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In Chopin\\u2019s Rubato in Cancer Care, by Rajiv Agarwal, an oncologist finds appreciation on how music can inspire his care for patients with cancer. Read by JoBeth Williams.

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The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

Welcome to JCO\'s Cancer Stories, The Art of Oncology, brought to you by the ASCO podcast network, a collection of nine programs covering a range of educational and scientific content and offering enriching insight into the world of cancer care. You can find all of the shows, including this one, at podcast.asco.org. Chopin\'s Rubato in Cancer Care.

Years ago, my art was different. I mastered how to read and interpret the language of music. I spent over two decades learning from mentors, Bach, Mozart, Haydn, Chopin, Beethoven, Brahms, and Rachmaninoff. I adapted to each of their styles, forcing my fingers to move in unfamiliar ways until muscle memory took over, changing the pressure by which I applied my fingers to piano keys to produce different textures of sound. Now, as a oncologist and palliative care specialist, I have come to appreciate how my musical background has inspired how I care for patients with cancer.

The notes, the rhythm, the beat, the freezing, the harmonies, the softness and loudness, the intentional silence, and the underlying musical theory and history that grounds it all. These are analogous to the scientific principles I practice and uphold in medicine today. But as in music, the art and the artistry of medicine are found in the performance.

Below is my sonata. Exposition. I was approximately seven years old when I first met Frederic Chopin. From the start, I understood Chopin\'s science. I listened to him, I heard what he said with his notes, and heard why he chose to say it in that manner. Chopin tested me and I responded. Not always with perfection, but always with sincerity, emotion, and resolve.

Even so, I never really understood his art. I saw his notes on the page and relayed synaptic signals to my fingers to produce the corresponding sounds with accuracy and precision, but this was not enough. As I was playing one of Chopin\'s nocturnes, which I practiced for months, my piano teacher stood up in the middle of her living room and raised her hand signaling me to stop. What could I have done differently? I had perfected those notes, perfected his rhythm. I thought I had reproduced his results.
She sat down on the piano bench in my place. She did not play, she performed. She started similarly to establish the foundation of the song, and then she did something different. Her right hand was not completely in sync with her left. She deliberately played faster then intentionally slowed down. She stole time from certain notes and added the time back in others, temporarily changing the structure and timing of musical phrases without losing its integrity.

She shaped a new interpretation that was uniquely hers, nuanced and free but without completely abandoning Chopin\'s scientific arrangement. In essence, she deviated with reason. This experiment spanned a total of a few seconds, and the result was beautiful. My rendition was mechanical. Hers was expressing and living.

She explained to me that this was Rubato. In that moment, I discovered that art, or at least my interpretation of it, was an expression of individuality and a result of innovating within a theoretical framework. With Rubato, the musician discovers rhythmic subtleties to produce a novel and meaningful interpretation of a melodic phrase. And perhaps most importantly, the musician cannot be radical, lavish, or wander too far.

He or she has always pulled back with an understood force to the fundamentals of musical theory and the notated language. To distort or deviate too much would be destructive. A musician must always remember and respect the scientific background upon which art is produced. Development. More recently, I have realized that Rubato exists within the practice and performance of medicine.

As I learn medical science and the historical evidence that guides decision making, I marveled at how seasoned physicians knew when and the degree to which to adjust and innovate in clinical practice. For me, this became most evident in my observations and experience while caring for patients with cancer. I completed my training in both oncology and palliative medicine with Chopin\'s music playing in the background.

The interplay between the scientific knowledge and artistic freedom in oncology is fascinating and is perhaps that which brings verve to the care that we provide. We practice clinical oncology with rigor and technique, using an algorithmic logic that is rooted in a growing field of scientific evidence. These are the notes on the page.

As oncologists, we understand why we recommend standard treatment regimens because this is the science that we honor and apply. In addition, we contribute to our science and advance our discipline through research. We test and combine pharmacological instruments to compose new and sophisticated regimens with the goal of improving the lives and outcomes for our patients, potentially reaching a larger audience. Yet, not every clinical presentation or situation is the same.

At times, we are asked to improvise and think beyond the written notes and beyond our comfort zone, acknowledging that our understanding of what to do is limited to an extent. We often extrapolate with nuance and stretch what is known to fulfill the unique needs of each patient. And above all, in our assessment and treatment planning, we incorporate who the patient is as a person. In doing so, we fine tune our approach and add artistic style.

The final product is a performance of evidence-based notes that is deeply personal and powerful and one that cannot be simply replicated. It is in the performance that we apply our clinical judgment. We personalize cancer care, and ultimately, we build a meaningful relationship with each of our patients. I witnessed my mentors in oncology practice their art with ease. They use their experience to manage patients both within and outside of guidelines, using individualized rationale and intention.

They made modifications to treatment on the basis of a patient\'s comorbidities, preferences, and life outside of cancer. They were experts in knowing when not to take treatment breaks, when and when not to consider local regional approaches. When and when not to advocate for investigational agents, and when and when not to expand beyond the available data, all done to carefully tailor treatment and provide individualized care.

They acknowledged their variations in management and never lost sight of the theory that grounded all aspects of their clinical decisions. Drugs were not offered if there was neither a molecular nor clinical rationale to do so. They made decisions with controlled instinct, yet never broke the fundamental pillars of our science. They performed.

In palliative medicine, the conversation is the song. As palliative care specialists, we rehearse communication techniques to create a therapeutic alliance and partner with patients facing serious illnesses. We are taught how to structure a conversation and are often reminded why language and discourse matter. We use mnemonics, validated questions, and logical transitions to effectively communicate in the clinical encounter.

We cover a range of topics from addressing symptoms to eliciting the values, goals, and preferences of patients and their loved ones. We value the science and mechanics of our song. But what continues to amaze me is when adjustments have to be made in this process in spite of the guiding principles that have been so well studied. A subtle change in communication occurs, and in just seconds, the clinical encounter can be transformed.

I listen to how my mentors in palliative care performed their art. They shifted and directed the conversation to match the needs of the patient, and the flow of conversations unfolding to create new meaning and understanding for both parties involved. I observed how some patients preferred not to discuss their code status or divulge what mattered most to them on their first visit with a palliative care specialist.

When this happened, my mentors paused. They remained fully present. They avoided rushing into the next notes when the timing was not right. This was the artistic rest needed in the music to give our patients time to reflect on what was previously said and played.

It became clear to me as we learned difficult conversations that I had to expect and encourage variation within the structure of the clinical encounter. Conversations could not be robotic or purely technical. I found art in the performance of palliative care when we led conversations freely and did so out of instinct, while always remembering the core principles of empathic communication.
I discovered that the science of palliative care and communication was not neglected if questions remained unanswered and that intentional silence during family meetings often created a powerful space that could unite everyone, patients, family members, nurses, oncologist, and palliative care specialists. My palliative care mentors taught me to be meticulous, yet flexible.
We stole time from certain topics only to invest time in others, tailoring discussions to meet the individual needs of each patient. Through our artistry, we listened and our patients felt heard. Recapitulation. The musical already mastered years ago has informed the art of oncology and palliative medicine that I perform today.

Chopin\'s Rubato has changed how I listen, how I make medical decisions, and how I converse. It has helped me understand that the art of caring for a patient with cancer hinges on the regard for the science of oncology and palliative medicine, while also recognizing the value of innovation and making subtle adjustments when needed. Finding freedom within the structure of oncology and palliative medicine can be beautiful and rewarding.

Displaying too much freedom, however, can be dangerous and unsettling. Like a musician, a physician must always remember and respect the scientific background upon which art is produced. Both in music and in medicine, Rubato comes with practice and experience. I am and always will be refining my art. Today, when I sit on my piano bench after a day in the clinic treating patients with cancers, I thank all of my musical and medical mentors for sharing with me their expertise and inviting me to their performances, and most of all, I thank Chopin.

[MUSIC PLAYING]

Welcome to Cancer Stories, The Art of Oncology Podcast. I\'m Lidia Schapira, your host of its program, and with me today is Dr. Rajiv Agarwal. He\'s an assistant professor of medicine in the division of Hematology and Oncology at Vanderilt-Ingram Cancer Center. Welcome, Rajiv.

Thank you so much for having me.

It is a pleasure. Rajiv is the author of "Chopin\'s Rubato in Cancer Care", an essay that was just published in Art of Oncology and JCO. Tell us a little bit about your career as a physician, musician, and how this art of performance informs your practice?

Sure. I was introduced to music really early on and really it became my first love playing when I was three, and my piano teachers really pushed me in a way that, I think, really informed how I practice medicine now. Over the course of medical training, I\'ve had less opportunities to perform in public spaces, but I\'ve been able to transition some of the skills that were in the music to my performance as a physician, and I think that\'s really what this piece is about is how to find meaning and reflection and nuance in the art of oncology and medicine as a whole.

And one of the aspects of the piece that sounds so interesting I\'m sure will resonate with readers is that you talk about communication as the tool for palliative care physicians and perhaps even oncologists, and you talk about the delivery as a performance. Tell us a little bit about how you think about the delivery, the communication, as performance.

Yeah, that\'s a fantastic question. So I trained in both oncology and in palliative medicine, and in my palliative medicine training, I really witnessed and heard, which I think is the key point of my training is I heard experts in the field communicate. And I think when you approach a conversation with a patient or with any person, you are aware of what you want to say, but you also reflect and adapt the conversation based off of what is heard, and I found in my experience listening to people have these conversations, which are very sensitive and pertinent conversations that it didn\'t always follow a formula.

There was a structure to the conversation. We could address symptoms physical symptoms, emotional symptoms, it then could segway into discussing illness understanding, and then it could segway into discussing goals and preferences and values, but it didn\'t always have to follow in that exact structure. Sometimes the conversations would adapt, and that\'s the part that I found to be the most artistic, and frankly, the most musical.

Tell me a little bit more about some listening aspect of these conversations. In just a few minutes we\'ve spoken together, you\'ve used the word heard and listened. How does your training as a musician perhaps inform your ability to listen to patients?
So I think what Rubato really embodies as a musician, and it\'s how do you listen in between the notes? You can move from one note to the next, which is written on a page of a musical score. But it\'s almost the instant pause or the instant rest in between notes. How do you move from one note to the next, and when you fully listen to that change in a musical piece, I think that\'s where you can find a lot of meaning.

And similarly, in a conversation what I found to be the most important is how do people use words and then connect those words and have a pause, or where do they pause in their conversation? I think you can gain a lot from, not only what is said, but how it is said. And that, I think, as a palliative care physician, has really helped me with my musical background, because if a patient may say something, they may say it in a different tone or they may have different pauses between the words they\'re using and their language, and that can directly impact how I would respond or whether it\'s needed to continue that direction of the conversation and do we need to make a shift. That I think it\'s a skill set that has really been, in a way, impacted by my musical background.

I found this so fascinating, and boy, your patients are lucky to have you. Rubato really means the stolen, so what your piece is about and your reflections are about is the reminder that sometimes we need to borrow a little time or speed it up or slow it down, and you need to have a mastery over the music and we feel it in order to know when to do these things, and this is what you tell us you\'ve learned from your role models. Can you tell our listeners a little bit more about this idea of the rhythm of conversations and the flow of a dialogue between physician and patient?

The way I think about Rubato is, on a musical piece, you can look at the musical notes, and if one were to just play those notes as written with the exact time and exact rhythm of those notes and rests, it would be almost too perfunctory, too mechanical. And so what Rubato does is allow the performer to look at those notes, and the key point is that you can\'t sway away too far because it destroys the integrity of the key, but you\'re able to really interpret those notes in a meaningful way.

And I think in a conversation between patients and physician, it\'s almost the exact same thing. You can walk into a clinic or walk into a hospital room and have a conversation with the patient, and we know what we need to discuss that physicians. Sometimes the topics can be can vary from addressing symptoms to very serious conversations about where people are, what their values are, and how they\'re processing their illness in the context of their lives.

And when you\'re able to kind of listen to the rhythm of the conversation, and if that means taking a pause, allowing there to be a breath space in the conversation where you normally would not have done so and just allowing patients to speak, that really I think can guide a conversation in a more meaningful manner. Another way to think about it is even if we do all of that, sometimes conversations don\'t happen the way that we intend for them to happen. And I\'ve found that it\'s best to kind of reflect on those conversations and think why was that the case.

Sometimes it\'s not the context of what is being-- content of what is being said, but it\'s more of whether patients feel as though they are being heard, and I think hearing patients in that rhythmic manner can really have a profound impact.

That\'s beautifully stated. And music is so much about feelings, although you\'re remind us that there\'s also a science to it and a structure to it and an order that needs to be respected in order for it to be beautiful and to be played as it was written and intended by the composer. Tell me a little bit more about how you practice and how you teach your fellows now some of some of these incredibly wise things that you\'ve just shared with me.
I think one thing that I tried to really uphold in my practice is to always remember the science, because I think the evidence is really what guides us in our field. And so we have to honor and respect that, and that means not doing something too outside of the box. You have to be able to understand where the evidence lies and the treatments of certain cancers, where the evidence lies in the ability to have a conversation or how to impact advanced care planning. I think that is really key because it lays the foundation, but what goes beyond that step, then is where to add the nuance.

How do you add your individual flair to practicing medicine without really swinging too far away from the theory and the science that we have to uphold. Sometimes, it is important to really just stick by the science, and that should always be the very first step, but we have more cases than not, where we have to think outside of the box. And in doing that process, I felt that transitioning or seeing medicine through the lens of Rubato has allowed me to understand the limits of swaying away from science and swaying away from the fear and evidence that we have, because one cannot truly try to create something novel without evidence.

That\'s not what a musical piece is intended to do, which is to have notes on a page and then for you to improvise completely. There\'s still a force that\'s pulling us back towards the evidence and science, and so that\'s really what I always try to teach fellows, residents, med students, and even myself constantly is that we have to always remember what are the notes on the page.

That\'s, again, beautifully stated, and music provides so many metaphors for medicine, doesn\'t it? Do you ever talk with your patients about music? Have you bonded with a particular patient to also share a love of music and performance?

I\'ve had a few patients. When I talk with patients, I always ask, what matters to you in life and what are some of your hobbies and what are some of your goals, and usually, when I ask, then I\'m able to get to know patients of people, and some of the patients have told me in the past that they were pianist themselves or they have a deep love for classical music, and in that, we\'re able to share stories, and I think that\'s very human is to be able to bond with someone, irrespective of their illness or where they are in life through a sharing of a story or a connection.
And so in those conversations with the few patients that do have that same reflection of music, it\'s nice. It\'s comforting, I think, both for the patient and for myself to be able to share that human bond in a way.

Sure. There have been so many programs around the country that try to bring physicians to the arts. Literary arts, visual arts, and certainly music. Have you participated in any or do you have any preferred programs that you\'ve been exposed to?
Yeah, so when I was in college, actually, I used to volunteer for an organization called Musicians on Call, and it allowed musicians to locally, nationally, to perform for hospitals and other clinic settings, and so that was something that was very unique for me at the time. And throughout medical training, I\'ve adapted and I\'ve performed a few places for patients where I can. At Vanderbilt, I do know that there is a group of physicians and nurses and health professionals that get together, and I am-- after writing this piece, actually, I was invited because I\'m still relatively new to Vanderbilt at this moment, and I was invited to be part of this group, so I\'m looking forward to more opportunities at my institution.

Well, Rajiv, thank you for a lovely conversation and for sending your work to JCO. A beautiful reflection of the art of performance, the art of oncology and all of the enormous gifts that music can bring to our lives and to our work in the service of patients. So thank you very much, and I hope you send us another essay sometime.

Thank you so much, Dr. Schapira. It was an honor to be able to have this conversation with you today.
Great. So I look forward to sharing more conversations with you about the art of oncology.

Until next time. Thank you for listening to this JCO\'s Cancer Stories, The Art of Oncology podcast. If you enjoyed what you heard today, don\'t forget to give us a rating or review on Apple Podcasts or wherever you listen. While you are there, be sure to subscribe so you never miss an episode. JCO\'s Cancer Stories, The Art of Oncology podcast is just one of ASCOs many podcasts. You can find all of the shows at podcast.asco.org.