The humanities, from music and painting to literature and poetry, offer limitless opportunities to grow as a professional and as an individual.

For physicians in particular, although medicine is doubtless an endeavor into the sciences, their knowledge and expertise can only be improved with a dollop of the arts — and the empathy it can inspire.

“I think that we are in a time where we need more humanities in medicine to balance the science that we are blessed with,” Leonard H. Calabrese, DO, director of the RJ Fasenmyer Center for Clinical Immunology at the Cleveland Clinic, told Healio Rheumatology.

That science, and the advancements it has made possible, from the revolution in biologic therapies to the emergence of precision medicine and improved diagnoses, has been a boon for rheumatology — both for patients and providers. However, there is another side to patient care, one that is strengthened not by trials and data but through exercising empathy and connecting with patients.

According to Calabrese, physicians who take part in various artistic pursuits, be it classical piano, reflecting deeply with a piece of writing or examining the life of artists long passed, can bring those qualities — empathy and human connection — from the studio into the clinic.

Yet, this requires an understanding that the humanities and the arts can be just as important as the hard sciences.

“It’s almost like the art of medicine is not given any credence, it’s all hard data and science, and there’s a lot more to medicine than that, I think,” Ronan Kavanagh, MD, a rheumatologist at the Galway Clinic, in Ireland, told Healio Rheumatology.

Kavanagh, who had a previous life as a musician before pursuing medicine, is also the founder of dotMD, an annual 2-day “festival of curiosity” for physicians and other health care professionals that seeks to “awaken a sense of wonder and curiosity about medicine that some may have lost along the way,” according to its website. The festival accomplishes this by, among other means, “viewing medicine with fresh eyes through the lenses of culture, the arts, philosophy and technology.”

According to both Kavanagh and Calabrese, and others, rheumatology requires a balance between the seemingly — but not necessarily — opposing disciplines of science and art, a balance that becomes easier to achieve when providers are steeped in the humanities.

Maintaining the Engine of Empathy

For medical doctors, the humanities formed the cornerstone of the profession until the 19th century, when the scientific setting of the laboratory seemed to remove medicine from the arts, according to Calabrese. The result of this divergence, he explained, was rising skepticism regarding the value of indulging in the humanities. One prevailing opinion was that the feeling and passion involved with music, literature and the like made the humanities all but incompatible with the data-based path medicine seemed to be following.

However, according to Calabrese, by engaging in the arts, either through active participation or passive observation, the humanities can provide physicians with the opportunity to develop their humanity and empathy — attributes that are key in medicine.

“Empathy is an incredibly important attribute of the healing relationship,” Calabrese said. “It’s transmitting feelings.

“This is not just to make someone ‘feel good,’ but it has the capacity to both heal in terms of empowering patients and strengthen the healer-patient relationship, as well as imprint the messages from the visit,” he added. “Our patients may forget the details of what we instruct them, but they never forget how we made them feel during a visit.”

As such, Calabrese said he considers engagement with the humanities to be an amplifier of personal empathy, which can then be drawn upon “to both help our patients and enrich ourselves at the same time.”

Specially, engaging with the arts on a passive level, be it reading an enthralling novel or attending a gripping concert, can “soften up the edges,” for physicians, making them able to better connect with patients, said Kavanagh.

“If reading a book helps me empathize or connect with a patient a bit better, I think that has to be a good thing,” he added.

Meanwhile, active engagement with the arts can exercise myriad qualities that can be invaluable in practice, including not only empathy but also curiosity and self-awareness.

Iris Y. Navarro-Millan, MD, of the Hospital for Special Surgery and Weill Cornell Medicine, in New York, describes herself online as a musician who happens to be a doctor. A lifetime of playing music with family members and singing her way through college as an undergrad before joining a band has resulted in a sharpened sense of empathy, she said.

“I think empathy, kindness and curiosity definitely lend toward understanding patients’ reality, and eliciting their specific goals,” Navarro-Millan said, adding that involvement in the arts has also helped to sharpen her self-awareness.

According to Navarro-Millan, empathy gained from her involvement with music lends itself toward reflecting more on the world around her, allowing her to connect with her patients much more easily.

“I think it makes me more sensitive, more self-aware,” she added.

As an example, Navarro-Millan recalled one patient from Colombia who spoke only Spanish. When the patient asked Navarro-Millan if she knew a specific song, the two sang together, forging a connection between patient and doctor that Navarro-Millan still recalls fondly.

“I do think that the humanities, as a broader field, is very important, and that we should not be allowing ourselves to become one-sided in terms of the science,” Ronald F. van Vollenhoven, MD, PhD, professor of rheumatology at Amsterdam University Medical Center, and a classical pianist, told Healio Rheumatology.

Although the humanities have the power to foster empathy and deeper understanding between patients and their caregivers, for many involved in both the arts and medicine, their connection to the former long predates their career in the latter.

A Lifetime Pursuit

For many who play and have a connection to music, it is not uncommon for that connection to have been forged at a young age. Vollenhoven originally picked up piano as a child at the urging of his parents, and kept up with the habit throughout his life. Additionally, both Kavanagh and Navarro-Millan played music in various capacities before ultimately finding medicine.

According to Navarro-Millan, music is not necessarily something to be performed for other people, although she has done a fair bit of that as well. When she was growing up and family got together, music was guaranteed to fill the air.

“Nobody wanted to be famous — it was about having a good time and a connection while enjoying music,” Navarro-Millan said.

In a family filled with musicians and singers, there was always the chance to join in the song or pick up a guitar. Navarro-Millan was trained as a bel canto singer in high school and sang mezzo soprano opera throughout college, before joining a band with some peers in medical school.

“It was something that I felt like I needed to do because it gave me purpose,” she said. “It is something that is so mine and only mine. It doesn’t depend on a peer review process or the outcome of a patient.”

Navarro-Millan’s relationship with music, from informal song performances with family to playing bars in Mexico through medical school, has rarely remained static for long.

Similarly, others with a strong relationship to music have had to put the passions of their youth aside to continue professional development.

Kavanagh, who practices rheumatology in his hometown of Galway, Ireland, said that the musical and artistic culture of the city seeped into his personality. In the late 1980s, he was part of the original line-up of The Stunning, playing keyboard. Their 1988 single “Got to Get Away” reached No. 17 on the Irish charts, and the group would eventually become one of the most well-known rock bands to come out of Ireland.However, just before The Stunning exploded in popularity, Kavanagh made the call to step away and study medicine.

“I played keyboards with them for about 2 years, but really, like Pete Best and the Beatles, just as they were about to really take off, I had to make a call, and I decided I was going to continue with my medical studies,” Kavanagh said. “I live in a town that is deeply immersed in the arts and culture. So, everything that’s done, is done surrounded by a culture of music and theater, and it somehow seeps into your pores.”

Meanwhile, Vollenhoven’s own musical journal started with piano lessons as a young child before finding a deeper passion for music as a teenager.

“It’s something I have done all my life. I mean, I was a kid when I started taking piano lessons, and I guess I was in my teenage years when I really found the enjoyment in paying and also listening to piano music,” he said. “I also had times in my life where I did not have that much time to play piano, so there were periods of time where I had hardly any time to spend on it.”

Still, no matter the duration of those stretches of time when other duties denied him the opportunity to regularly play, Vollenhoven said he always — eventually — has been able to return to music.

Lives filled with art and music also give physicians the ability to view rheumatic care not only as a sterile science, but also as a performance.

Improvisation ‘At the Heart’ of Patient Care

According to Kavanagh, there is bound to be something missing when physicians practice medicine, be it rheumatology or any other specialty, strictly as a science.

“The more you know, and the more patients you see, the more automatic your decision making becomes, and the more possible it becomes to stop thinking of yourself and your own performance,” Kavanagh said.

For that reason, it is important and useful to approach rheumatology, at least in part, as a performance, including everything from improvisation to communication between doctor and patient, he added.

Influenced by the work of Penn State medical educator Paul Haidet, MD, MPH, who has written about the connections between jazz and the art of medicine, Kavanagh has looked to legendary trumpeter Miles Davis as an inspiration in the school of thinking of patient care as a performance. The way Davis used improvisation, from paying attention to the music made by those performing with him to responding with the perfect notes and rhythms, can teach rheumatologists a lot about interacting with patients, he said.

“I believe that improvisation is at the heart of really good patient care,” Kavanagh said, noting the importance of listening and taking each individual patient factor into account before recommending a course of action.

Although many aspects of patient care can be completed simply by following algorithms and ordering the appropriate tests, this may not always be appropriate in every situation. Just as performing a composition exactly as written may leave a piece sounding a bit lifeless and without expression, so too should physicians, including rheumatologists, emphasize communication and think beyond the algorithm in patient care, according to Vollenhoven.

“Even if you do exactly as it says on the sheet in music, it will sound boring and not very inspiring. There is so much more to be done,” he said. “If you do that in medicine, you’re also missing something, because you need the art of medicine on top of that.”

By incorporating your own communication and treatment styles, it not only brings life to the practice of rheumatology, but makes that practice more humane and creative, Vollenhoven said.

Additionally, although music offers a great pathway to achieve this, it is by no means the only route.

Long before Navarro-Millan met and sang with the patient from Colombia, she was regularly attending plays and theater productions while in college. She credits those experiences, combined with the near-constant presence of music, with helping to develop her ability to connect with patients.

“I think it is something that makes me also reflect on the world around me,” she added. “I do think that it makes me more empathetic and more compassionate to the reality and challenges of my patients.”

Although a history of deep involvement in the humanities can have the impact of improving communication and increasing empathy with patients, there are also conferences and events that can help to reframe and reorient the goal of patient care for art-minded physicians.

Reframing the Focus

Kavanagh’s dotMD, the arts-meets-science conference he founded to help expand the horizons of health care professionals around the world, has been attracting rheumatologists, primary care physicians, psychiatrists, hospitalists and emergency physicians to Galway since 2013.

“The aim of the festival is to reawaken a sense of wonder and curiosity about medicine that some of us may have lost along the way,” Kavanagh said, adding that many who attend are able to find deeper meaning in medicine.

The joke, he says, is that dotMD is a meeting for doctors who “used to play the piano.”

The meeting is billed as “anti-reductionist,” and serves as a way for a wide variety of speakers to help attendees gain a different perspective, Kavanagh said. What the meeting lacks in traditional rheumatological lectures, it makes up for in talks focusing on the parallels in developing expertise in non-medical and medical professions.

Although Vollenhoven and Calabrese have not attended dotMD, the idea and goal of reawakening a passion and unlocking perspectives is one that both agree is a worthy cause. Calabrese regards attending the meeting as an item on his wish list, while Vollenhoven would appreciate a wider adoption of similar events.

“I very much applaud that kind of initiative,” Vollenhoven said.

In terms of success, Kavanagh measures dotMD not by the number of attendees, but through the impact it has on those who attend.

“We do a simple questionnaire for feedback afterwards, and 98% grade their experience as ‘excellent’ or ‘very good,’ but the best possible outcome is not the information they learned, but the feedback we get about how the meeting makes them feel,” Kavanagh said.

Recalling feedback, terms like “transformative,” “sublime,” and “breathtaking,” come to mind, he added.

Although it is important to engage with medicine in non-traditional ways, such as at meetings and talks that allow for some artistic reflection, rheumatologists can also learn from the artists themselves who have dealt with life-changing diseases such as RA and scleroderma in their own time.

Determination and Passion

Throughout history, many artists, including several iconic painters, have dealt with rheumatic and musculoskeletal diseases. James Louie, MD, professor emeritus of medicine at the University of California, Los Angeles, has spoken about several of them and how they attended to the challenges of their rheumatic diseases, as well as how their determination enabled them to display the beauty of their art in personal, technical and philosophical terms.

“To enable patients in their decisions for best care of their rheumatic diseases, it is often helpful to describe how other famous persons throughout history had met their challenges and continued the creativity and grace of their lives,” Louie said.

For example, Pierre-Auguste Renoir (1841-1919), the renowned French painter who contributed to the impressionist style, developed rheumatoid arthritis at the age of 47 years. According to Louie, he sought out the best available physician, took the non-steroidal therapy of that time, designed his own physical and spa therapies, and continued to mature his style of painting.

By age 71, Renoir could no longer ambulate and was restricted to a wheelchair and bed, yet he continued to paint with enthusiasm until his death at age 78 years, saying, “The pain passes but the beauty endures.”

“That was his goal in life, to share his sense of beauty as he saw life, regardless of what he went through,” Louie said.

In the next generation, Raoul Dufy (1877-1953), French painter and designer of artistic tapestries, fabrics and ceramic pieces, developed rheumatoid arthritis at age 58 years. When he no longer responded to gold injections, at age 73 years, he traveled from Paris to Boston to participate in a therapeutic study of corticosteroids.

“He then returned to his painting,” said Louie. “His friend wrote, ‘Viva le difference.’ While continuing his cortisone, he died of a gastrointestinal bleed two years later.”

In the last generation, John Outterbridge (1933-2019), an assemblage artist and sculptor in Los Angeles, developed rheumatoid arthritis at age 60 years. When he sought out best care, he enrolled in a study of a TNF inhibitor and returned to his constructs, directing the Watts Towers Art center for 27 years.

“Using refuse from the Watts riots, he built a ship with three masts for children to walk through,” said Louie, who provided care for Outterbridge. “He explained to me, ‘I want the children to know that after a riot and life is a mess, if you reach down, pick up the pieces and build something that raises your eyes up to God, you will be okay.’”

According to Louie, the determination and dedication of these three artists encourages patients and physicians to pursue the best care together, particularly as science has provided more effective therapies.

“Ben Franklin suggested, ‘Teach me and I remember, involve me and I learn,’” he said. “And Franz Kafka predicted, ‘Anyone who keeps the ability to see beauty never grows old.’”

For Calabrese, engagement with the arts began early in his career when the Cleveland Clinic assumed the care of the newly formed Cleveland Ballet.

“That was at a time when the field of dance medicine was in its infancy,” he said.

Calabrese described how exciting it was to combine medical care for injured dancers with research into the epidemiology, risks and attendant medical problems they were first noted to be experiencing. Soon after, he began to perform similar work with instrumentalists as part of a newly formed collaborative multidisciplinary group dedicated to care and research across the arts.

According to Calabrese, this early exposure and experience enriched him both professionally and personally in ways that have remained with him for his entire career.

“To me, it was an opportunity to grow,” he said. “My involvement with dance and dancers over these many decades has been very fulfilling for me. I think it has helped me grow as a person.”

After caring for dancers throughout his career, Calabrese said that he grew to appreciate the art form.

“You don’t have to be a performer to reap the benefits of arts in medicine,” Calabrese said.

In Galway, Kavanagh has similarly cared for musicians throughout his career.

“I kind of found myself, full circle, learning from them,” Kavanagh said.

Enriching the Profession

According to Calabrese, engaging with humanity-enriching art is an essential part of the profession of caring for patients.

“This is important because humanism is vital for a successful and fulfilling career as a healer,” he said. “I think that through the arts, we can fuel this humanistic need that we all have.”

Calabrese, who describes himself as a “guerilla writer,” offers reflections in Healio and other outlets, but he is also involved with the reflective writing course for medical students at the Cleveland Clinic.

“We de-emphasize the grammar and the style, and we instead emphasize sharing what is on your mind,” he said.

Meanwhile, Vollenhoven and Navarro-Millan satisfy their artistic impulses by finding time to attend concerts and visit museums when the opportunity arises.

Losing the art and becoming engulfed in the science side of things presents a “real risk,” Vollenhoven said.

“Music can be just a very superficial enjoyment, but if you take a little bit more serious interest and try to discern the reasons behind the composition, there is much to be learned from that,” he added.

Similarly, Kavanagh argued that the more perspectives an individual has access to, and an understanding of, the better life can be.

“If reading a book helps me empathize or connect with a patient a bit better, I think that has to be a good thing,” Kavanagh said. “It expands the human dimension of who we are, to be immersed in arts and literature. I think it would make them better human beings.”

According to Navarro-Millan, music in general can ignite joy and provide a sense of purpose. That joy transcends every facet of her life, she said, including rheumatology, and allows her to connect with patients more naturally.

“I think that authenticity is what probably makes me take better care of patients,” Navarro-Millan said.

Apart from engaging in the humanities through active or passive involvement, it is imperative that no matter the inclination, diversity of style in the rheumatology field remains strong.

Although art and the humanities offer ways for physicians to connect to patients, and see and be seen as “real people,” there is still a significant place in medicine for professionals who do not, or cannot, engage as vehemently, Kavanagh said.

“There is no question in my mind that there are people at the very top of their game in rheumatology, who dedicate their entire lives to the mastery of our specialty through the lens of science, who are wonderful rheumatologists,” he said. “You need people who have those supreme analytical skills to deep-dive and get to work in the lab. We wouldn’t be where we are in medicine without those people.

“However, I guess what I’m advocating for is a broader perspective of how we look at our specialty — one of course firmly grounded in science, but also one where multiple perspectives from the world of the arts and performance science are valued,” he added. “I think it has made me a better rheumatologist.”