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Dean's Speech: Apollo’s Legacy: Medicine and Music by Professor Gabriel Leung at 22nd AJS McFadzean Oration, Hong Kong College of Physicians

21 October 2017

Secretary Chan, President Li, honoured members of Council, President Lau of the Academy, Presidents and Officers of the other Academy Colleges, fellows, distinguished guests, ladies and gentlemen,

When President Professor Philip Li rang just before the summer inviting me to deliver the 22nd McFadzean lecture, I leapt at the opportunity for two reasons. First, becoming a McFadzean orator is a warm reassurance that I may have finally arrived, having resettled back home for the better part of two decades. More importantly, it was a rather unusual request for a named lecture to have specified the topic a priori, as opposed to allowing the speaker to decide on one’s pet subjects usually related to his or her professional expertise. I have been designated to speak on medicine and music. Indeed two successive McFadzean orators, my distinguished predecessor Professor Joseph Sung and yours truly, were previously miscast by our raucous media in an apparent spat over my real domain – medicine or music.  Of course nothing could be further from the truth and our cordial relationship is more accurately depicted in this photograph taken during a recent shoot for a 20th anniversary-related RTHK documentary.  In any case, the present occasion affords an opportunity to not only clear the air, but also allows me to share a few random thoughts on the topic of the College Council’s choice. As the wise aphorism in The Analects goes: “夫如是,故遠人不服,則修文德以來之。既來之,則安之。”.

The provenance of the aforementioned media incident came from an interview at the beginning of my deanship when a once popular weekly magazine branded my personal profile with the action news (動新聞) headline: “阿爸逼我讀醫”.  In it I shared my mental struggle as a high school leaver whether to pursue medicine, a longstanding career ambition since I had been little perhaps affected by my sickly childhood, or music, a romantic adolescent dream. The whole affair settled, as with most things in my family, with my late father’s no-nonsense decisive declaration: I was to study medicine or else…so that was that!

The reason I bring up those distant memories from three decades ago is because they ring echoes with what I still hear now as dean every year during student recruitment. Many of our students, and indeed not a few alumni, are excellent musicians in their own right. For instance, here are but a few superb performing artists who could have made a decent living as professional musicians but chose to pursue medicine first and foremost. As it happens, those shown are all orthopaedic surgeons – intriguing association although hardly causal. There are yet many more aficionados who are an informed and supportive audience. Earlier in June, we were able to showcase the musical talents of our students and alumni to a packed house at our 130th anniversary concert.  

Here you have just heard the resurrected University Anthem performed for the first time by a chorus and orchestra composed mostly of HKU students and alumni, unlike the official recording often played during ceremonial occasions or indeed at its première a century back. The performance was also the last time the late Professor Sir David Todd attended a concert, which incidentally he thoroughly enjoyed. This is a bitter-sweet memory that still stirs the heart every time I think about it.

Coming back to the story of our burgeoning physician-musician tribe, the flip side however is that nowadays many aspiring parents who wish their children to become doctors, or even the students themselves, have confused this apparent association of musical and medical tendencies with causation. In fact, a chain reaction has been set off in the past 20 years as follows:  admission into medical school (with a brief exception during the dotcom bubble) has been increasingly competitive, principally triggered by the sudden and drastic reduction of places following the 1997 Asian financial crisis, through SARS and then the 2007-8 global financial tsunami (which has only been corrected very recently) and cessation of recognising Commonwealth qualifications just before the repatriation in 1997 . The projected continuing dire shortage of medical manpower in the coming two decades has only made medicine even more of a lucrative career choice for high school leavers.

In parallel, there has been progressive a priori quality differentiation of school types, importantly including the direct subsidy scheme (or DSS) schools, the so-called “international schools” both locally and overseas, in addition to the more traditional elite grant schools and top government schools.  Virtually all these schools have enhanced their curricula around the pedagogical ideal of whole-person development, especially experiential learning and participation in team sports and music and the performing arts. This reorientation is backwards reflected in a more and more discriminating admissions process for high school, primary school, stretching back all the way through kindergarten and even pre-nursery.  In response, parents have pushed their children to take up musical instruments of all sorts, and of increasingly exotic variety at that, hoping that this would give them an edge to gain entry. Of note, even the contemporaneous slump in total fertility rate,  reaching a nadir of 0.9 per woman not so long ago and only recovering to about 1.3 currently, has not threatened their ever desirability, given that these elite schools are only vying for a tiny fraction of the overall pupil pool. Once the students are admitted, they find that their musical talent is nurtured and honed through annual competitions, locally and abroad, which have garnered awards aplenty for the schools, thus setting up a positive, self-reinforcing feedback loop.

Therefore  the conflation of a medical human resources shortage, thus desirability of medicine as the preeminent career choice for high school leavers, with a more differentiating quality gradient, whether real or perceived, amongst elite schools has sharpened the selection for the musical trait in prospective undergraduate recruits. Not intending any puns, the “instrumental” value of a musical education outside as well as inside the formal curriculum from a very early age has commensurately increased.

The recency of this accelerated selection pressure notwithstanding, music has in fact always been a pastime for the bourgeoisie including doctors. Many people could rhyme off the famous 3B’s of classical music, who are of course Bach, Beethoven and Brahms. Less commonly known however is that the third “B” had originally been Berlioz, of Symphonie fantastique fame.  Even more obscure was the historical footnote that the 18-year-old Hector Berlioz was first a medical student in Paris. He advanced so far as what in our system was the “first MB”, before having been attracted away by the operas of Gluck at the Paris Opera. He eventually enrolled at the Paris Conservatoire, but not before having been embroiled in an eight-year-old tussle with his family over pursuing music as a vocation. Evidently he won his father over where I failed. Berlioz worked incredibly hard to win the famed Prix de Rome for aspiring composers, and the rest, as the saying goes, is history.

There are in fact an additional 3B’s whose careers straddled medicine and music, namely Billroth, Boerhaave and Borodin. Borodin is more popularly known as the composer of Prince Igor whereas his full-time profession had actually been Chair of Chemistry at the St Petersburg Medical-Surgical Academy. In other words, he was chair professor of a preclinical discipline at the medical school. He published a series of seminal papers on aldehyde chemistry and his name is immortalised by the Hunsdiecker-Borodin reaction.

Even amongst internists, we would all recall learning about Theodor Billroth’s eponymous abdominal operative procedures, the Billroth I and Billroth II.  He pioneered many surgical firsts – the first gastrectomy, the first laryngectomy, the first oesophagectomy, and so on. In contrast to Berlioz and Borodin who are better remembered by their musical than medical achievements, Billroth’s talents as a violinist and pianist have largely been forgotten. He was in fact one of Brahms’ closest friends, whom trusted Billroth’s musical sense so much that many of his draft scores were first sent to him for comments. Brahms’ first two string quartets were dedicated to Billroth.  The former chair of surgery at Zurich then Vienna once proclaimed: “It is one of the superficialities of our time to see in science and in art two opposites. Imagination is the mother of both.

By way of this X ray let me introduce the final “B”.  The most astute clinicians amongst you wouldn’t need the radiograph to make the diagnosis, after having taken a history of lower chest pain, retching and vomiting, and a recent history of an OGD. But with this X ray clearly showing subcutaneous emphysema, Mackler triad has been fulfilled and the eponymous syndrome is made. The CT showing pneumomediastinum, and free gas in the soft tissue spaces of the neck, around the great vessels, chest wall and the epidural space of the spinal canal confirms the diagnosis definitively. Herman Boerhaave took his first lessons in the lute when he was a young medical student at Leiden, then went on to become a very respectable amateur player throughout his life.

Closer to home and in time, certainly McFadzean himself was an avid music fan. His disciples, like the late Sir David Todd was a most discerning musical connoisseur. I still ravel in the wonderful chamber musical moments at Schwarzenberg on the recommendation of the late professor.  He used to attend with Dr Betty Young, former Chief of Service in Paediatrics at Pamela Youde Nethersole Eastern Hospital and a HKU Class of 1976 alumna. No less your Senior Advisor Professor Richard Yu was once reminded not to neglect the musical side of his education by Sir David more than half a century ago, shown here  in an inscription on the inside cover of a book on Wagner’s operas.

Surely music amongst our ilk is not limited to internists but cuts across, with the pun fully intended this time, to the surgical disciplines. While the type of music aired in operating theatres can sometimes be a bone of heated contention around the world, I know many surgeons who would swear that they could not possibly slice, burn and suture without their favourite tunes stimulating the motor cortex via the Brodmann areas.  

In fact the importance of being able to choose one’s own music extends to patients who are on ventilatory support in intensive care. Compared to noise-cancelling headphones and usual care, those who are played their choice of music are less anxious and require less frequent and intense sedation.  In another study, patients undergoing surgery under spinal anaesthesia with light sedation to the level of giving a lethargic response when called by their name, were randomised to being played music or the sounds of breaking sea waves at the same volume. Those in the music-listening group had lower propofol consumption, and lower cortisol levels, compared to the non-musical control group. Nevertheless I should not wish to leave you with the impression that the state of the science is conclusively in support of the healing powers of music, however much I enjoy and practise it as a favoured pastime. A 2012 Cochrane review of all published studies of the effects of music in hospitalised patients show general but not unequivocal benefits where much better and more research is still required.   

On a related note, music therapy has become an actively pursued novel frontier as bona fide adjunct therapy in some conditions, such as stroke rehabilitation. The following edited video clip explains how the mesolimbic dopaminergic system could potentially mediate exposure to pleasurable musical stimuli and cognitive or even motor functional recovery.  Menon and Levitin at Stanford provided some of the first experimental evidence supporting such mechanisms about a decade ago. More recently, Säkärmö and Soto published two clever sets of experiments in the Annals of the New York Academy of Sciences showing that music may also improve cognitive outcomes through enhancing positive emotional responses, perhaps mediated by neural plasticity, given that cognition and emotion are demonstrably tightly linked. A third mechanism that has been posited concerns the glutamate-NMDA complex.  Rat brain studies have shown that an enriched soundscape could upregulate the expression and receptor function of NMDA in the auditory cortex and anterior cingulate, and in contrast sound deprivation could reduce NMDA receptor expression. This then forms the putative path of memory recovery amongst recovering stroke patients. Finally, neurogenesis, synaptic plasticity and axonal myelination elicited by an enriched sound environment may contribute to adaptive rewiring of the brain through molecular and structural plasticity.

So we are really just scratching the surface of the many and myriad neural pathways underlying the potential effects of music on health and disease. In time with the brain mapping projects of China , the EU  and US  steaming full speed ahead, much more will surely be discovered and uncovered.

Regardless of the specific mechanisms however, whether one should prescribe music as a low-cost, little-risk intervention, and indeed whichever songs one chooses to listen to, whether by surgeons, anaesthetists, physiatrists or patients in the OTs, ICUs or rehabilitation wards, the following must surely top the charts. 

Aside from getting oneself admitted into medical school, improving surgical performance, reducing anaesthetic and anxiolytic use, facilitating rehabilitation and so on, music can be used to describe the mastery of clinical medicine. Let me explain. Except for the jazz cognoscenti in the audience, have the rest of you ever wondered how musicians in a jazz band manage to improvise apparently at will, teasing out a seemingly unlimited number of variations that are different every time a piece is performed, all from memory and never getting out of sync with one another? It is in fact remarkably like how expert clinicians make a diagnosis of a condition they have never seen or surgeons overcome challenges imposed by rare anatomical anomalies in a bloody operative field. In medical school, we start with learning the basic sciences that provide the lattice on which clinical knowhow is built. Similarly in jazz, the drums and bass, and occasionally the piano, usually form the musical frame around which the solo instruments carrying the melody revolve. In both jazz and medical practice, the more expert one becomes, the more effortless flexibility there appears to be, even brilliant flourishes that lend an air of elegance to the outcome. Key to it all is the constancy of the structured outer frame that gives a robust architecture, thereby yielding a predictable pattern against which artistry can develop. Therein lies the Florestan and Eusebius of music, or the art and science of medicine. Let me now illustrate what I just described by playing you one of the most popular pieces of jazz music.  Incidentally a prize awaits whomever first comes to me with the name of the piece we just analysed.

Ladies and gentlemen,

Let me finish this talk by returning to its title – “Apollo’s legacy: medicine and music”. Apollo, as the Greco-Roman scholars amongst you will recall, is the Greek god of healing and of music, as well as god of light, sun, truth, prophecy, plague and poetry. As you can tell, he was a rather busy, omnibus god. He represented the ideal of kouros, as depicted in this, which is a sculptural genre of the beautiful, beardless athletic youth. His connection with medicine has been perpetuated through one of his more famous sons, Asclepius and his iconic staff and coiled serpent , which incidentally graces your College’s crest  as it does the Academy’s, the World Health Organisation’s and many other medical organisations’. The Apollonian lyre that symbolises the Greek god’s patronage of music is seen here in a statue atop Palaise Garnier, home of the Paris Opera that so captivated the young Berlioz when he was a medical student. Here is another example of Apollo the musician with his choir of the nine Muses in a John Singer Sargent commissioned mural in the rotunda of the Museum of Fine Arts in Boston, which incidentally is a ten-minute walk away from where I studied public health.

So, if in the future should anyone ever again doubt the inextricable link and relevance between the twinned art of healing and of music, I trust I have provided sufficient justification from 8th century BC to the latest neuro-immuno-psychiatric experimental postulates. As healers in 21st century Hong Kong, Apollo’s legacy is ours to perpetuate in its best tradition. Once again thank you so much for making me a part of the legacy of the McFadzean orators. I shall end by playing you a newly commissioned song to celebrate the 130th birthday of my school and that of many in this august audience, the HKU faculty of medicine. Let the students, as always, have the last word.