The Healing Power of Art, Music, and Surrounding Spaces

This transcript has been edited for clarity and length.

What is the impact of art and music on patient experience and staff well-being? Can a view of nature improve the healing process? Which types of noise stressors have been shown to cause fatigue in ICU nurses? This SoundPractice podcast episode offers answers to questions like these and covers many other aspects of how the spaces that surround us can help or hinder health and wellness.

Cheryl Toth: Our guests today are Dr. Esther Sternberg and Lauren Robb. Dr. Sternberg is the inaugural Andrew Weil Chair for Research in Integrative Medicine and Research Director for the Andrew Weil Center for Integrative Medicine at the University of Arizona in Tucson. Lauren Robb is an author, independent art curator, and curator of the Healing Art Program at Tucson Medical Center. Lauren and Dr. Sternberg, I am so looking forward to our conversation today.

Esther Sternberg: Thanks so much. It's really a pleasure to be here.

Lauren Robb: Yes, it's really exciting to be here.

Toth: Well, before we dig into our topic of art and nature as medicine and how surroundings can impact healing, I'd like listeners to get a flavor for each of your backgrounds and roles. And I'm going to start with Dr. Sternberg, who is internationally recognized for her discoveries in the science of mind-body interaction in illness and healing and the role of place in wellbeing. And she's the founding director of the U of A's Institute on Place Wellbeing and Performance and holds joint appointments at U of A as Professor of Medicine and Psychology. Dr. Sternberg has also written two books, Healing Spaces: The Science of Place and Wellbeing, and The Balance Within: The Science of Connecting Health and Emotions.

Dr. Sternberg, that is a lot of responsibilities that you have to juggle. What is the thread that ties them all together? I mean, what drove you to choose this area of work?

Sternberg: That's a really interesting question. Well, the thread that ties them all together is really the science of the mind body connection and what drove me to that was a single patient. I was called to see a patient at the Montreal Neurological Institute where I was training at McGill as a rheumatologist. I was called to see the patient and the question from the neurosurgeons was is this autoimmune scarring inflammatory disease that the patient has related to the experimental drugs we were giving him for epilepsy for a rare form of fatal ... A rare form of epilepsy called intention myoclonus.

And I was convinced at that moment, which was Christmas Eve of 1978, that the brain had something to do with the immune system that doing something to the brain could potentially cause an autoimmune inflammatory disease, and that changed the course of my career. I was going to become a clinical rheumatologist consulting in the same family practice that I had been working in prior to going back and training as a rheumatologist. And I completely shifted to a research career to try to figure out how the brain and the immune system can talk to each other and whether that communication is important in health and disease.

And back in 1978, '79, certainly through the eighties and even the mid-nineties, the scientific community didn't believe that the brain and the immune system could talk to each other. The notion that stress could make you sick or believing could make you well was considered frankly flaky, but my research then at the National Institutes of Health, where I was up until 2012 when I moved to the University of Arizona, really shed light on that relationship. I found back in 1989 that the brain stress center, the hypothalamus, is very important in susceptibility and resistance to autoimmune inflammatory diseases in rats. And when you can prove that connection in rats, then the scientific community sits up and listens.

So, it really became the science of the mind body connection. So how do you go from the science of the mind-body connection to place and wellbeing? Well, again, it had to do with a single question. The then research director of the US General Services Administration that builds and operates all non-military federal buildings came to me at NIH as a sister agency and asked me if I could help him measure in quantitative ways the impact of the built environment on health, wellbeing, and performance.

So, we began what has now become a 20 year collaboration using wearable devices to measure the impact of many different aspects of the environment on health, wellbeing, and performance. And so that's how I came to do what I do. In the course of that research, I wrote my book, Healing Spaces: The Science of Place and Wellbeing, that basically explores sensory neuroscience and how what you see, hear, smell, touch and even taste and certainly do in a place and space can impact your health and wellbeing, both physical and emotional health and wellbeing.

Toth: That is fantastic, and I'm really looking forward to digging into that more and talking about some of the specific things that you've learned. And let me turn to Lauren first. You've been a museum curator and gallery owner, Lauren, and you've also published three books, but this is your first role in healthcare at TMC, so tell us how you came to the Healing Art Program at Tucson Medical Center, and just a bit about what the Healing Art Program does.

Robb: Sure. Well, let me start with how I got there. In 2014, my contract was up at the University of Arizona Museum of Art where I had been the curator and the couple that was founding the Healing Art Program at Tucson Medical Center really wanted me to take the job and kind of spearhead this brand new program, and they kind of talked me and my former boss into hiring me. Of course, he didn't know me from Adam coming from the hospital world, but it turned out to just be a really great fit for me.

So just briefly, what the Healing Art Program is about, in a nutshell, it brings the art and music that exists in the hospital into Tucson Medical Center. So, we're responsible for all the art and music that's there, and we're constantly looking to expand our foray into different humanities and how they can affect the experience.

Toth: In doing so, creating a surrounding, this is the genesis of this episode, is that I attended one of your curated walks of the art in the hospital, and the surroundings there are just so interesting.

So, Dr. Sternberg, what does research tell us about the power of the spaces around us and what's there and the healing power or the non-healing power?

Sternberg: Well, there's a lot of research that comes from a number of different domains. As I mentioned before, sensory neuroscience is rich in many different studies that show not only that what you see and hear and smell and touch and do in a space can help you heal or can stress, but also how those different sensory inputs can impact the stress response. Different pathways in the brain, like the dopamine reward pathways and the endorphin anti-pain pathways, and how in turn those can affect the systems that impact the immune system directly.

So, there are studies that show looking at a beautiful view, this was the landmark study by Roger Ulrich back in 1984 in Science Magazine. And in that study, he found that patients who were recovering from gallbladder surgery who had a view of a grove of trees out their window in hospital, left hospital a day sooner, needed less pain medication, and had fewer negative nurse's notes than patients on the same ward taken care of by the same staff who had the same surgeons and had the same underlying conditions. Those patients with a view of a brick wall were worse off.

That really was the first time that looking at a beautiful view was shown to have a quantitative effect on clear health outcomes in a hospital setting. And those kinds of studies have been reproduced over and over and over again, and it's led, I think, to an understanding from hospital administrators of how important the physical surroundings are in hospitals.

Toth: Yes. Well, you've given us a great example of that study in the hospital setting, improving health. What about the opposite? In a hospital setting, is the research showing the surroundings that make patients sicker or slow their healing?

Sternberg: Well, there again, one needs to piece these pieces of research together like a jigsaw puzzle, but there's no question that stress can make you sick. So chronic stress has been shown to slow wound healing, predisposed to more severe and more frequent viral infections. If a chronically stressed individual goes out and gets a vaccine, there's a lower take rate to the vaccine. Chronic stress also speeds chromosomal aging and speeds some forms of cancer growth.

Toth: Most of our listeners are physician leaders in hospitals and health systems. How, based on that information, would you advise somebody in that role in terms of how they might apply that research to what they're doing in their hospitals?

Sternberg: Well, it certainly doesn't make sense to have a patient come into hospital who's already sick, who's already anxious, and put them in an environment that will make them more sick and more anxious. So the other piece that's known about the built environment and health and stress is that just as there are elements of the built environment that can calm, there are elements of the built environment that can stress. So for example, too much light, glare, heat, that's temperature and humidity that's out of the comfort zone, foul odors, mazes, loud noises. Does that remind you of some kinds of hospitals?

Toth: Yes.

Sternberg: When I speak to general audiences and I give that list and I describe it and I say, "Does that remind you of any place in particular?" And they all burst out laughing, hospitals. Sometimes airports. But it's sort of a no brainer to make sure that you don't have those elements in a hospital. In terms of mazes, we know that mazes have been used for over a hundred years to test the anxiolytic effects of anxiolytic drugs on rats. Okay? You put a rat or a mouse in a maze, that's a huge stressor.

Now many hospitals are fundamentally mazes and the reason they're mazes is they've grown up piggledy piggledy with many different wings added and poor signage. And how many times have I passed a patient in a hospital who's carrying their x-rays under their arm and looking totally stressed, not able to find the radiology department or looking for the lab? So, these kinds of things are very basic in terms of building design and operation. Optimal humidity is very important to reduce viral infection. Less than 30% relative humidity has been shown to be associated in hospitals with a higher level of viral infection. That's extremely important nowadays, especially.

In our studies with the General Services Administration, we also found that less than 30% relative humidity was associated with a 25% increase in stress in the physiological stress response. So we can get very granular in terms of the data that's out there, but it really behooves the hospital administrators and leadership to create hospitals that have all the elements of the built environment that calm, that reduce anxiety, that enhance health, and to rid that environment of those elements that increase stress and potentially worsen disease and infection.

Toth: Well, Lauren, let's turn to you because that's a great segue to say that the leadership in your hospital at Tucson Medical Center have prioritized art and music and the surroundings there are a bit different. So, describe how the art collection at TMC and the installations are a little bit different and what kind of responses you're getting from patients and from staff.

Robb: Thanks. The biggest difference between our hospital collection and a lot of other hospitals is that we do have an embedded curator. So, because I'm a part of the community, the art that's in the hospital is reflective of the artists and collectors that live here, and it's very much Tucson oriented, but it's also oriented very much towards our audience. We give a tremendous amount of thought to who our audience is, and we don't like to impose art or try to educate them with art or try to be fancy with the art. The art is designed to make the people who are going to see it feel better.

And sometimes those can be kind of squishy requirements that are hard to describe, but after six years of doing this, we kind of know what's going to make the patients, visitors, and staff happy, and what might be a bit off putting. We don't do a lot with abstract art, for example, because our audience isn't there to get an art education. They don't need to interpret the art. They just need to be able to look at it and feel good. And so, we do a lot of things that they can recognize. We do a lot of art that would be considered realism, but despite all that, it's a very varied collection. We're really interested in quality but not necessarily in value. So, we do care about the skill with which the artwork was made, but we don't care if the artist is completely unknown.

Toth: Well, and what I remember is that a lot of it, the way it was hung, I guess is the right art work there, in collection. So, you would have a bunch from one artist, so it wasn't just random pieces of art around, but you had a collection here and a collection there, and you talked about the artists when you did the tour. What do you hear from patients about that or just about the art that is there? You have over 900 works, is that right?

Robb: We have over a thousand now. Yes.

Toth: Okay.

Robb: We have a lot of art.

Toth: What do you hear? What do they say?

Robb: It's really interesting that you asked about the patients because one of the things that surprised me after we started installing the art was that the most impact of the art program is actually on the staff, not as much at all on the patients. The patients tend to come into the hospital, they go directly to their units. In a second, I can talk about what the units at Tucson Medical Center are like because they are quite unique in the country. But it's the staff that was walking through these hallways that were completely empty before and now are filled with art.

So, I hear from the staff constantly about what a difference it's made to their environment and how much the place just looks and feels so much less like a hospital. Visitors sometimes come in on it too, but the best response we get from visitors is usually when they recognize someone, either a donor on a plaque or the name of the artist because they know that artist. Then sometimes we hear from them. But often visitors are in a state of being somewhat distraught and what I always feel is they take in the fact that the environment doesn't feel institutional. It doesn't feel cold. It feels warm and comfortable, but what they don't necessarily see is the art at the time that they're there.

Toth: They're focused on other things, their families.

Robb: Yes.

Toth: Dr. Sternberg, can you tell us about what the research says about art and happiness or wellbeing? What connects the dots here with the art being hung at TMC?

Sternberg: There's another landmark study that addressed that question about art and healing and patients' wellbeing. Professor Sean McCann, who ran the bone marrow transplant unit for all of Ireland at Trinity College Dublin, did a study called Open Window. It was published in 2011, and what he did is interesting because it's similar to what Lauren described. He convened a committee at the hospital that consisted of an art historian, an artist and curator, himself a physician, and many different members of the staff, nurses, physical therapists and so on, and the patients and the lay public.

And they were very careful and selective in the kinds of art that they chose, and this resonates with what Lauren said about not picking abstract art. They did focus groups with the patients to ask what they would like to see when stuck in the bone marrow transplant unit for six or eight weeks and unable to go out and unable to see a beautiful view out the window, by the way, because unfortunately, the bone marrow transplant unit was in a retrofitted 200 year old Dickensian workhouse, and the only place they could put the HVAC equipment to have positive pressure in the rooms was right outside the patient's windows so all they could look at was this HVAC equipment. Not very calming, is it?

Toth: Very important.

Sternberg: Yes, very important. Yes. So he did these focus groups and he also worked with artists who were creating art in Ireland as they worked, and they brought existing art and also views and videos, the kinds of things that the patients wanted to see, which were very calming, horses and cows grazing, meandering in a canoe down a quiet stream, beautiful views of nature. And things specific to individual patients, what they wanted to see, pictures of their family. One patient used to walk on Dún Laoghaire pier to walk his dog and watch the boats go by.

So, all of this art was funneled into a computer program that was then projected on the wall of the patient's rooms through an LCD projector, and the patients could use a little clicker just like you use for changing your television channels to look at the different images. In the course of this study, he also worked with the city of Dublin to install webcams on Dún Laoghaire pier or other places so that the patients could actually see what they wanted to see in real time. And at the end of the study, he found that the patients who had access to this open window project had an improved quality of life, were less depressed, had less anxiety than the patients who didn't have access to it, and it was universally approved by the people who went through this experience.

Toth: I'm so fascinated by this and I'm wondering if similar things hold true with music. So, let's talk about music for a second because Lauren, you at TMC, you have a strolling musician program. You'll correct me if that's not the right way to say it, but you have like eight musicians, classical, that play in patients' rooms. Tell us about that and what results and feedback have you gotten from patients, from staff about music on the floors?

Robb: So our music program is by far the most impactful thing we do for the patients. We have musicians, as you call them, we actually call them medical musicians, but we made up the term so it's not official. But they're very special people who have self-identified as wanting to do this work. And we have harpists, violinists, classical guitarists, and they have to be very sensitive to what's going on in any particular unit they might choose to work in. Sometimes they get asked to go into patient's rooms, so they have to kind of feel out that situation. And occasionally they get asked to actually serenade someone at the end of their life as they're actually dying. It's very emotional, very rewarding work, and we get spontaneous notes, emails, letters, phone calls all the time about somebody who was in a room. The information might come from the patient or their family or even from the staff, and they'll just talk about how this patient was there, they weren't responsive, they weren't having a good day, and then all of a sudden they hear the live music and it changes everything. They're engaged, they're awake, they're interested, they want to hear more.

So I've been thinking a lot about why live music has so much of an impact as compared to any music that you could possibly stream into the room, and I think Dr. Sternberg could probably tell me whether I'm on the right track. I think it has to do with the vibration. I think it has to do with the fact that it's two senses, so you're hearing it and you're feeling it. And I think that sometimes for patients, just having that vibration kind of hit their bodies, kind of gives them a sort of piece that they can't get from music in another way.

Sternberg: Wow, that's a really interesting observation. There's a lot of research on music, on making music and on listening to music. I'm not aware of research on the vibration piece, but it makes a lot of sense. I mean, there's no question that when you look at a beautiful view, a picture, a painting, it's not as impactful as if you are actually in nature. And it's because in nature, you're receiving all these sensory inputs, what you see and hear and smell and do. And I suspect that when the live music is happening, that you are getting multiple sensory inputs that can impact many different aspects of your emotions and health.

There's a large literature looking at the impact of music on all sorts of outcomes of health, on antibody production, on certainly, moods. There are books written on it. Julian Thayer who was at the National Institutes of Health and now is at UC Irvine did a lot of research on this using heart rate variability as the outcome measure. There's research showing that when kids listen to or watch movies that are either exciting or sad and induce different emotions, you can certainly detect changes in their heart rate variability, that is their stress and relaxation response. So there's a huge literature showing that music can calm and can activate just as different aspects of the physical environment can calm or stress. And the people who know how to do this best are the composers for movie scores.

Toth: Yes. Right.

Sternberg: We worked with a seven time Emmy winning film scorer, Gary Malkin, who does this, and I asked him how do you that? How do you make the music stimulate or be sad or get you anxious? When he gives his talks, he shows just a video of driving down a New York street and he turns the sound off. And when you look at it with no sound, you’re just driving down the street. When you look at it with sound that's uplifting, it feels happy. When you look at it with sound that's ominous, you feel anxious. So composers do this intuitively, but there's no question that different kinds of music impact our emotions and our physiological responses very immediately.

Toth: Now, Dr. Sternberg, in your book Healing Spaces, you talked about the emergence of this thing called evidence based design. I didn't really know what that was. Explain a little bit about that and how we should be thinking about designing hospitals to enhance healing.

Sternberg: Well, evidence-based design really is what it says, you design. There are two ways that architects design a building. One is intuition, and of course, that's how artists create. You base it on intuition. Unless you're painting by numbers, an artist is really coming up with a creative idea or spark, and then creating the art. And architecture has an important element of art in it. On the other hand, when you're designing a building and you know that certain elements of the built environment can impact different aspects of health, it's important to follow a prescription for a healthy building.

Just as physicians, we know a healthy range for any given medication; too much is not good and too little is not good, and there's an optimal dose. Well, there's an optimal dose for virtually every element of the built environment, and we've found this in our studies with the GSA using wearable devices. So, we know that relative humidity between 30% and 60% is optimal for reducing the stress response. And in fact, somewhere around 45% plus or minus 5% relative humidity is the best. In terms of sound, high decibel sound is known to not only impair hearing, but also cause a lot of stress. And again, we've found that something in the range of 30 to 50 decibels, but not more, and actually interestingly not less, is optimal for the stress response.

There are studies in intensive care units looking at nurses and their sleep quality, where when the sound in intensive care units can be as high as 90 decibels. That's a motorcycle firing at near range. And nurses who were in intensive care units where they changed the ceiling tiles to be more sound absorbing had better sleep quality at night, and they weren't aware that the ceiling tiles were being changed. Now you can imagine if you're a patient in the intensive care unit, that's really bad too because your stress response is going to go up and you can't tell anybody about it.

So, I mean, these are specific examples, I could go on and on, but we don't have enough time on this podcast. But these are specific examples where studies have been done to find the exact dose and range of different elements of the built environment that are optimal for different aspects of health. So, for example, carbon dioxide, the more people there are in a small enclosed space where the ventilation is poor, the more carbon dioxide that you breathe out builds up and that impairs cognitive performance. It can lead to medical errors. This is a huge problem. What if in your medication room you have poor ventilation and you have more people in there than should be in there who are measuring the numbers of pills that a patient needs? There could be serious medical errors.

Toth: And I would think the same, your example about the nurses getting the right amount of sleep and not being awoken with the sounds.

Sternberg: Absolutely. Absolutely. So, Robert Wood Johnson Foundation sponsored a project back about 10 years ago, which was led by the Center for Healthcare Design, which I'm sure your audience has heard of. It was called the Pebble Project, where they measured the impacts of different hospital designs as 50 different hospitals around the country were retrofitting or adding wings or wards. And they purposefully created these wings and wards to incorporate all of the different things we're talking about, the views to nature and the light, circadian light. That's another thing that's really important for healthy sleep is bright sunlight in the morning. There's a tremendous amount of data on that. And dimming light as the afternoon and evening wears on is very important for healthy sleep and improved moods and falling asleep faster, so sleep latency as well as sleep quality.

What they found in this Pebbles Project was that not only was there better health outcomes, there was better nursing satisfaction, less nursing turnover, better patient and staff satisfaction, family satisfaction, fewer medical errors, fewer falls, fewer infections. And adding it all up, it's good for the bottom line. I mean, what organization doesn't want to have a better experience of the people inside the building that they operate? The hotel industry knows this. Why shouldn't the hospital industry know it?

The good news is that the hospital industry is, I think, improving tremendously, as is the example of the TMC and paying attention to this. I've visited other hospitals around the country, other organizations where there's no question that there is a lot of attention paid to the patient experience and what is important for creating that patient experience. The minute you walk into a hospital, you don't want to smell foul odors, being confronted with a maze in a dark, scary area. You want to immediately convey to that person walking into the hospital or being wheeled into the hospital that this is a safe and happy place where we are going to take good care of you.

Toth: Absolutely. Lauren, what would you say at TMC has been done and some of the things that Dr. Sternberg has mentioned on some of these design elements. What do you see being done at TMC and maybe what you're even instituting in the healing art program to support that?

Robb: For those of you who have never been to Tucson, Tucson Medical Center is the largest single story hospital in the country and because they had all this space, they designed most of the patient rooms around courtyards, and the courtyards are really nicely landscaped with lovely cacti, and most of the rooms have very large windows. And it's just a design aspect, I don't know if they did research on this or that was just the advantage of having the land, but it does make for a much more pleasant room experience.

And then what we've done is following the research about nature and realizing that there were still patient units in parts of the hospital where people don't have windows and views, we have put beautiful landscape photography in those areas of the hospital. And one of the things we do that I'm proud of, that I think is kind of unique, is when we go to put landscape photography in a unit, we don't want to just impose that landscape photography on the staff there, we want to get their buy-in. So, we go in and we ask them what kind of landscapes they would really like to see. And so, we have units that have desert views, we have units that are all the Grand Canyon. We have units that like seascapes, units that like tropical views. So, each one is kind of unique and it's been nice for the staff to have that input.

Toth: Lauren, let's continue on this idea around the staff and their role. As part of your role in the Healing art program, you've trained some of the TMC nurses in something called 'Visual Thinking Strategies'. And for those unfamiliar with it, it's a method that facilitates discussion of visual art like a painting, and it's done to increase engagement, performance learning. Tell us about the feedback that you've received from training, a little bit about what that is and how many nurses you've trained and how that works, and what feedback you've gotten.

Robb: Sure. So we've done at this point I think five classes of nurses. I think we have about three classes a year, and there's anywhere from 30 to 60 students in each class, so I can't do the math that quickly, but it's a lot. It's a good number of nurses. It's a lot of nurses now. And these are the new nurse graduates, the new nurses at TMC, they get mentored for a year, so it's kind of a unique program and they have actual classroom time. So, we were able to bring visual thinking strategies into the classroom to try to improve their observation skills, their communication skills, their collaboration skills, and their comfort with ambiguity. And I think it's pretty self-explanatory why all those would be good skills for nurses.

Visual thinking strategies are kind of unique as an art teaching method because it's very bottom up as opposed to top down. So rather than a curator telling this group of audience what they should see or think about a work of art, the audience has to figure out what they think or feel about a work of art and what they're seeing. And so, it's very bottom up, as I said that the students basically just get asked, "What's going on in this picture? What do you see that makes you say that and what else can we find?" And the discussion moves on from there.

And what's been a really interesting journey was that the benefits of better observation and better communication and collaboration and all this other stuff happens by magic seemingly if you do it in a museum setting. But we had to find out that when you do it with a bunch of people who have no interest necessarily in art at all, you really have to explain to them why you're doing it and what they're going to get out of it, and you may have to repeat explaining to them why you're doing it and what they're going to get out of it a number of times.

But we finally figured out that there are certain artworks that work better with nurses than others, and so we've devised this four-part series of classes where the first two weeks you look at fine art, just works that are not terribly, but really interesting. And then the next week you look at professional artistic photographs. And then in the last week, we look at clinical photos and we see how we can apply all the things we've done up until then to that.

And when we first started, our reviews were not that great. The nurses were like, "Well, we don't understand why we're doing this. It seems like a waste of time." But we finally got it to the point where the nurses rave about it. They really love it. It's a lot of fun. They understand why they do it and we're hearing anecdotally that it's making a difference in their careers. I think it'll take a while to really figure out how much of an impact it's having, but at least they like it and it seems to be successful.

Toth: One of the things that it's attempting to do is help them, you said collaborate, but also focus or with decision-making?

Robb: Yes. I mean, one of the things that happens with new nurses, it's so interesting is some of them are very self-confident when they come into the hospital, but some of them are not, and one of the things that this gets them comfortable doing is speaking out loud in an environment where there's no right or wrong answers. So, we want them to get comfortable in speaking up and we want them to get comfortable in talking about what they see because in any field, when people have been in the field a long time, they have a certain sort of preconceived notion every time they walk up to a patient. And they may be absolutely right, but they also may not be seeing something that another nurse will come along and see, or it can just be different points of view.

We always point out how the same person can walk into a room and see two completely different things, and they're both potentially valid, but they're just seeing two sides of a story. So, we want the students to just get really used to talking about what they observe and not being shy about it, and listening to the students around them because they're going to need to collaborate like that when they're on the wards. So, there's that aspect.

And then personally, I really love the fact that it gets the more comfortable with ambiguity because I think what I know having had loved ones in the hospital is that most of the people these days who are in the hospital for any length of time, there's something about their situation that's ambiguous, either the medicines that we thought were going to work don't seem to be working or we can't quite figure out what's wrong with them. Or we don't know what is a red herring and what's really their illness.

And so those feelings of uncertainty really weigh on the family members that are in the room and sometimes on the patient themselves. If the nurse can walk into the room with this total comfort with the ambiguousness of the situation and how it may seem really confusing, but don't worry, it's all going to work out, that goes a long way towards reassuring everyone that's there, so I love that aspect of it.

Toth: Dr. Sternberg, from a physician's perspective, improving the observation and listing skills and comfort with ambiguity, how do you see that as improving the care team?

Sternberg: It's absolutely critical. And in today's world where every single member of the team is equal, it's not quite the same patriarchal team structure that I grew up with when I was coming up through the ranks. It's really important to work hand in hand with the nursing staff, with all the other healthcare professionals, to come up with solutions, and unless you can make an observation that's accurate and know how to speak up, I think that it's only going to be good for the teamwork.

Toth: So many of the folks listening, as I mentioned, work in large hospitals, they work in health systems. How would you advise the physician leaders that are interested in all of the things you've been talking about today? I mean, clearly the research supports all of these things, art, music, nature, sound, all of these things. How would you advise them to begin moving forward? If they were intrigued and inspired by what you've talked about, where could they start? Dr. Sternberg, what would you suggest they do?

Sternberg: Well, I think one of the great resources is the Andrew Weil Center for Integrative Medicines training programs for all levels of health professionals, all physicians, allied health professionals, and so on. I would definitely recommend that you can reach out, you can look up Andrew Weil Center for Integrative Medicine's offerings and trainings. And we talk about a lot of these different kinds of integrative approaches to health, which go beyond medical interventions, and the whole idea of integrative medicine is not to throw out the baby with the bathwater. Of course, you want to use whatever surgical and medical interventions, space age interventions work, but in addition, use these other kinds of approaches, which include art and music and the physical environment to help a patient heal.

I want to give a couple of other examples of other hospitals that have incorporated these kinds of interventions. One is the Walter Reed National Military Medical Center's NICoE, the National Intrepid Center of Excellence. They found that these art programs and music programs, and even they have labyrinth for walking meditation, were so successful at the Walter Reed National Military Medical Center in Bethesda, they're incorporating all of these kinds of interventions in all of the NICoE hospitals that are being built across the country. And it's good for the staff, as Lauren mentioned, and good for the families and good for the wounded warriors with post-traumatic stress disorder and traumatic brain injury.

And another example is in Vermont, I was invited to speak by the Susan Sebastian Foundation, where the mother of a woman who died after a long illness and spending many, many, many months of her life in hospital, the foundation honored the patient's request, which was to put a painting, a piece of art, an artwork, an original artwork, in every single patient room in every hospital in the state of Vermont.

Toth: Wow.

Sternberg: And it was really moving to me because the patient who had died had been inspired by my book, Healing Spaces, to wish that others could have this kind of experience if they're in hospital and facing illness.

Toth: That's wonderful. And I actually watched the video of part of that talk that you gave in preparation for the podcast, and I just thought ... My boyfriend was born and raised in Vermont, and I told him that and he said, "Wow, that's really interesting because to have an original work in every hospital room, I just thought that was astounding." So, what a great example to point out definitely.

Sternberg: Thank you.

Toth: Lauren, tell us what you think. How would you advise just given the program there at the Healing Arts Center, where could the hospital leaders start if they want to implement something?

Robb: Well, the first thing I would tell them is it doesn't have to be an expensive program. All of the art at TMC is donated, so we do have to raise money for things like my salary and the installation and framing and the labels and things like that. But in terms of the art program, you can start small and build it up. I would say it's a great idea if you're going to do this in your own institution to have someone who is locally known in the art community because it will just increase your ability to raise money for the program and to get donations of art from artists and collectors.

Toth: And what about the music side of things? Because you really got energetic around the music, and you've had some success there.

Robb: We have a team of professional musicians that are paid. They do work for way less than they would normally get at their gigs, which is kind of a contribution. I consider it a contribution on their part. On their part, they consider it an honor to do this work. They love it so much. Most of them are very serious musicians who compete a lot and one of the things they love so much about playing at the hospital is that everyone is so delighted with them, so happy. There's no critique ever, it's just pure joy. So, they get a lot out of it. We get a lot out of having them there. So no, we don't pay them a huge amount, but what we get back is absolutely amazing.

Toth: So, what I'm thinking is if a hospital wanted to start small and have a program of five or six musicians, that's another cost effective approach.

Robb: Oh, absolutely. And you can use volunteers. We also have a lot of volunteer musicians. Most of them play the piano in the lobby, which is fantastic. But yes, you can definitely start small.

Toth: Well, this has been so interesting for me to hear all of these ideas and the research. Final thoughts to physician leaders about just about the healing power of what the two of you are doing and experiencing.

Dr. Sternberg, I'll start with you. What are your final thoughts to physician leaders?

Sternberg: I think that we all take for granted the physical spaces that we move through throughout our lives, day and night, home office spaces, hospitals, and we don't realize, unless you're an architect, you don't realize how much these physical spaces impact every aspect of your emotional and physical health. And simply paying attention to designing with health in mind is really important. Healthcare design architects have been doing this for a long time, and as I said, it's really much, much improved from back in the day when I trained. But really consciously paying attention and doing what can be done to optimize the physical environment is essential, especially now in the post Covid era.

One of the things that is going to change enormously in the post Covid era and all these design standard setting, building standard setting organizations are now working together feverishly to come out with guidelines for healthy buildings in a post Covid era. So, there's building operations of ventilation and filtration of air and air exchange, surfaces to be clean. All of those things, which are the foundation of a healthy building are essential, but in the post Covid era, people are afraid. They're scared. They're stressed. They don't want to be going into a hospital or into a building that they don't know whether it's healthy.

And so hand in hand with making sure that the building design and operation is healthy to prevent viral transmission and prevent susceptibility or reduce susceptibility to disease as much as possible, hand in hand with that must go attention to how the physical environment and every element of it impacts the emotional health and reduces stress, and can signal immediately upon walking into that building that the person is safe and will be happy and healthy.

Toth: That is such a great point. Maybe that's one of the silver linings in this dark cloud of Covid, that paying more attention to the surroundings and to the experience that patients and families have and staff in the building, it's going to get prioritized more than it has in the past, which would be a wonderful outcome.

Sternberg: Definitely.

Toth: Yes. Lauren, how about you? Final thoughts to physician leaders about the healing power and what you've seen at TMC?

Robb: Yes, I wanted to mention the importance of beautifying the environment for the staff. When I first started doing this work, I was really surprised by how many staff members would come up to me and say, "We feel so appreciated by this program. We feel like the hospital really wants to make our environment better for us." And to them, it was like the hospital was saying, "You matter, and we care what your work environment is like." And so, any institution that's thinking of doing something like this should know that it will come back to them in staff satisfaction and retention, and that's always a good thing.

Toth: It's a great thing. It's a great dividend to a program like yours.

So, thank you, Lauren. Thank you, Dr. Sternberg. This was just a fascinating conversation today, something a little bit different from what we usually talk about, but nonetheless, very important. And I hope that our listeners think about this, put this on their agendas and think about it within the context of all the other initiatives that they have going on. Thanks so much for being our guests today on SoundPractice.

Listen to this episode of SoundPractice.

Resources

Tucson Medical Center’s Healing Art Program  (including the portfolio of its art collection)

Books by Esther Sternberg, MD: Healing Spaces: The Science of Place and Well-Being and The Balance Within: The Science of Connecting Health and Emotions. 

Information about Visual Thinking Strategies

Can Art Help Heal ? Video of Dr. Esther Sternberg presentation

University of Arizona’s Institute on Place, Wellbeing, and Performance  and Andrew Weil Center for Integrative Medicine