A new member of the household

Every time I enter my living room, I’m pleasantly surprised by the sight of this new member of the household. He’s large, dark brown and very beautiful: my new pedal harp.

Due to extremely lucky and amazing circumstances I was able to buy a pedal harp. Apparently, my parents and grandparents were secretly saving up for me. I remember how I often whined to my parents that I’d like to have a better harp than the clunky old thing I have – now I feel slightly ashamed, knowing that they were working on it. I think I prefer it this way, not knowing that they were planning to buy me a harp and now being extremely pleasantly surprised by it.

It is a dream come true, a lot sooner than I expected. I was just coming to terms with the fact that things like getting my diver’s license, buying a car, finally buying some decent furniture have a higher priority than ‘saving up for a harp that costs four times as much as the car we’re looking at’. My harp teacher gave me really awesome pieces that are very challenging so I had myself almost convinced that I wasn’t ready for it anyway.

And then the pedal harp happened. I’ve always been a huge lever harp proponent – no the lever harp isn’t a starter harp, you can have fun with it for life!!! – but this instrument, well it’s something completely different. The pedals are one thing, but the size and increased string tension is another factor: I actually got muscle aches all over after having it just one day, it takes a lot more core strength to play it. They’re both called ‘harp’, but playing on this huge guy is more like tango dancing than blues dancing, it really demands a lot in terms of technique and posture. And I love it. It’s like starting a new style of dancing, getting to know your body in a different way, finding faults you hadn’t noticed before and discovering something completely new and amazing you didn’t know that existed. The sound; when I pull the bass strings it sings and resonates through the entire house!

My harp teacher forbade me to practice more than 1 hour a day and told me to practice in 3 blocks of 20 minutes to avoid overstraining my muscles. Just one hour is really short and after 20 minutes I am just getting into it! I can totally imagine why some patients ignore their doctor’s advice… :) Of course I tried to play all the pieces I’ve always wanted to play (these pedals take some time getting used to!) and every now and then I’ll remember another cool piece and add it to my ‘finally able to start studying this!!!’ list.

So the lever pieces are now on hold (Clair the Lune, I will get back to you!!!) and I’m working on some pieces to get used to the pedals: the Serenade Melancholique by A. Hasselmans, the first prelude in the first prelude book by Bernard Andres and the sonata in C minor by Sophia Dussek. Yes, the sonata in C minor with the awesome bass part. My struggles with the sonatina in G major did pay off because I can manage this piece, it is most definitely less difficult than Clair the Lune. Apart from the pedals it only consists patterns I’m familiar with, it’s a lot like a cross between the Händel concerto and the Sonatina in G. It is sooo nice to finally play this!!!

Here’s the first line in practice tempo, of course it doesn’t sound like how the professionals play it. But just to produce these lines of music myself… It really is a dream come true.

A most precious gift

Clinical research would be impossible without patients who generously donate their blood and other tissues. We use their samples to validate data gathered in animal or cell-based studies – a certain treatment may work wonders in mice but if it doesn’t work on human cells it’s probably not worth it to investigate the compound in clinical trials. Donated samples are also essential to gain knowledge regarding fundamental processes in the body and how disease affects them.

On a daily basis I ask patients if they are willing to participate in research. It’s a short conversation in which I briefly explain the goal of the study, what participation entails and the pros/cons of participation. In the case of a blood donation it usually means donating a few extra tubes (10-20 mL), scheduled to coincide with their regular blood draws so there is almost no discomfort involved (no extra needle stick). However, sometimes participating involves taking a skin biopsy. This is a more invasive procedure with more discomfort and you’ll have a small but visible scar afterwards.

So naturally not everyone wants to participate. And that’s okay, because it’s still your body and your decision. I am very happy with the samples I can obtain, they’re irreplaceable gifts to the field of medicine – but it’s not like my day is ruined just because someone said no. That’s sort of the reason for informed consent – you always have the option of declining and no one will hate you for it.

For some patients, this is hard to understand, they tell me how bad they feel that they don’t feel like ‘giving something back’ or they are worried that it will impact my research projects. This really touches me, because why would they feel bad? I’m the one asking an outrageous question – would you be willing to receive a scar so I can look at your cells in the lab?

Apparently, not all scientists have this mindset because the rules regarding clinical research are very strict (for instance, the reason that there are physician-researchers who are not directly involved in patient care is that the doctor-patient relationship isn’t tainted by a request to participate in a study). You are not allowed to make the patient feel pressured in any way, so if someone declines you can’t really persuade them to participate anyway, apart from providing factual information regarding questions they have.

When a patient expresses that they feel bad about their decision to say no, I try to take some time to reassure them that it really doesn’t matter. I wonder whether they really understand, though. So hence the blogpost – I value it that people are willing to talk to me and consider participating, I see it as my job to help people reach the decision they want, I’m not afraid of checking if they are completely sure if I notice that they seem a bit unsure. I’d rather exclude someone than include a person who didn’t participate of their own volition. And, in the end, I’m doing this research to benefit patients. The end doesn’t justify the means, if I don’t do justice to their right to refuse, how can I still say I’m all doing this for the patients?

Sometimes, this short informed consent conversation develops into a longer interactions where patients tell me about their journey in medicine so far and how interesting is is that someone finally respects their decision. Interactions like these reinforce my idea of how I’d like to practice medicine. Patients should always be given a voice when it comes to important treatment decisions. And not just ‘do you consent to this operation’, but listing all the options, the pros and the cons and the alternatives. Because that’s what we do in clinical research, so why not in clinical practice?

Fundamentals of harp playing

When I go to a folk dance event, I always get excited by workshops promising to cover ‘fundamentals of dancing’ or ‘dance technique’. Such workshops won’t teach fancy moves but you get to explore the instructor’s view on quality of movement and connecting with your leader/follower. Even just two hours of working on posture, breathing and walking around can make the evening’s social dance a completely different experience when compared with how I danced before. Every teacher emphasizes something different and sometimes things I’ve struggled with for a long time just fall into place.

The workshop ‘extend your technique’ by Tristan Le Govic during the 2015 the Harp Friends Meeting sounded like just that, but then for the harp. I’ve taken workshops from him before and it was always a great experience – he really gets to the core of harp playing.

I’d like to share some insights Tristan provided during the workshop, as workshops like these seem to be quite rare in harpland, the workshops where you mostly listen and maybe try a few moves (notes).

 You can’t extend on something that’s unstable, so you need a solid foundation of technique. But how do you progress from playing scales quickly to creating music? You need full control over your fingers. Can you make all the notes in a scale sound exactly the same? What happens when you play a scale with just one finger? Does it sound like this due to chance or did you intend it to sound like this?

(Tristan le Govic, paraphrased from my notes)

When I once met Remy van Kesteren after a concert I asked him, how do you progress from simple pieces to the real repertoire, what do you need technique-wise to become more advanced? Unfortunately, he was stung by a wasp just after I asked him, so I never got his answer. The questions that Tristan raises, however, provided the answer I was looking for. Extending your technique begins with trying to gain control, to be aware of the sound you are producing and being aware of how you can manipulate it. Of course, when speaking about sound, you need a framework to describe sounds in so we can understand each other when describing sounds.

There are various dimensions to a sound, various textures. On one axis, we have volume, from pp to ff. On another axis there is depth – is it a very tinny, frail sound, or is it a full, warm bass? From which direction does it come? And there is time – is it a long, lingering note? Does it stop immediately? Is its texture filled with a subsequent note?

(Tristan le Govic, paraphrased from my notes)

He showed this by demonstrating how to do the bass line of a plinn he wrote. He didn’t just randomly decide to play the string this high, he was looking for a specific sound and found out how to produce it. You can hear how the sound of the bass evolves when he plays the string lower and lower. For me, this way of reflecting on the sound I produce was quite new. My harp teachers tend to describe it in terms of emotions (angry? sad?) but I always have trouble understanding – what does she mean? Volume? Tempo? Now, a few months later, I have less trouble with creating the sound or flow in a piece, Tristan seems to have opened an entire new dimension in my playing.

Technique is also about how to economize energy, to reduce unnecessary or even harmful movements. Let’s start with posture. How can your shoulders be unlocked and relaxed if you are slouching?  What if you wanted to cut bread while sitting like this (mimes cutting a bread while slouching on a chair)?

Where does your movement start? How do you generate sound at the harp?

When walking, we sink into the ground a little before stepping. Thus, ‘motion’ requires a fixed point – and this fixed point is the hara, the center.

(Tristan le Govic, paraphrased from my notes)

This really is where dancing meets playing the harp. I’ve been taking argentine tango lessons for a while now and we spent a lot of lessons just walking, to figure out where the movement starts. Real argentine tango isn’t the showy over-the-top dance you sometimes see on TV, it is an improvisational dance with no fixed steps and a huge emphasis on connection. Connection doesn’t work if the leader or the follower don’t have a frame, a kind of dynamic tension/relaxation in their bodies. ‘Too much’ frame causes tension and muscle aches, ‘not enough frame’ causes a kind of floppy wobbly dance. Connection also means that you have to be aware of your body’s axis and torsion – the leader doesn’t drag their follower across the floor but invites the follower to a movement – if the follower responds, the movement flows through their body and a shared movement (a step, a turn) happens. When done correctly, it feels as though you are moving like one person, you can both have input on what happens and it’s all one big exploration of the music and movement (here’s a little movie, it’s hard to find good ones!).

So of course, why not apply this to the harp? Where does my movement start from when I play? It is easy to forget when I’m completely into something very technical, but it doesn’t really help the sound if I’m all tensed up. And why shouldn’t I bring the nice, relaxed feeling of having an open chest and relaxed shoulders to the harp?

This part is much harder to apply, I think I have still a lot to learn in the field of body control and awareness. Being relaxed when doing microscopic finger movements is somehow more difficult than being relaxed while doing weird cross stepps… I’ve looked into Alexander technique lessons, but these teachers are really rare, unfortunately, especially AT-teachers who play the harp.

Breathing is key. A performance involves both breathing and gestures.

(Tristan le Govic, paraphrased from my notes)

We did not spend much time on this but I would love to explore this further. I notice that I sometimes stop breathing when practising a difficult passage. How do I gain control?

During the workshop it became obvious that some of the other attendees had hoped for the fancy moves and techniques, while Tristan covered more abstract topics. So I tried to share one of my experiences with how important and helpful controlling your breathing can be.

As a doctor, I’ve done venipuncture and intravenous line placements countless times, but I have been blessed with tremor when I’m nervous, or when I’ve had coffee or when it’s time for lunch or sometimes just because I’m me. For a patient, it’s very disconcerting to see their doctor’s hand shaking (it’s a real macroscopic tremor). I’ve found that it helps me to sit up straight, relax and take a few deep breaths from my center and then do the ‘stick’ on the exhalation. It steadies my hand and calms the nerves that arise when I see the tremor (trying to focus on ‘not shaking’ usually doesn’t help). So ‘breathing control’ isn’t something just for health nuts who like yoga, it’s something very fundamental in how to control your body and movement.

I think the harp world was really lacking these ‘fundamentals’ type of workshops – if there’s one thing that can change your playing it is working on fundamentals that you don’t need a harp for to practice. I really hope that Tristan will continue sharing ‘the message’ and maybe, in the future, workshops where we don’t touch a harp but spend lots of time walking, breathing – and perhaps even dancing – will be the workshops we’re looking forward to.

A doctor for the soul

A couple of years ago I read this awesome commencement address to musicians but I lost the link. A beautiful post by Heart to Harp triggered me to start looking for it again.

If we were a medical school, and you were here as a med student practicing appendectomies, you’d take your work very seriously because you would imagine that some night at two AM someone is going to waltz into your emergency room and you’re going to have to save their life. Well, my friends, someday at 8 PM someone is going to walk into your concert hall and bring you a mind that is confused, a heart that is overwhelmed, a soul that is weary. Whether they go out whole again will depend partly on how well you do your craft.

Karl Paulnack (link)

I don’t have much to add to this. Of course, music doesn’t always have to be about the bigger picture, music can also provide personal enjoyment and that is OK as well. But this piece reminded me that music isn’t just a trivial hobby, when done right (and I’m still far from that) it can bring healing, it can be a gift to other people.

Harp checkpoint

Recently A few months ago I was inspired to start writing again, so I finished some draft posts and scheduled them to appear on the blog. I didn’t even know that I missed blogging until I started again. I’ve accumulated a lot of stories and experiences, it felt so good to get it ‘out of my head’. It actually feels a bit like I’m making space for the new experiences in my new job (clinical research).  I am fortunate in that I still have loads of patient encounters, and the fact that I’m not their doctor enables me to take a step back, to observe, to reflect. The hard thing is to keep it all in until I’ve gathered enough to create a story that takes elements from experiences with several patients.

So the next few blogposts will be mostly about playing the harp! A lot has happened, it’s been about 1,5 year since I last posted about harp-related stuff. And even more happened during the time I took to finish this post (I think I started writing this in March or so).

First of all, aside from finishing the last internships and graduating, I also moved to the other side of the country. That meant finding a new harp teacher. Distance-wise it’s somewhat closer to where my first harp teacher lived, but it would still be quite a journey to get there, and after an entire day in the hospital and commuting, I wasn’t really looking forward to another long commute to harp lessons. Another advantage of looking for a new teacher would be a fresh look on my playing and technique, I’ve known the other teacher for 15 years or so, so we probably had some blind spots.

Through the folk harp workshops I met my new teacher. She was also classically trained, but she is into modern folk harp as well. So that means that my lessons are now a very pleasant mix of classical music AND folk harp things that I’ve always wanted to learn.

I’ve started working on ostinato-like accompaniments in the left hand. For me, it’s quite easy to improvise over an ostinato, but playing a ‘song’ while doing it is an entirely different story. Here is a jig with the ostinato-thing, and of course, I couldn’t resist trying a set with another jig. But you can hear that I’m obviously not there yet due to the change in tempo… :) You can also hear that I sometimes tend to rush. I’m really working on it to ‘keep calm’, to keep my enthusiasm in check, but that isn’t really easy.

https://soundcloud.com/chordaetendinae/sets/harp-checkpoint/s-XV0zv (the jigs refused to be added as a seperate song).

To add to this, she gave me an etude by Maeve Gilchrist which is a very good brain twister. The ostinato and the melody stay the same but it moves by one count every round. I can now sort of play through it without getting completely stuck, but I’m trying to be able to count out loud and play everything exactly on the right moment, sometimes I’m a little late/early. I really love these kinds of etudes.

On the classical spectrum of things, I’m now learning a part of the sonatina in G major by Dussek. I’ve always found this kind of music very hard to play. On paper, it’s not too difficult (no new techniques), but it’s so hard to make these endless sequences of ‘on the beat’ notes become a musical story instead of a flat barrage of sound. To start, is very important to be spot on with every note, so you can focus on the dynamics part instead of the fingers. And then a seemingly rather simple pieces turns out to be more difficult than expected, I definitely couldn’t play it on speed, my fingers would stumble over several passages. So I tried to fix that to bring some more ‘life’ in it, and I think it’s getting there, though a long way from perfect.

Maybe you heard a difference in the harp? I’ve rented a Lyon and Healy Troubadour from my first harp teacher and I’ve completely fallen in love with it. This harp is a lot more ergonomic than my own harp, now I can finally sit straight and try to be in my core while playing.

I’ve also started learning Clair de Lune by Debussy. I don’t have a recording of that yet, becase I’m still in the training-my-fingers to do what I want stage. There are a lot of big chords and after a year of only playing melodies with one voice I need to reacquaint myself with translating these chords to what to do with my fingers. So now I am able to sort of survive the first two pages + 6 measures. But it’s so nice to really ‘struggle’ with a piece, to need to take it very slowly and after some practice, these mysterious notes finally begin to sound a little like music… And I really love Debussy, I didn’t know that he used such nice harmonies in his music – and that it’s possible on a lever harp. It’s completely different from other music I’ve played on the lever harp. The disadvantage of learning this piece is that it takes some time to get ‘into the zone’ of really working on something intensely. I don’t always have the energy for that, so then I only play the easier pieces – and of course, that delays the learning process of Clair de Lune…

The most important concert

I never had the joy of having a ‘typical’ grandparent until I became a part of my husband’s family. Both my mother’s parents died early, she was only 24 and my older siblings barely remember her. My father’s mother went through a lot in her life and combined with her frail health condition, she wasn’t able to act like a stereotypical grandmother* .
However, my in-law grandmother really plays the part, in the sense that they stuff you with food, ask questions about every aspect of your life and offer lots of unasked for but valuable advice. She is the kind of person who really grows onto you and it’s never a pain to visit her because you know that that afternoon will be memorable.
My grandfather was a musician and a theologician, until he had several strokes that left him almost unable to communicate or play his instrument. I never knew the kind of person he was before the strokes, but even now his very strong and loving personality remains. He hated the home he lived in, they put on the TV all day and had them listen to Dutch popular music, while my grandfather had always loved classical music. We’d given him an ipod with classical music but he was dependent on the nurses to turn it on for him, so he rarely got to listen to his preferred music genre.
So of course, I really wanted to play the harp for him, but I didn’t want to just play some celtic tunes on my bardic but I wanted to play the Handel concerto. That is the most classical piece I know and I felt that only that would be worthy enough for such a first-class musician as he had been. On a 27-string harp the Handel is quite a challenge. I’ve tried it for fun but there are some spots where you can’t change the octave and it just doesn’t sound right. Bringing my 34-string harp wasn’t an option because we don’t have a car, so I resigned to the fact that it would be quite some time before I could let my grandfather hear what the harp sounds like.
A few weeks ago, we were planning to visit my grandparents in their new home, but I also had to take my bardic harp along for a band practice session in another city later that day. I hadn’t planned on ‘giving a performance’ but of course I couldn’t let that thing sit in its case…
All the things they say about playing for people are true. It isn’t about playing the correct notes, it isn’t about complex music, but it is about touching people, telling a story and forging a connection. I first played some celtic tunes to warm up, then I made a go for the 27-string version of the Handel. While it was certainly interesting, it didn’t really go as intended. Sometimes I had to stop and go back, sometimes I sort of hesitated. I hoped he’d show recognition the piece of music or maybe show that he liked it. No response, even though he was sitting a few feet across.
So I started improvising a bit over the idea of the Baroque flamenco, the menuet part, then some flamenco-inspired thing – and I don’t know what happened but I noticed that my grandfather had noticed the music and was listening very intently. I was suddenly very aware of his breathing and his awareness. I continued to play, most of this piece works rather well on a 27-stringed harp – and I could still feel the tension, his attention.
The baroque flamenco has a cadenza, where you really build up suspense by tapping on the harp sound board – and then you play a few notes in the high register, still keeping the tension –
Anyway, it worked. I finished the piece and I looked at him and he looked at me and I knew I had accomplished my goal, connecting through music. While it was very profound and moving for me, it wasn’t like there was a huge silence, the moment lasted maybe a few minutes.
This is what making music is all about, and apparently, you can’t force it, it just happens when you least expect it. Sometimes I am really intimidated by all the fabulous professional harpists with their superior tone control, they really can tell a story with their music – but some aspects of this are also available to amateurs, as I discovered that day. Actually, in hindsight, I think that this experience really has a lot in common with what I experience with a patient a while ago! I never felt like I was a very spiritual person, but the spirituality seems to find me

* Regarding my paternal grandmother: I’ll cover this in a blogpost in a while, I discovered that she indeed deeply cared about her grandkids, even though she did not always show it to us in an obvious way.

Skill development

A couple of years ago, I was really worried by the whole ‘qualified and competent’ principle in the law that governs medical actions. Here, the law is that certain professions are allowed to do certain procedures (venipuncture, physical exam etc), but only if you are both ‘qualified’ (either a doctor/nurse/midwife/dentist or under supervision of one) and ‘competent’ (having had the correct training). The second part underlines your own responsibility in this, if you do a procedure that you are allowed to do but haven’t been trained in, you can’t hide behind your qualifications if something goes wrong. I certainly didn’t want to do things I was not allowed to, being quite scared of the disciplinary process that was drilled into us during lectures.

Now it’s quite amusing to read about my somewhat naive concerns. In medicine, there’s a lot of see one, do one, teach one going on. Atul Gawande writes about it in his book Complications and it is true: sometimes, patients serve as guinea pigs for medical students to learn procedures. I’ve contributed to it myself during my final internship by asking the medical students on their internal medicine rotation to draw blood for me on my patients. I remember how important it was for me to get lots of opportunities to draw blood in order to build a routine – and now I was passing on that privilege, knowing that sometimes, patients would have to be stuck twice (or more) to obtain a blood sample.

Actually, venepuncture is taught quite well in medical school – first on a plastic arm, then on a fellow student, then during one afternoon at the outpatient lab where patients are asked if they will allow the medical student to draw blood. So before I unleash a student on a patient, they will have done the procedure 5-6 times at least. For starting IV lines – another common medical student task – they were less well prepared, having done it once or twice or maybe thrice if a kind resident let them during the junior clerkships. However, most hospitals offer a kind of crash course, in which you get to place IV lines in the OR, so again, by the time you enter the ward, you’ll be somewhat familiar with the procedure.

However, a very important procedure, obtaining an arterial blood gas sample, isn’t taught in medical school at all. I was shown once how to do it during my week-long rotation on the Pulmonology ward. When the next ABG had to be drawn, the resident asked me to list the supplies, the steps and how I would explain it to the patient – then she sent on my way – give it a try, if it isn’t succesful, come and get me. Are you sure? I have never done this before. Yes, I’m sure you’ll do fine!

I went to the patient, explained the procedure, conveniently leaving out the fact that this would be the first time ever that I did it. Fortunately, I got my sample in one try. The week after, I coached another medical student through the steps, even though I’d done it only twice by then.

Did I throw away my principles? I could have refused and demanded more training. And still I trusted in my own ability and obeyed the order  given to me. Well, that’s not completely true. I trusted in my resident’s assessment of me. I knew the theory, I just had to gain the hands-on-skills. The point is, like Gawande also argues in his book, there is only one way to learn a procedure: by doing it. Until you actually try it, you can’t learn. Of course I always got help if necessary. Really. I’ve asked an attending to repeat my blood pressure measurements on a patient (the most basic of basic tasks) because I wasn’t sure of my readings. I felt really embarrassed but I knew I couldn’t stand the feeling of maybe having made a mistake.

Eventually, I also realized that someone needs to do the job. As a medical student, it’s easy to get your supervisor. I often went to get them when I couldn’t feel a vein, then I didn’t even try. As the supervisor, you need to call anesthesia to place an IV line, so you better try it at least a couple of times before you start the process of enticing them to come to the ward. So I’ve slowly grown used to starting a procedure even when not completely sure because if you won’t do it, eventually, it will be very difficult to get someone who will.

I haven’t touched much on the most important perspective: the patient’s view of all of this. I’ll come to that in later blog posts, but a vital aspect of medicine still is knowing your limits. I still hold myself to a ‘two tries’ limit – if I can’t place an iv/draw blood/ do an ABG in two tries, I’ll get help. But I will allow myself the space of thes two tries. Gradually, I noticed that I was now able to place IVs in more difficult to see veins – apparently, by taking the time and trying, I slowly built my skills repertoire.

For me, learning how to become a doctor was a big lesson in how to deal with uncertainties and my own insecurity. This example of ‘skill development’ is intended to illustrate one aspect of that learning process – and especially how difficult it is to stick to your principles in the daily reality of clinical practice. Some people become a confident doctor-persona overnight, in others it takes a little longer. And, most importantly: doctors aren’t saints. Doctors aren’t perfect and the process of how to learn isn’t perfect either. But we try, we go on, because we have to -personally, I couldn’t imagine doing something else than helping people.

For those who were curious: I finally learned how to do intramuscular injections during the primary care internship in year five. I don’t think that half of the vaccination was supposed to leak out after I’d removed the needle, but the doctor’s assistant who supervised me, pronounced it as a correct vaccination. I did two more injections, now supervised by the doctor herself and that was it.

And then I consolidated these skills by vaccinating a boatload of unsuspecting first year medical students during my social medicine internship. ‘You’ve done this before, haven’t you?’  ‘Yes’. ‘Great! Here are the vials and here are the syringes. I’ll stay for the first few injections to see whether you’ll be alright.’

I remember how a very insecure looking woman vaccinated me during my first year while an elderly man watched – an exact mirror of the situation I was in. Before she actually injected me, she practiced the ‘throwing a dart like movement’ a few times. I remember being a little bit put off but I didn’t dare to comment. In hindsight I think she was also a social medicine intern who hadn’t had much experience with intramuscular injections… :)


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