Dying to Tchaikovsky

 

Synopsis

 

Family medicine physician Catherine Sonquist Forest listens to one of her classical music idols serenade a dying loved one in the hospital.

 
 
 

LISTEN

 
 
 

Storyteller

 

Catherine Sonquist Forest, MD MPH FAAFP is a family medicine physician, public health expert, writer, and Clinical Associate Professor teaching at the UCSF Natividad Family Medicine Residency. Dr. Forest has worked on policy issues in Santa Cruz County and the State of California for over 20 years. She was previously the Medical Director of Stanford Health Care at Los Altos and the Medical Director of the Santa Cruz Women’s Health Center. She has served for over 15 years on the legislative affairs committee of the CA Academy of Family Physicians (CAFP).

 
 
 

RESOURCES

 
 
 

CREDITS

Hosted by Emily Silverman.

Produced by Emily Silverman and Marina Poole.

Story Development by Adelaide Papazoglou.

Sound Engineering by Alberto Hernandez.

Assistant Producing by Kirk Klocke.

Illustrations by Lindsay Mound.

Original theme music by Yosef Munro. Additional music by Blue Dot Sessions.

 
 

TRANSCRIPT

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The Nocturnists: Stories from the World of Medicine
Season 2 | Ep 6 – "Dying to Tchaikovsky"
Transcript

Emily Silverman
Hearing is one of our most potent and emotional senses. But when our patients die in the hospital, it's often to a soundtrack of noisy hospital equipment. What if, instead, we could drift away with a voice or a song? I'm Emily Silverman and this is The Nocturnists: Stories from the World of Medicine. In this next story, family medicine physician Catherine Forest tells us about a melodic experience that she had in the hospital, which transported her back to her childhood. Afterward, we talk about incorporating music into the healing process, and being a woman and a mother in medicine. Allow me to introduce Catherine Forest.

Catherine Forest
Of course it was the ER nurse that figured it out. This motherly Ukrainian woman sidles up to me and pats my belly, "You are with child, no?" How did she know? Only two days before, I'd been hiding in the nurse's bathroom in the ER, propped up in the stall with pregnancy test in my hand, waiting to see what I was going to find. And when that second pink dot lit up, that I was pregnant, I practically screamed holding it in. But that was going to be a secret.

You see, this was the 1980s. And to my knowledge, there had been only one woman at my university, which shall remain unnamed, that had had a baby in training and hadn't dropped out of medicine completely. The nurse promised me she wouldn't tell anyone. But whenever I came into the emergency room, she gave me that knowing look.

This was Mount Zion hospital. It's in a neighborhood that, at that time, was largely Eastern European and Russian. We had mostly immigrants for our patients. I remember this one feisty, older Hungarian woman who had life-size posters of the 49ers in her room, and would page me overhead excitedly, when she found out that I was from Hungarian heritage. And when I got there, you know, we were all about Roger Craig, and Joe Montana's latest play, but mainly, she just wanted to pinch my cheek, "XXX" she would say, just like my Hungarian grandparents. It was really a sweet and wonderful time, in so many ways.

The morning I found out that I was pregnant, I had admitted a 92-year-old Russian woman to our service. I was a third-year medical student on the team, and she'd had a stroke and was in a coma and unresponsive. And her son comes walking up and tells me and the intern, "We want her to have dignity," he says. And the intern, like, looks blankly at him. "Keep her this way," he says. "We want her friend to come visit like this," and the intern's, like, completely clueless.

But I could hear English in anyone's speech. In fact, when I was nine years old was when I figured out that my grandparents didn't speak English like other people. I thought that's just how older people spoke. You know, my friends would come over and I'd be translating English into English. So when this 92-year-old woman was there and her son was trying to speak with us, I could step in and translate. And I did. I was able to say that this woman had a living will—the family wanted her to live–and that a special guest would be coming that evening. "It is Isaac Stern," he says. Isaac Stern—only the greatest violinist of that time. My jaw drops. But my classical musician's heart leapt two octaves.

So later that night, quite late, this older, balding, sick man comes striding up to the nursing station with his worn violin case. And I go to meet him. "I would like to find Ms. Bina," he says. Mrs. Bina—I'm making up her name. And I'm completely speechless because I recognize Isaac Stern. So we walked down the hallway. A nighttime hospital is a sacred place, and really quite odd. There's that blue light from rooms for people watching TV. And there's the sound of, you know, canned laughter and mechanical sounds of respirators. And the nurses are all different places charting, but there are no visitors.

So, together, we walk down the hall, and he says, "She was like a mother to me." And I say, "Well, she's not awake right now. And if you can communicate with her, you'll be able to connect. You should feel free to do that." And we arrive at the door and he says, "It is okay if I can play violin?" "Absolutely," I say, "Absolutely." And then I realize, "Is it okay if I listen?" And he says, "Yes." And I take his hand and we walk into her room together. And there's my patient with her head on the pillow, her face sagging, looking ashen. And there's Isaac Stern, transparent with emotion.

I say, "Isaac Stern is here to play some music for you." He takes his violin out of the case and begins to tune up. I step out of the hallway, and I sink down onto the floor, hands on knees to listen.

When I was just a kid, my brother and I used to climb under the piano of my grandfather. My grandfather and my father were playing four hands—piano versions of symphonies. And we felt like we were inside that piano, like the music was part of us. So Isaac started to play this Tchaikovsky violin concerto that I know so well, but never have I heard played like this. Tears are just streaming down my face. And I feel my grandfather actually with me, "Beautiful," he says, "Beautiful." I'm just crying.

After about 30 minutes, Isaac Stern comes out of the room with wonder in his eyes, and he says, "She opened her eyes. She looked at me." I looked at him. He looked at me. We held hands. I looked in his eyes. And he knew that I knew what had happened. I stepped inside to see my patient, Ms. Bina, and there she was, peaceful looking. And a couple hours later, she died.

That night, as I climbed into my bed, I felt actually completely at peace in the universe. I had heard celestial music being played. And I was very excited about this life inside me. And I just hoped with all my heart that my child would be able to experience music the way I had that night, just coursing through my body.

The next morning, I get up, put on my lab coat, get off to morning rounds, reach into my pocket, pull out those index cards—yeah, index cards—and Ms. Bina's is blank. "She died in the evening," I said. But what I longed to say was that I learned something really important about human connection, and that Isaac Stern's music had made the most beautiful death possible for this person.

Emily Silverman
Hi.

Catherine Forest
Hi.

Emily Silverman
How are you?

Catherine Forest
I'm doing well. Thanks.

Emily Silverman
So I'm sitting here with Catherine Forest, and Catherine, do you want to tell us what your current job description is?

Catherine Forest
I'm currently a clinical associate professor of family medicine in the UCSF family medicine program in Salinas, California. And I still work at Stanford Health Care in the urgent care clinic as well.

Emily Silverman
So I'd love to learn a little bit about why you decided to tell this story out of all of the stories that you no doubt have accumulated over the course of your medical career.

Catherine Forest
So I think that the most important thing here is that it was the trifecta—it was like this amazing combination of things. I had just found out that I was pregnant. I wasn't sure what was coming up next with the pregnancy, or how it would work at UCSF. No one had ever gotten pregnant in medical school and stayed, to my knowledge. I was amazingly touched by the music—my absolute hero in classical music came into my world that day. And we were able to provide an experience—a dying experience—that was, if there is such a thing as a good death, a good death for one of my patients.

Emily Silverman
One of the things that strikes me most about what you just said, was that back then, nobody who was in medical school who got pregnant stayed in medical school. And I think that's just a testament to how times have changed. Can you maybe remind the listeners of what decade or what kind of year are we talking about, and maybe reflect a little bit on the culture shift with women in medicine?

Catherine Forest
So, in the year before I entered UCSF, it was 12% women, and there had never been anyone who had gotten pregnant and stayed in medical school in the history of the school. So if you chose medicine, as a woman, you chose a life that didn't include reproduction. And then, when I was in my first year of medical school, there was this group of, they called us "the bent arrows". That was the nature, like we're not normal, we're bent arrows. And it was a change. It was a part of the reentry movement of the 1980s for women returning to professional schools. And I'd already had a career in public health. I was applying to school at that point. One of my friends, actually in our second year of med school, so 1987, I believe, got pregnant.

Emily Silverman
The year I was born.

Catherine Forest
Right? It’s put in some perspective. And I was 30. The story is that she had gotten pregnant by choice, went to the dean—the male dean—to find out how will this work and was told the following words, "You are promiscuous, and you are precocious, and there's no place for you in medicine." So that was the culture from the Dean of Student Affairs. He actually left that year and the first woman dean at UCSF came into the position of Dean of Student Affairs. And when I went in to talk to her again–mcy own reproductive path was really complicated. If I didn't have children then, actually, it was a good possibility I wouldn't be able to have biological children. It was a tough decision. But when I went in to talk to her, she said, "Let's figure this out." And we did. So that was the culture a little bit. And I can tell you stories about how complicated it was. Like, there was no opportunity to pump milk. I was tired and exhausted. There was no chance to change the linear pattern of the call schedule, which, at that time, there were no controls on call. I was on, you know, for 36 hour shifts, etc. It was really hard. But then we were 25% women in my class, and by the time I finished residency, 50% women in medical school. So it really represented the second wave, right, the first wave was small. But it was the second wave of women in medicine that I was fortunate enough to be a part of.

Emily Silverman
Wow. And it sounds like having a woman come into that leadership role really catalyzed the culture change that was unfolding before your eyes as these numbers shifted over time. But I'm wondering as you started to grow and show with your pregnancy. What was the reaction of your colleagues? Of your patients? Of other people in the hospital environment who maybe were embedded in the old culture? And what was that like, and how did they treat you?

Catherine Forest
I think that the culture overall was still fairly hostile towards women. And my experience was not different. I mean, I went at one point to talk to the Dean of Graduate Student Affairs—and I was a top student, I wasn't you know, a half-assed student—who used the words like, "There's no place for girls in medicine." And when I asked about being in shorter surgeries, for instance, because it was difficult to not, uh, I needed to use the bathroom more often in my late pregnancy, the answer was a straight, "No. Wear an adult diaper," literally, "Wear an adult diaper."

Emily Silverman
Really?

Catherine Forest
So really pretty hostile…

Emily Silverman
Wow.

Catherine Forest …at that time. And there were some people who were fine with it, you know. But I would say that most people were just dubious that it could be done, and sort of doubted my commitment to medicine, I would even say. None of my peers were having the experience that I was—very few. So I experienced that as really hard, on the one hand. On the other hand, I really worked on being able to transition to home. So when I got home, I had left the hospital, and my angst, and the work, and my worry behind. And I was the queen of efficiency and effectiveness. So that when I came home to my family, I could be present. I had read a book about how using iconic or essential images could be useful just to help transition. And in the myth of Persephone—I don't know if you guys know this myth of Persephone—she marries Hades and is in the underworld. And she loves both worlds. She goes to the underworld and she loves being there. And then the pomegranate seed is her transition to coming into the above world. And it’s the seasons, right—the winter and the summer—and that transition is the fall and the spring. That really resonated with me, like, I love both of these worlds. I cannot believe my good fortune, being able to be a physician in my lifetime, especially a family physician. It’s an extraordinary life experience. And I completely love being a mother and in my social world and a sweetheart to my husband. So I actually put pictures of pomegranates in my car, and I still to this day have one at my desk. So as I transition, I look at that. And I just remember to say goodbye to this world as I go into this other world. So I think if I hadn't had some of these ideas of how to transition, I would have felt much, much more alone.

Emily Silverman
If you don't mind, I would love to pivot a little bit to talking about music, since it featured so prominently in your story. And classical music, specifically. I love classical music. My husband loves classical music. He won't listen to anything modern. It's just Beethoven, Beethoven, Beethoven, in the car, on walks. And it's this incredible moment where Isaac Stern, your lifelong classical music idol, walks into the hospital with his violin case and serenades this patient, and gives you permission to sit outside and listen along. And you say in your story, "He played this beautiful piece by Tchaikovsky that I had heard so many times, but never like this." Can you describe it?

Catherine Forest
I think what was so amazing about that night—and again, it's like yesterday, and it's now 30 years ago, right?—was that he was playing for someone he loved more than anything. I mean, he adored this woman. And I could hear that, I could feel that love in his music. And there are times when you hear music, where the audience and the performer know that something extraordinary has just happened. There's probably a word for it in a language, I don't know. That sense that just after someone finishes playing, and that everyone is quiet and gasping, like, "We got to experience this with this performer." And that was what that was.

Emily Silverman
I think what you say is so powerful about the shared experience—that there's the giver of the music or the story, and then there's the listener and the receiver. You can't just have a listener, and you can't just have the giver, or the musician, or the storyteller. And I feel like we probably sometimes get that even in medicine when it's a patient interaction, or in your story's case, an extraordinary death—a death that was, as you describe, a good death, a peaceful death, a loving death. And I wonder if you ever think of your interactions with patients almost the same way you think of the interaction between a musician and an audience, with a doctor and a patient. Have you ever made that analogy before?

Catherine Forest
I love the analogy. I don't think that I have thought of it that way. But I will now. I do think that there's this moment when you realize that you were the one who was right for that moment. And it could be actually a tender connected moment—which medicine is such a privilege—to hold someone in their vulnerability around health. But it also could be a moment of just—you got that diagnosis and no one had yet. And the patient knows that it was your commitment to the science that got us to this new place of possibly treatment, or just the relief of finally knowing what was wrong with you. So I do think it's an incredible privilege.

Emily Silverman
Did you get any interesting reactions from friends or family in the audience who heard you tell that story for the first time, 30 years later?

Catherine Forest
A few friends who were there who were musicians with me at UCSF, you know, after we talked about “How does music play in?” For instance, we now play music, in a lot of settings—if someone's having a procedure done, or if they are on life support and sedated and have a respirator breathing for them—how important it is to just try and get that music in. So it led to this really interesting conversation about reinstigating, actually, music into our practices differently.

Emily Silverman
I think that's so true. Because when I think about the arts, and I think about the different forms that it can take, for me music really rises to the top as the art form that just gets me every time. And, you know, Oliver Sacks wrote an entire book about music, and the way that it affects the brain, and it is so powerful. And so, I think exploring ways that we might incorporate music into the healing process should be something that we're looking at more.

Catherine Forest
I absolutely agree. And we were just looking at doing end of life care, and at people for choosing medical aid and dying, for instance, and one of the questions we actually ask people, whether or not they choose to do something to hasten their own death or not, but just thinking through when you can't make those choices. “Do you want music?” “What music might you want to accompany you?” And it's because it's very, very at the cellular level. And I have a friend who's also a physician who is probably more knowledgeable about music—contemporary music— than anyone I know. But we both wrote it down on our advanced directives.

Emily Silverman
You chose the music that you would hear at the end of your life? Can you share with us what it is?

Catherine Forest
Brahm's Piano Quintet in F for sure. It moves me like almost nothing else. That's my favorite.

Catherine Forest
And then there's this couple of symphonies that I love—Beethoven amongst them. And then the Entr’acte from Carmen. Not everyone is as specific as me.

Emily Silverman
I don't know, I have to really think about what I would want to play at the end for me.

Catherine Forest
There's recent studies that show that the music that really resonates with you is the music you loved when you were 12 to 15. Like there's really good data for that. So like with older people in skilled nursing facilities, or if you're trying to engage people who are not verbal anymore, if you play the music from their era—from 12 to 15—boom, up they come. So they illuminate.

Emily Silverman
I was just thinking I might have to queue up Spice Girls and No Doubt playlists for my own personal end of life.

Catherine Forest
There you go! Excellent, excellent.

Emily Silverman
You mentioned earlier, using in your work that you do you at end of life care, palliative care, incorporating music more into the dying experience for your patients. And I'm wondering if you can give us an example of a time that you've used music as a tool to try to create a peaceful death for a patient.

Catherine Forest
The most recent was somebody who had chosen…In California, medical aid in dying is legal, and I have participated in that as a physician. And I had one patient who had come to the end of his life. And I just asked the question, "At the time, is there some music that you'd like to be playing?" I believe it should be patient driven. So the experience is patient centric. And he chose exactly the music that he wanted playing at the time. And he was so relaxed, it just put him into that place of, "This is the music that transports me." And of course, he was transporting to the end of this lifetime, right, hastening his death. It was very moving. I'm hesitating whether to tell a story because I might cry, but a year ago my father was dying. And he was also a classical musician, an amazing musician. And I absolutely knew what to play. It was clear that what was going on with him was going to be the end of his life. He wasn't eating or drinking, and that was his choice, that he wouldn't want to be transported to the hospital, he wouldn't want artificial measures. And both my siblings and I knew that—he'd been very, very clear with us always. And we took turns being at his side. But unlike my siblings, I was the one who continued as a musician. So I played music with him every time I saw him, since I was four years old. I mean, there was never a time that we didn't get together, that we didn't play music, or share music, or go to music. So it was actually that thing that we're talking about, that bonding thing that we're talking about. I knew what would go deepest inside him with peace. And knowing that that was, like my patient all those many years ago, the music that would reach the deepest inside him. But also bonding for me, you know, this experience of staying with him in those last days of his life.

Emily Silverman
Thank you for sharing that with us.

Catherine Forest
Thank you for putting up with my tears. Sometimes I think a little bit about what it was like for my dad, because he was in and out of consciousness. He wasn't, you know, in a coma for the first little while. And I think that it was deeply reassuring. I think it was…it's a good death, if you can say such a thing, right? I think all of us would like to just check out one night, you know, you're here, and then you're not here. But sometimes there's a time period, and we may or may not intervene, or the patient might make choices that hasten their own death. And I think for my father, given that he didn't just, you know, die in his sleep, that time period that included music, made it tolerable.

Emily Silverman
Do you think that was because he was such a passionate musician? Or do you think that any one, any human, would have that response?

Catherine Forest
In my medical experience, I think that for many, many people, it’s the experience of the music that speaks to their soul. And I'm using that word, not religiously, but just something deep within them, that is part of their humanity. And as they leave this lifetime, this body, this earth, that there's something profound there.

Emily Silverman
That's my instinct, too. Personally I'm not a musician, although I love music. And there have been times where I've gone through periods of intense anxiety. And I've, in a fit of fear, gone to my computer and googled, "Most relaxing song in the world," in an attempt to calm myself down. And there was one song that I found, and I can't remember what it's called. But I think it's widely considered to be one of the most relaxing songs in the world. And part of the reason is it starts with this drumbeat, that is, I don't know, maybe 90-100 beats per minute. And over the course of the song, the drum beats slow down until it reaches more, you know, 50-60 beats per minute. And I think the idea is that it's coaxing your heartbeat or coaxing your body to that calming place. And this idea, that your body could sync with the music, I find so interesting. And I personally at first thought it was kind of cheesy or gimmicky. But then, I did feel my body relaxing as I listened to it.

Catherine Forest
Yeah, you're going to send me that later. I teach mindfulness in medicine to my patients with a colleague of mine. And when I was researching, you know, decades ago about that part of ourselves that quickly goes to fight or flight, we realize that there's many ways that people tap into the parasympathetic part of our bodies. That you can look at mindfulness from a whole lot of ways, but essentially, it's kind of that. What is it that reaches the deepest parts of you so that you slow down, that you're able to stop that spinning thing that happens for humans, because of anxiety, or rage or fear or any number of things. We only have two settings. There's, you know, fight or flight, or everything's chill. So how can we get people back there? And yeah, I think that your point about music is that for many people, music does that. But how cool that there's music structured that will assist you in going to that, what we consider a rested heart rate, which of course is when you're not in fight or flight.

Emily Silverman
Right, well, on that note, thank you so much again for coming and speaking with us. I think we got some really nice extra insight into who you are and your story and what it was about. And it was a pleasure to chat with you.

Catherine Forest
Likewise. And thank you for that.

Season 2The Nocturnists