KIND OF BLUE: IMPROVISATIONS AT THE BEDSIDE | Tyler Jorgensen
I have often felt that our different fields of medicine mirror different types of music. Emergency medicine, my old specialty, evokes punk rock—hard-hitting, rough around the edges, with a never-say-die attitude. Though I’ve never practiced anesthesiology, it seems to echo ambient electronica with its finely-tuned instrumentation and subtle, constant adjustments. Hospital medicine conjures Italian opera with its emotional swings and technical proficiency, its tragedies and triumphs.
A few evenings ago, after dinner with the kids, I played an old jazz record on our family turntable—“Kind of Blue” by Miles Davis. Dishes done, kitchen clean and kids upstairs, I sat down in my favorite chair to relax with this vinyl and decided to read the essay on the back of the album sleeve, expecting to learn a little about the legendary trumpeter. Instead of a standard artist bio, however, I found an essay called “Improvisations in Jazz” by Bill Evans, the album’s pianist. As I considered his reflections on jazz, I realized I was also reading about my new specialty, palliative medicine.
When we as doctors walk into a hospital room for a palliative medicine consultation, every human present is a part of our jazz band. We introduce ourselves and suggest the song we hope to play, but the other musicians—the patient, the loved ones, the caregivers—take it from there, sometimes in unexpected directions. If we are going to turn this encounter into music, we must attend to what the other musicians are playing. Did mom just play a blue note? Is little sister hitting minor chords? Did the patient let out a sunny chorus that seemed a bit out of place? Creating harmony out of dissonance requires an artful touch. As Evans writes, “Group improvisation is a further challenge. Aside from the weighty technical problem of collective coherent thinking, there is the very human, even social need, for sympathy from all members to bend for the common result.” We may not like the notes a loved one is playing, but to make this music we have to listen carefully and meet them on their sheet of music.
Jazz is not all free form and sympathy, of course. Each recording on “Kind of Blue” has a unique structure. Miles Davis had a template for his improvisational pieces. According to Evans, “As the painter needs his framework of parchment, the improvising music group needs its framework in time.” Likewise, we start our palliative encounters with a form in mind, but we watch and listen to how the other musicians in the room respond, how they improvise, how they react. When we pick the melody back up from our fellow performers, we see if we can bring the song back around. Sometimes we get back to our desired template, and sometimes we don’t. Sometimes, in the eleventh hour, we just have to. But if we clang ahead without agenda, unyielding and unsympathetic, the result may be a consultation checklist accomplished but a cacophony of non-therapeutic noise.
A couple winters back, our team met Carl, a 63-year-old with lung cancer, sitting up in bed and working hard to breathe with his boxy shoulders and barrel chest. He struck me as the kind of guy I might find in a small-town diner, sipping black coffee in a smoke-stained flannel jacket. We awaited the right moment to perform our usual song and dance about symptom management as his wife spoke about third-line treatments and traveling to a bigger cancer center, and the need for second and third opinions. Carl grimaced and exhaled through pursed lips; with a pleading look, he whispered, “I’m tired.” That’s a note we weren’t expecting, so we explored. We improvised. We dug deeper into Carl’s story and found he felt it was time to make peace with the inevitable and stop disease-directed treatments to focus on comfort at home. His wife broke down and held her husband of 44 years. A peace came over the room, even as we all wiped tears from our cheeks.
With a few years of palliative medicine under my belt now, I feel ready for cases like Carl’s. I teach my students to listen carefully for clues like, “I’m tired” or the words “die” and “death,” and not blow past them. You never know what’s behind those words if you don’t pursue them. But there are still some melodies that throw me off.
Ally was 26 years old when she broke her neck in a car accident. No one thought she would live, but after multiple surgeries, months with a ventilator and a tracheostomy, she was able to graduate to inpatient rehab and eventually made it home. Her trach was removed, and she was able to speak again, but she remained completely paralyzed from the neck down. Life had been unimaginably hard over the last few months. Due to her weakened diaphragm, now three years out from injury, her breathing was getting bad again. A couple of invasive pulmonary procedures in the ICU had cleared her lungs up a bit, but she told her doctors she wouldn’t allow another intubation and would not accept another tracheostomy.
Her smile was disarming as I introduced myself. So young, so energetic, so positive. So easy to forget when talking to her face that her body could not move—until I went to hold her hand. She looked down at my awkwardly placed hand and grinned. I could tell I wasn’t the first person she’d had to reassure. Her smile faded. “The only thing I have left in this world now is my voice.” We talked about her lungs worsening, how she would need a tracheostomy and a ventilator to keep living. “That’s out of the question,” she countered. “They took my voice away once before with a trach, and I’m not gonna let them do it again.”
I found this all so unsettling. She’s too young. She’s acting too rashly. What about speaking valves? She’s throwing her life away. We talked about her spirituality. She said the closest thing she ever experienced to spirituality was visiting Denali. There was something different about that mountain that awoke something in her. How’s that gonna help her now? I wished she had the sort of faith I’ve seen so many other patients lean on. We asked the chaplain to meet with her and had psychiatry consult to make sure this wasn’t the black dog of depression leading her astray. No black dog. Being of sound mind, she had every right to refuse a trach and let this disease run its course, rather than prolonging a machine-dependent life, devoid of the rock climbing and the trail running that gave her meaning.
I struggled at home each night thinking about her decisions. Would I choose the same? I don’t think I would. I have somewhat flippantly told my wife that if I’m severely injured, as long as I can think and blink out communication, I want more time. I’ll have more to say until I blink out the words, “The End.” But is that true? Does it even matter what I’d choose? I haven’t lived the daily reality of Ally’s paralysis. I haven’t seen everything I care about stripped away with no prospects of anything except unacceptable physical suffering. Trying to imagine her experience, her perspective—that’s the kind of sympathy Bill Evans wrote about in his “Improvisations in Jazz” essay. That’s what this job demands.
My last couple of visits to her room were more social than medical. I checked in on her and her sister, made sure plans for discharge to home hospice were coming together, and we listened to some '80s synth pop we both enjoyed and shared some laughs. The day of her discharge she invited me and a few nurses to a send-off party she was having at home hospice: drinks and karaoke and stories. I had to miss it because of out-of-town commitments, but I didn’t know if I would have been able to celebrate with her anyway. I was already mourning the life she chose not to live.
At the hospital a couple weeks later, I got the news she had passed peacefully. Most days now in the hospital my rounds take me past the room where I met her, and if I slow my pace enough, I can still hear her voice. I hear it now as I write these words.
Back at home, “Kind of Blue” plays on. I ponder each song, and I wonder if my next patient encounter will sound more like the steady groove of “Freddie Freeloader,” the turbulent undercurrent of “All Blues,” or the elegiac dirge of “Flamenco Sketches.” I’m learning that if I stay curious and present, then I’ll be able to tell just what song I’m in and where it’s going. At a jazz bar in New York many years ago, a friend commented that the most important part of a jazz musician’s body is his ears. True, too, for us at the bedside. Listening is the key that unlocks empathy. The best care, like the best music, happens when we find that artful balance of form and flow, of leaning in and listening, of hitting the right notes, and helping our patients find their voice.
Tyler Jorgensen, M.D., is an assistant professor of internal medicine at Dell Medical School at the University of Texas at Austin where he practices and teaches palliative medicine. In his academic work he seeks novel ways to integrate music into clinical encounters and physician well-being efforts. Jorgensen's creative writing has previously appeared in the Annals of Emergency Medicine, the Journal of General Internal Medicine, and Examined Life Journal. His narrative and interview podcast, “My Medical Mixtape,” can be found on Spotify; his "Crash Cart Campfire" musings are on Substack.
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