neuroscience background. Back in the 1970s, I was working in a nursing home and was amazed at how people with end-stage dementia, with little to no cognitive ability or awareness of their surroundings, could still process familiar music. I started wondering whether music could be used as a specific therapy to arouse cognition in patients with severe dementia.
When I came to Beth Abraham in 1980, Oliver Sacks was the attending neurologist and had been asking similar questions about the postencephalitic patients he wrote about in Awakenings, wondering how music and arts affected people who'd lost brain function through disease or trauma. And so we sought each other out and became good friends.
We worked together, him using music to test patients and me clinically applying music to help people recover or improve function. Both of us realized that there was something important going on here, and in the mid-1980s, we began seeking out scientists who could help us study the effects of music on brain function. In 1985, Oliver's book The Man Who Mistook His Wife for a Hat became popular, and I was president of the American Association for Music Therapy. Our administration took notice of the attention both Oliver and I were receiving from the media and asked whether there was something they could help us do to expand upon our ideas. And so the Institute was formed as a center dedicated to studying music and brain and bridging the clinical and neuroscience communities.
Medscape: Can you speak about the origins of music therapy and how it's been used over the years?
Dr. Tomaino: The therapeutic aspects of music have been noted in societies for thousands of years; however, interest really grew around the time of World War II, in part because the Works Progress Administration (WPA) program started bringing musicians into veterans hospitals. Doctors and nurses observed that people who seemed to be totally unresponsive would come to life when music was played. The hospital staff wanted to bring more musicians in, but training was needed to prepare them to better understand the conditions and needs of the patients. The approach gained attention, and eventually music therapy came together as a profession in the late 1940s. We now have a certification board, and the American Association for Music Therapy oversees academic and clinical training approaches.
The scope of music therapy has become very broad. It's been studied and shown effective in psychiatric illness; developmental issues; and medical conditions, including pre- and postoperative settings. However, Dr. Sacks' and my interests and contributions to the field have been in the area of neurologic function.
Medscape: In which neurologic conditions has music therapy shown the greatest effectiveness?
Dr. Tomaino: There are so many, but one of the most recognized areas is motor initiation in patients with neuromuscular and movement disorders, such as Parkinson disease (PD). Patients with PD often have a slowness of movement and a shuffling gait. Music, specifically highly rhythmic music, has been shown -- and there's quite a bit of supporting data here -- to help them in training and coordinating their movements and gait. Music also enhances the length of their stride and improves balance.
Later in the course of PD, cognitive and short-term memory decline are common; in this case, music has been shown to be an effective mnemonic tool, a memory enhancer for remembering basic information -- phone numbers, people, addresses, things like that (I'll get to other forms of dementia in a second). My work and that of some colleagues has also shown that singing and using music to enhance voice and communication is also beneficial for people with PD.
Medscape: Is music therapy used preventatively or symptomatically to address the cognitive component of PD?
Dr. Tomaino: Ideally, it's started early to help prevent memory decline and create new associative memories early in the disease -- linking acquaintances, places, and events, for example, in order to prevent or slow future memory problems and enhance recall. Recent research is really enhancing our knowledge of neuroplasticity. Forming these associations -- these new neuronal connections -- appears to be neuroprotective.
Medscape: Another area researched at the Institute is using music therapy to help patients with nonfluent aphasias recover speech -- patients who comprehend language and know what they want to say, but just can't find the words. How successful has this approach been?
Dr. Tomaino: These are patients who have had damage, such as a stroke, to the Broca region of the brain, in the left frontal lobe. Some do have mild cognitive impairment, but mostly they fully understand what's being said to them -- at least, that's the case in the patients we work with.
We apply several techniques depending on the patient's residual skills: for example, can they sing a simple song and tap their finger along with the rhythm. We cue them to sing along with familiar lyrics from memory and help prompt word retrieval by leaving pauses within the lyrics -- you leave out a few lyrics in a familiar Beatles song and have the patient try to find the words without losing the beat. This helps a great deal. As the person improves, we move toward a more traditional form of melodic intonation therapy (MIT), focusing on the tone and rhythm or normal speech phrases rather than singing lyrics to songs.
Traditional MIT, developed by a team at the Boston Veterans Affairs Hospital in 1973, is being studying by such neuroscientists as Gottfried Schlaug at Harvard Medical School. A simple, 2-tone sequence -- a high and a low pitch -- is used to pattern the inflection of speech. It has 4 levels, beginning with humming and tapping short phrases and gradually moving toward a Sprechstimme, or a more normal rhythmic speech with little melodic change.
Patients are asked to repeat single words with the beat and tones, gradually increasing to more complex phrases, such as "Good morning, how are you today?" [Editor's Note: Imagine each syllable alternating between 2 tones.] The repetition overlaid on the music helps reinforce the patterns of normal speech and helps patients recover words and fluency. Neuroimaging studies indicate compensatory changes in the right frontal lobe areas.
Music therapy is also used to as a psychotherapeutic application in mental illness and can help alleviate stress and anxiety. This has an impact on neurologic function as well; for example, multiple sclerosis symptoms can be exacerbated by stress. Preliminary research shows that music can be an excellent tool for self-relaxation and stress management in these patients. And one of the most fascinating areas in which music is used is dementia and amnesia.
Medscape: Dr. Sacks has written about a number of patients who, despite exhibiting severe amnesia, can remember song lyrics perfectly. What does this say about the neuronal pathways involved in musical memory vs say, declarative memory, our ability to consciously recall information? And what is the therapeutic potential here?
Dr. Tomaino: They are most likely primarily processed by separate brain systems. So a person with dementia or amnesia may not consciously recognize a familiar song, but something in their subconscious knows it's familiar. There are feelings, emotions, or moments of history in there somewhere. And if they listen to those songs, we're realizing that sometimes these feelings or the emotions are so strong that they trigger fleeting glimpses of pieces of memory. If we can work with those fleeting moments and build upon them, maybe stronger connections can be made and more memories experienced.
Medscape: Do the memories and recollections last once the music has stopped?
Dr. Tomaino: It depends on the patient. I've had a few patients with short-term memory problems in whom using music, and progressing from older memories forward, have then been able to recall recent events. In people with Alzheimer-type dementia, who have seemingly lost the ability to recall past events, music with strong emotional ties and meaning can lead to enduring remembrances and recall.
Medscape: Several case reports -- including a recent documentary clip that went viral on YouTube -- have demonstrated how effective music can be in helping patients with dementia open up and engage with their environment. How much of this is an actual heightened sense of awareness vs reflexive neurologic activity in response to the music?
Dr. Tomaino: It's both, depending on the individual. Initially, it's more reflexive and reactive. But if the musical interventions are provided on a regular basis and for longer periods -- 15 minutes, 20 minutes, an hour -- we find that their short-term memory and attention improve over time.
We did some studies years ago that were funded by the New York State Department of Health and engaged people with mid- to late-stage Alzheimer disease in music therapy sessions for 1 hour, 3 times a week for 10 months. We found that over time, their awareness of other people improved significantly. Some even recognized those people by name, increased their group interactions, and demonstrated improvement in memory and awareness -- they once again knew when it was lunch time.
So yes, in patients with dementia, things that you think are lost forever are retrievable over time with this kind of stimulation. I believe there is now scientific evidence showing this -- that when somebody's engaged in an activity that's meaningful, it involves regions of their frontal cortex that stimulate short term memory and attention. Then if you can hold somebody's attention with something that's meaningful for a long period, the very mechanisms that are breaking down in somebody with dementia are actually being enhanced and activated.
Medscape: Interesting. So, music-based therapies work via a variety of musical qualities, with aspects like rhythm, melody, and emotional familiarity having much different effects, respectively?
Dr. Tomaino: Right. There are totally different mechanisms at work here. The emotional and personal connection is important in dementia, whereas in PD, we're looking at the person's ability to perceive and feel the beat. In patients with PD, rhythm is so important and unique to the patient. Instead of just picking a beat and using a metronome, we experiment with different rhythms and rhythmic styles to see what the person responds best to. They have to feel the pulse in order for that pulse to drive their motor function. So when we talk about "music therapy," we're talking about components of music, such as rhythm, tone, melody, harmony, song -- all of these qualities can be used together or individually to affect the patients with certain conditions.
Medscape: I'm curious about how an individual's degree of engagement with music before therapy affects the outcome. Does a person's musical skill or appreciation come into play? Does a classical violinist benefit most from music therapy? A music critic? A Deadhead?
Dr. Tomaino: Anybody can benefit from music therapy, but their background in music can help or hurt them. Most humans have an affinity for sound and can process it in highly complex ways. However, in certain diseases people may lose this ability, and in fact sound may get so distorted that they have a negative response to it, even if they'd loved music before their injury. This is especially evident in people with damage to the right temporal lobe: These patients often lose their perception of pitch. In fact, I think in Musicophilia, Dr. Sacks writes about a classically trained, professional musician who, after localized brain damage, is a quarter tone off in his perception of pitch.
Medscape: That's right. And he ended up just tuning his piano up a quarter step!
Dr. Tomaino: Yes! So that's where the music therapist really has to look at what a person is able to perceive. This patient's perceptive problem probably wouldn't have bothered someone who couldn't tell the difference. With a professional musician, you can imagine that their neural connections to sound and perception are greatly enhanced.
For example, we treated a percussionist who'd had a stroke. The traditional therapy would be to work with the nonaffected side to encourage the intact side of the brain to take over function. For example, a right-handed person would be taught to perform tasks with the left hand. But because percussionists and musicians, by nature of their craft, presumably have stronger bilateral neural representation, we convinced the physical therapist to try working with the affected side of the brain and body. The person was able to regain function. By encouraging the patient to use the affected limb, we try to restore as much function as possible to this limb rather than compensate with the other side.
Medscape: We know that certain areas of the brain are highly dedicated to certain aspects of perception and information processing. The left frontal and temporal lobes are highly involved in speech recognition and production. The occipital cortex processes visual information. But music and sound perception and processing seems to involve numerous regions all over the brain. Can you speak about how the brain perceives and processes music, and how this lends itself to therapeutic applications?
Dr. Tomaino: There are some areas of the brain that are known to be involved in specific aspects of sound processing, mainly through looking at people who have lost certain abilities through certain brain lesions. As I mentioned earlier, patients with a lesion in the right temporal lobe often experience loss of pitch perception. We know that singing is dominant in the right temporal lobe; however, syntax of both speech and music is left dominant. And there are areas on both sides of the brain that inform and coordinate with each other when it comes to music, because music isn't just one specific skill. That said, music processing is incredibly complex, and as far as I know, a complete map of the areas responsible for music and sound processing doesn't yet exist.
This complexity is probably why music is so beneficial as a therapeutic tool. It's processed bilaterally: in the cortex and subcortically, where it stimulates evolutionarily primitive areas of brain function, such as the cerebellum and the basal ganglia. So when a person does have a deficit, there is still some part of the brain functioning properly that is involved in music processing and can be stimulated through sound.
Another interesting aspect here is that in patients with damage to higher cortical regions -- those with frontal temporal dementia (FTD) -- their appreciation for music may change. Oliver wrote about a classically trained musician who didn't care for any other types of music; after developing FTD, he starting liking rock and roll.
Functional imaging studies, such as those by Dr. Schlaug that I mentioned earlier, are really helping us understand neural plasticity as well as which areas of the brain are involved in what. You can first isolate the components of music, studying where pitch is processed, and beat, and melody. Then you can put them all together, and it becomes very complex. With functional imaging, it became possible to literally watch the brain work in real time while it listens to music.
Medscape: In reading Musicophilia, one of the things that really fascinated me was the idea that our memory for music is far more high-fidelity than it is for nonmusical creative sensory stimuli. Our recollections of visual art and narrative are often distorted or approximated; however, musical memories and dreams have been proven highly accurate in pitch, melody, mood, and rhythm. How does this distinguish music therapy from other forms of creative arts-based interventions, such as art and drama therapy?
Dr. Tomaino: I should admit that I used to be biased when I sat on the board for the creative arts therapy coalition, because I knew that music -- especially the components of music, such as rhythm -- could directly affect brain function rather than requiring the interpretation by the arts therapist. I think the big difference is the other arts therapies tend to work psychotherapeutically. And in fact, many music therapists work psychotherapeutically, which can be very effective.
But myself, Dr. Sacks, and a few of our colleagues became interested in the neurologic underpinnings of music and how sound itself could arouse and stimulate basic brain functioning. Whereas art and drama tend toward the emotions and personal associations -- a sense of self and ego, and all those areas of psychotherapy -- the specific components of music can actually affect brain function in a very measurable, functional way.
Because of this, music therapy is one of the therapies still available to people with devastating diseases, such as Alzheimer disease and neuromuscular conditions, in whom the other creative arts therapies would no longer have a therapeutic benefit. Music can bypass upper-brain processes and higher cognition, as well as stimulate some of the fundamental lower and midbrain areas.
I should say that although we don't treat psychiatric patients at our facility, so often neurologic and psychiatric illnesses -- as well as medical illnesses -- are intertwined. So the psychotherapeutic component of our music-based interventions are very important to our patients too.
Medscape: How widely accessible is music therapy, and how many therapists are there in the United States?
Dr. Tomaino: There are close to 6000 music therapists in the United States. It's not that many, when you think about how many people could benefit from it.
Medscape: Short of having access to a music therapy resource for referral, how can clinicians incorporate music therapy techniques into their practice?
Dr. Tomaino: It's really great that something so effective is available to everyone. Although it is always important to seek out a professional music therapist first, there are therapeutic applications of music that others can make use of: for example, using personalized music to help someone with Alzheimer disease feel connected, or using rhythmic cues to help increase stride and gait in someone with PD.
And we haven't even touched on children. Professionals who are working with children with autism-spectrum disorders should really seek out music therapy because it's been very, very successful with this population. It can be so important in developing early language and motor skills, as well as self-identity and social skills.
I could also see a psychiatrist or social worker who's having a hard time having a patient open up asking them to bring their favorite piece of music in; it could be an effective entry point into forming a relationship. Speech therapists who have a patient with aphasia can ask the persons to sing.
Likewise, a physical or occupational therapist can use rhythmic cues to help with motor problems. It's amazing how little rhythm is used in rehabilitation especially in helping people with PD move more effectively. Just remember that each patient responds to different musical cues and rhythms, which requires time to navigate. I've talked to a few neurologists who will put on a Sousa march and expect a patient to immediately get up and walk!
Editor's Note: The American Music Therapy Association's Website maintains a list of music therapists in the United States, many of whom provide Skype services for remote patients.
1. Wallin NL, Brown S, Merker B. The Origins of Music. Cambridge, Ma: MIT Press; 2001.
2. Sacks O. Musicophilia: Tales of Music and the Brain, Revised and Expanded Edition. New York, NY: Vintage;2008.
Medscape Neurology © 2012 WebMD, LLC
Cite this article: Mending the Brain Through Music. Medscape. Oct 29, 2012.
6. MIT’s ChemLab Boot Camp Episode 7: Chinese Wedding.
7. Climatologists suggest that because of global weather changes, storms are expected to be more severe.
They may have a point.
8. Marginalia: Very, very bad things happen to students when they are tardy for classes.
I rest my case.
Dr. Stan Eisen,
Caduceus Newsletter Archives: http://www.cbu.edu/~seisen/Caduceus.html