Music in medical education: A critical interpretive synthesis

Abstract

Introduction

While many have championed the value of music in medical education, research specific to how and why music has been offered in medical education is sparse and there have been few attempts to synthesise the literature.

Methods

A Critical Interpretive Synthesis (CIS) of 56 texts including published articles, correspondence, abstracts and one thesis published between 1977 and 2022 was undertaken to explore the evidence basis for offering music in medical education.

Results

A total of 52 music-focused programmes/activities were described, encompassing both curricular and extra-curricular, receptive and participatory music activities and a wide range of musical genres. Inductive analysis of data extracted from texts revealed a variety of rationales for the use of music in medical education, which could be grouped within seven interrelated themes: well-being; supportive learning environment; affective engagement; teaching and learning; developing skills for clinical practice; humanism in medicine; and creative expression (identity).

Discussion

The results of this synthesis demonstrate that there remains a gap between what is claimed about the affordances of music and what has been explicitly addressed in medical education research. Despite a paucity of research in this area, the available data support that the affordances of music are ‘multiple’ and may not be well represented by linear models. Evidence that engagement with music is beneficial for medical students is strongest in relation to the affordances of music for well-being, facilitating a supportive learning environment, affective engagement, memorisation and creative expression (identity). That engagement with music might enhance humanism, including developing skills for clinical practice, requires further investigation. Accounting for student agency and the ‘multiple’ affordances of music will ensure that future teaching and research are best positioned to benefit medical students' well-being and personal and professional development.

1 INTRODUCTION

A consanguinity between the practices of medicine and music has long been recognised, with many doctors also being active musicians and choosing to engage in extra-curricular music activities.^1-3 However, although many have championed the value of music in medical education,^4-6 its use in medical curricula is still relatively rare in comparison with other creative arts such as literature, visual arts, theatre, TV and film.⁷ There is a longstanding tradition of using arts-based teaching to promote humanistic values and skills such as empathy, communication and cultural understanding, with some educators claiming that music has qualities that make it ideal for developing these capacities.^4-6 Medical students with a musical background are reportedly advantaged in tasks that require empathic communication,⁸ attentive listening⁹ and fine motor dexterity.¹⁰ Recent research has also suggested lower levels of ‘burnout’ in medical students who have engaged with the humanities¹¹ and music-related activities in particular,^{12, 13} leading some to argue that medical schools should try recruiting more musicians to the profession.¹⁴

The need for a more intentional approach to pedagogy in the medical humanities and creative arts-based teaching has been recognised.^{15, 16} However, there have been few attempts to synthesise the literature on music in medical education.^{7, 17-20} Our investigation was directed by these guiding questions:

1. How has music been included in medical education?
2. Why did medical educators choose to offer music and what aims and outcomes of using music were reported?
3. What is the evidence basis for using music in medical education?

2 METHOD

The method of Critical Interpretive Synthesis (CIS) was first proposed by Dixon-Woods et al. as an alternative to meta-ethnography and has become an increasingly popular method of knowledge synthesis, particularly in the health sciences.^{21, 22} CIS offers a valuable approach where the purpose is not merely to aggregate results (both quantitative and qualitative), but rather to critically appraise a diverse body of literature and the ‘assumptions’ that support it.^{21, 23, 24} The research is directed by a working question or guiding question that remains open to modification through an iterative process of critically engaging with the data.^{21, 25, 26} Identifying literature for a CIS demands ‘multiple search strategies’²⁶ and as in grounded theory, purposive sampling and theoretical sampling are often used, enabling sampling to continue while new theory is being generated and until theoretical saturation is achieved.²⁵ While appraisal of research quality is essential, research relevance is also valued as studies that have methodological or analytical weaknesses may still yield valuable insights in illuminating the research question.²¹ The method of a CIS should be replicable; however, as interpretation of data entails an element of creativity, it is recognised that other interpretations are also possible.²⁶

Our initial library and web searches using the keywords ‘music’ and ‘medicine’ scoped a varied literature spanning music neuroscience, music psychology, music therapy, music medicine, the medical humanities and arts-based teaching and learning in medical education. Thereafter, we determined to identify specific examples of music being offered in medical education (as articulated in our guiding questions). Combining the keyword ‘music’ with the phrases ‘medical education’, ‘medical humanities’, ‘medical student(s)’ or ‘medical school', we conducted a full text search in electronic databases MEDLINE, PubMed, PsycINFO and ERIC, plus a title/abstract/keyword search in SCOPUS and a title search in Google Scholar, which produced a list of approximately 1500 articles after duplicates were excluded. Article abstracts (or where no abstract existed, whole articles) were screened by the first author and articles were excluded at the outset if judged to be unrelated to the use of music in medical education. Articles in languages other than English were also excluded at this stage; however, we note that some of these articles could be relevant to our study (see e.g.²⁷). A decision was made to consider descriptive articles, correspondence, abstracts and theses alongside research articles to allow for a richer understanding of how music has been offered in medical education to date.

Although the selection of literature for a CIS need not rely upon inclusion and exclusion criteria,²¹ we found that such criteria emerged inductively during our review of the literature. To address our guiding questions, we identified texts that documented a specific music programme or activity in general medical education, whether curricular or extra-curricular. Articles that discussed the use of music in medical education without documenting a specific example were excluded, as were articles that discussed the use of music in medicine or the medical humanities without application to medical education and articles that were related to health professional education other than general medicine (i.e. pre-med undergraduate classes,^28-30 training for medical residents,^31-34 medical education training and development,³⁵ osteopathic medicine,³⁶ naturopathic medicine,³⁷ paramedicine, etc.). Articles were also excluded if the use of music described was prospective rather than retrospective^{38, 39}; if they described an opportunity for medical students to design and submit creative works without discussion of musical artworks created by medical students^40-43; or if the use of music was incidental in the service of another artform such as theatre,^{44, 45} video,^46-48 vodcast⁴⁹ or identity text.⁵⁰ Finally, articles were excluded if they described musical activities with a cohort of medical students not directly related to general medical education, for example, qualitative explorations of musical experiences in which medical students have been participants,⁵¹ studies testing a hypothesis about the effects of music with a cohort of medical students under experimental conditions,^52-62 or interventions carried out by medical students but tailored for a specific population group (e.g. aged care residents⁶³). These criteria reflected our judgement that texts describing specific examples of music programmes/activities in general medical education would enable the greatest insight in relation to our guiding questions, because they sought to integrate theories about music and medical education with student experiences and pedagogical reflections. Citation chaining was also used to identify several additional articles meeting inclusion criteria.

Data were extracted from each text including bibliographical details; details of the music programme or activity described including aims, whether programmes/activities were curricular or extra-curricular, whether programmes/activities were faculty-led or student-led, educational context including country in which the programme/activity took place, genre(s) of music featured, expertise of educators and rationale for how the inclusion of music addressed educational aims; secondary literature cited to support rationales; research design (if applicable), data collection strategy and method of data analysis; outcomes reported and conclusions drawn by the authors. Data were tabulated within a Microsoft Excel spreadsheet.

Research orientation,⁶⁴ methodology and limitations were identified through an appraisal of research quality using JBI Critical Appraisal checklists,^65-68 with each study rated independently by two authors and discussed until agreement was reached by the group. Analysis of the aggregated data set was undertaken by two authors (AO and JS). Music methods were categorised as per convention in music therapy as either receptive, re-creative, songwriting/composition or improvisation,⁶⁹ or for those programmes that offered theoretical perspectives or experiential learning about music therapy, music medicine or the reflexive use of music for personal well-being, as ‘learning about music and health’. As many texts were descriptive, with aims and outcomes sometimes difficult to distinguish, we chose the term ‘rationales’ to denote statements by authors that expressed assumptions about what music in medical education was intended or expected to do. Rationales were categorised through an iterative inductive process in which the identification of categories informed subsequent data analysis and refinement of categories and themes, until these were judged to represent as closely as possible the essence of the included texts and no further categories or themes were identified. A definition of each theme was constructed in line with our interpretation of the source texts and with reference to external sources where this enhanced clarity, and a critique of evidence for each theme was undertaken.

3 RESULTS

Table 1 presents a summary of examples of music in medical education included in the synthesis. A total of 52 music programmes/activities were documented, with several programmes described in more than one article^{84, 85, 88, 89, 92, 93, 103, 104} and one article describing two discrete programmes/activities.⁹⁷ There was a modest trend towards a greater number of relevant articles being published in recent years, as well as an apparent bias towards selection of articles from nations where English is the first language, particularly the USA. A broad range of musical genres were represented, most prominently classical, popular and jazz. Music programmes/activities within medical curricula predominantly used receptive music methods (i.e. listening to recorded or live music performances), while extra-curricular programmes/activities were most often participatory (i.e. involving re-creation of classical or popular music, improvisation or songwriting). Professional musicians (including performers, composers, conductors, music academics, music therapists and music teachers) were only occasionally involved in teaching^{74, 87, 113-115} but supported all orchestral programmes as conductors and as soloists.^{78, 81, 97, 125}

TABLE 1. Summary of examples of music in medical education included in the synthesis.

Author/s and date	Title	Country	Research orientation and method	Educational context	Music method	Music genre(s)
Egan 1977	Teaching medical student psychiatry through contemporary music^70	USA	Descriptive	Psychiatry	Receptive	Popular
Stokes 1980	Grief and the performing arts: a brief experiment in humanizing medical education^71	USA	Descriptive: descriptive statistics	Extra-curricular	Receptive	Classical, Jazz, Popular
Segal 1984*	Playing doctor, seriously: graduation follies at an American medical school^72	USA	Interpretivist: ethnographic	Extra-curricular (student-led)	Songwriting	Musical theatre
Udvarhelyi 1993	The Hopkins experiment^73	USA	Descriptive: descriptive statistics	Extra-curricular	Receptive, Re-creative	Classical, Jazz
Benor 1995	The Louisville programme for medical student health awareness^74	USA	Descriptive	Extra-curricular	Learning about music and health	Vocal intonation and chanting
Vora 1998	An anatomy memorial tribute: fostering a humanistic practice of medicine^75	USA	Descriptive	Extra-curricular (student-led)	Re-creative	Classical, Popular
Acuña 2000	Don't cry for us Argentinians: two decades of teaching medical humanities^76	Argentina	Descriptive	Elective	Receptive	Opera
Acuña 2003	Teaching humanities at the National University of la Plata, Argentina^77
Fraser 2003	Australian Doctors' Orchestra: mixing music and medicine^78	Australia	Descriptive	Extra-curricular	Re-creative	Classical
Frich & Fugelli 2003	Medicine and the arts in the undergraduate medical curriculum at the University of Oslo Faculty of Medicine, Oslo, Norway^79	Norway	Descriptive	Non-compulsory seminar	Receptive, Re-creative, Learning about music and health	Not specified
Murray 2003	Development of a medical humanities program at Dalhousie University Faculty of Medicine, Nova Scotia, Canada, 1992–2003^80	Canada	Descriptive	Extra-curricular	Re-creative	Band, Choral
Berger & Lasseron 2005	European Doctors Orchestra^81	International (Europe)	Descriptive	Extra-curricular	Re-creative	Classical
Blasco et al. 2005	Teaching humanities through opera: leading medical students to reflective attitudes^82	Brazil	Descriptive	Extra-curricular	Receptive	Opera
Arjmand 2006	Music lessons^83	USA	Descriptive	Extra-curricular	Re-creative, Receptive	Classical (string quartet), Opera, Folk (Flamenco guitar)
MacDonald & Saarti 2006a MacDonald & Saarti 2006b	Beta-blocker blues: Pharmacology with a blues beat^84 (abstract only) Blues for the lecture theatre – the Pharmacology songbook^85	Finland	Objectivist: quasi-experimental (n = 12 medical students within a larger cohort of medicine, pharmacy and chemistry students)	Pharmacology	Receptive (Songwriting by lecturers)	Popular (blues)
Sirridge & Martin 2006	Healing and the arts: a powerful metaphor for teaching about healing and for teaching medical humanities^86	USA	Descriptive	Elective	Receptive, Learning about music and health	Classical (Requiems), Musical theatre, Popular (blues)
van Roessel & Shafer 2006	Music, medicine, and the art of listening^87	USA	Descriptive	First-year medicine curriculum	Receptive, Re-creative	Classical (string quartet)
Cheng 2008 Cheng 2010	Physongogy^88 Singing and learning physiology^89	Malaysia	Descriptive	Physiology	Receptive (Songwriting by lecturer)	Popular song parodies
Mangan 2008	Medical-school curriculum goes interactive, online, … and hip-hop^90	Canada	Descriptive	Online Learning System	Songwriting	Popular, Rap
Butler 2009	Teaching about the traumatic impact of vehicular crashes: rock ‘n’ roll never forgets^91	USA	Descriptive	Family and Community Medicine	Receptive	Popular (rock)
Roncoletta et al. 2009	Listen to the music! Innovative method for teaching medical students: a humanistic approach of doctoring^92 (abstract only)	Brazil	Interpretivist	Family Medicine	Receptive, Re-creative	Popular, Flash mob dance
Janaudis et al. 2013	The sound of music: transforming medical students into reflective practitioners		Interpretivist
Field 2010	Music of the heart^94	Australia	Descriptive	Cardiology	Receptive	n/a
Perry 2010	Newborn twins of neuropathology education^95	USA	Descriptive	Neuropathology	Receptive (Songwriting by lecturer)	Original songs
Thompson et al. 2010	Out of our heads! Four perspectives on the curation of an on-line exhibition of medically themed artwork by UK medical undergraduates^96	UK	Descriptive	First-year medicine curriculum	Songwriting	Original songs/compositions
Moshman 2011	Reflections on a medical school symphony orchestra^97	USA	Descriptive	(1) Extra-curricular; (2) Cardiology	(1) Re-creative; (2) Receptive	(1) Classical; (2) n/a
Ortega et al. 2011	Is there a place for music in medical school?^98	USA	Descriptive	Extra-curricular	Re-creative, Improvisation	Popular (blues, jazz, Latin, reggae, rock)
Kumagai 2012*	Perspective: acts of interpretation: a philosophical approach to using creative arts in medical education^99	USA	Interpretivist: discursive	Family Medicine	Songwriting/Composition	Original songs/compositions
Montrezor 2014	The synaptic challenge. Advances in Physiology education^100	Brazil	Descriptive: descriptive statistics	Physiology	Songwriting	Original songs, Popular song parodies
Latha et al. 2014	Effect of music on heart rate variability and stress in medical students^101	India	Objectivist: RCT (n = 80)	Extra-curricular	Receptive	Carnatic classical
Srikanth et al. 2014	Effect of music on stress and academic performance of undergraduate medical students^102	India	Objectivist: quasi-experimental (n = 60)	Extra-curricular	Receptive	Carnatic classical
Anyanwu 2015	Background music in the dissection laboratory: impact on stress associated with the dissection experience^103	Nigeria	Objectivist: quasi-experimental (n = 260 Anyanwu 2015; n = 253 Anyanwu et al. 2016)	Anatomy (Dissection)	Receptive (background music)	Classical, Jazz, Popular (country, high-life, reggae, R&B, traditional)
Anyanwu et al. 2016*	Musical preferences and learning outcome of medical students in cadaver dissection laboratory: A Nigerian survey^104
Deshkar et al. 2015	Background music at the time of academic assessment as stress buster: perception of the students at Govt. Medical College, Bilaspur^105	India	Objectivist: analytical cross-sectional (n = 97)	Academic assessment	Receptive (background music)	Indian Classical
Ip 2015	The ‘L’ in PLME: A broad approach to medical education^106	USA	Descriptive	Elective	Receptive	Opera
McBain et al. 2015*	“I wanted to communicate my feelings freely”: a descriptive study of creative responses to enhance reflection in palliative medicine education^107	New Zealand	Interpretivist: inductive thematic analysis	Palliative Medicine	Songwriting/Composition	Original songs/compositions
Kollar 2016	Music medicine course for medical students in Hungary^108	Hungary	Objectivist: mixed method – descriptive statistics, content analysis	Elective	Receptive; Improvisation; Learning about music and health	Not specified
Nemoy 2016*	Experiencing resonance: choral singing in medical education^109 (dissertation)	Canada	Interpretivist: phenomenological	Extra-curricular (student-led)	Re-creative	Choral
Haidet et al. 2017*	Using jazz as a metaphor to teach improvisational communication skills^110	USA	Objectivist: mixed method - quasi-experimental (n = 30), analysis of qualitative data using narrative framework	Elective	Receptive	Jazz
Pabst et al. 2017	Ceremonies of gratitude following the dissection course: A report on procedures in departments of anatomy in German speaking countries^111	Germany	Descriptive: descriptive statistics	Extra-curricular (student-led)	Receptive	Not specified
Istadi 2018	Students who are listening to classical music during anatomic identification test have lower stress level^112	Indonesia	Objectivist: RCT (n = 148)	Anatomy	Receptive (background music)	Classical (Mozart)
Larsen et al. 2018	Conducting the emergency team: A novel way to train the team-leader for emergencies^113	Denmark	Interpretivist: mixed method - qualitative content analysis, descriptive statistics	Emergency Medicine	Re-creative (conducting)	Classical, Electronic
Ledger & Jones 2018*	“A huge part of my life”: Exploring links between music, medical education, and students' developing identities as doctors^114	UK	Interpretivist: mixed method – descriptive statistics, thematic analysis and longitudinal case studies	Elective (special studies project)	Learning about music and health	Not specified
Tsampiras 2018	Walking up hills, through history and in-between disciplines: MHH and Health Sciences Education at the tip of Africa^115	South Africa	Descriptive	Elective	Learning about music and health	Not specified
Diep et al. 2019	Music & Art in Medicine (MAM): the effectiveness of MAM events on the interest and perception of geriatrics and nursing homes by medical students^116 (abstract only)	USA	Descriptive: descriptive statistics	Extra-curricular	Re-creative	Not specified
Neustadter 2019	Working in recovery: A medical student's experience^117	USA	Descriptive	Psychiatry sub-internship	Re-creative, Improvisation, Songwriting	Popular (folk, rap, grunge)
Triastuti & Dewi 2019	The relationship between listening to religious music and reading al-Qur'an to anxiety levels of medical students^118	Indonesia	Objectivist: analytical cross-sectional (n = 59)	Extra-curricular	Receptive	Devotional music
Bellier et al. 2020*	Impact of background music on medical student anxiety and performance during anatomical dissections: A cluster randomised interventional trial^119	France	Objectivist: cluster RCT (n = 187)	Anatomy (Dissection)	Receptive (background music)	Classical, Jazz, Popular (electronic music, reggae)
Cao et al. 2021*	Reconsidering empathy: an interpersonal approach and participatory arts in the medical humanities^120	USA	Interpretivist: mixed method – quasi-experimental (n = 10), inductive analysis	Extra-curricular (student-led)	Songwriting	Original songs, Jazz, Popular
Fiala et al. 2021	Driving on a highway to hell I found the stairway to heaven. A mentorship lecture intermixed with rock music and a quiz^121	Greece	Descriptive	Summer school lecture	Receptive	Popular (1960s to 1990s rock)
Guimarães 2021	“A course on music history for medical students?”^122	Brazil	Descriptive: descriptive statistics	Elective	Receptive	Classical (from early Western music to post-war contemporary classical)
Hall et al. 2021	Utilizing chamber music to teach non-verbal communication to medical students: a pilot initiative^123	USA	Objectivist: mixed method – quasi-experimental (n = 72), descriptive statistics, thematic analysis	Workshop during Internal Medicine and Paediatrics clerkship	Receptive	Classical (chamber music)
Tee & Kuan 2021	The yin and yang of 24 season drums for physical and musical literacy among medical students: a narrative review^124	Malaysia	Interpretivist: narrative review	Extra-curricular	Re-creative	24 Season Drums
Brooks 2022	Wellness through the lens of a medical orchestra^125	USA	Descriptive	Extra-curricular	Re-creative	Classical

• * Denotes articles meeting JBI Critical Appraisal Checklist criteria.^65-68

The majority of music programmes/activities (32) were documented descriptively, whereas 11 were evaluated in objectivist studies and nine in interpretivist studies; however, many studies had substantial limitations, with only nine studies (asterisked in Table 1) assessed as meeting JBI quality appraisal criteria.^65-68 Experimental and quasi-experimental studies, with the exception of Haidet et al.¹¹⁰ and Bellier et al.,¹¹⁹ tended to have poor internal validity. Randomisation, concealing of treatment and blinding of participants and assessors were rarely reported, though it is acknowledged that it can be complex to conceal treatment or apply blinding when treatment conditions involve music.¹²⁶ However, many of these studies also had no control group^{85, 103, 104, 123} and it was unclear in one study whether treatment conditions were equivalent.¹⁰⁴ Many also lacked robust outcome measures, relying either upon single outcome measures,⁸⁵ non-validated outcome measures,^{112, 123} post-test only measures^{101, 112} and non-equivalent measures between groups.¹⁰¹ Analytical cross-sectional studies also had poor internal validity, with non-validated exposure measures¹¹⁸ and outcome measures¹⁰⁵ and failure to identify confounding factors.^{105, 118} Additionally, the majority of objectivist studies (again, with the exception of Haidet et al.¹¹⁰ and Bellier et al.¹¹⁹) relied upon on self-report measures only. Interpretivist studies, with the exception of Nemoy¹⁰⁹ and Ledger and Joynes,¹¹⁴ tended to lack reflexivity and sometimes had methodological incongruities, such as between methodology and research question,¹¹³ epistemology¹⁰⁸ or analysis and presentation of data.⁹³

Thirty-five categories and seven themes were identified through inductive analysis as interrelated ‘rationales’ for offering music in medical education (Table 2 and Supplementary Tables 1 and 2. Supplementary Table 1 includes evidence from source texts informing categories and themes, whereas the mapping of themes back upon source texts in Supplementary Table 2 helped make visible the alignment of categories with themes shown in Table 2).

TABLE 2. Rationales for offering music in medical education (themes and categories).

Theme	Definition	Categories
Well-being	‘[A] positive state … encompass[ing] quality of life, as well as the ability of people and societies to contribute to the world in accordance with a sense of meaning and purpose’ (p. 10).^127	Achievement Community Empowerment Enjoyment Reduce anxiety Reduce stress Wellness
Supportive Learning Environment	A learning environment that actively facilitates a positive learning experience for students.	Alertness Improve academic performance Reduce anxiety Reduce stress
Affective Engagement	The affective response to an experience that may engage attention or in interpersonal contexts, empathy.	Affective response Alertness Empathy
Teaching and Learning	A pedagogical process through which students are supported to achieve learning outcomes.	Affective engagement Develop skills for clinical practice Experiential learning Gain knowledge and understanding Improve academic performance Memorisation
Develop Skills for Clinical Practice	The development of skills required for ethical practice as a health professional.	Adaptability Art of performance Communication Creativity Critical thinking Cultural sensitivity Empathy Interpersonal relations Interpretation Leadership Listening Reflection Teamwork
Humanism in Medicine	The application of humanistic values in the practice of medicine.	Appreciation of the arts/culture Develop skills for clinical practice Dialogue Empathy Humanism Identity Process emotions about trauma, dying and death Reflection Social justice Spirituality
Creative Expression (Identity)	The performance of identity as an active, aesthetic expression of the self.	Achievement Creativity Empowerment Identity Interpretation Reflexive use of music Self-expression

3.1 Well-being

Studies by Nemoy,¹⁰⁹ Ledger and Joynes¹¹⁴ and Bellier et al.¹¹⁹ offered strong evidence that engaging with music during medical education enhances well-being through wellness (i.e. preventative health),¹⁰⁹ enjoyment and community, reducing stress and reducing anxiety. Their findings supplement extensive research in music therapy, music sociology, music psychology and music medicine, also invoked by these authors, to justify the use of music for well-being.^{109, 114, 119}

3.2 Supportive learning environment

Evidence that music may reduce stress,¹⁰³ reduce anxiety,¹¹⁹ promote alertness and improve academic performance⁸⁵ is congruent with research in music psychology (cited by Anyanwu et al.¹⁰⁴) in which improved performance in cognitive tasks has been attributed to the affordance of music in promoting optimal ‘arousal and mood’.^128-130 A growing literature on the use of background music by surgical teams in the operating room also documents this phenomenon.¹³¹ However, the use of background music in medical education requires further investigation, acknowledging the potential for this to distract rather than support some learners,¹⁰³ and a lack of knowledge at present about how music preferences may interact with students' experiences.^{104, 119}

3.3 Affective engagement

That music may afford affective engagement in the context of medical education has been explored by Cao et al.¹²⁰ and Nemoy,¹⁰⁹ as well as in a phenomenological study by McLellan et al.,⁵¹ and is congruent with research from music psychology (e.g.¹³²) and music sociology (e.g.¹³³). Cao et al. engage with theory to describe how emotional engagement relates to affective empathy and report a positive, statistically significant difference in empathy scores measured by the Jefferson Scale of Physician Empathy for students who paired with patients in a songwriting project, arguing that an ‘interpersonal approach’ focused on social justice outcomes is best positioned to support empathy development (p. 627).¹²⁰

3.4 Teaching and learning

That music may support memorisation in medical education is somewhat supported by theory¹³⁴ and studies on the use of songs in science education; several examples of which^{30, 135, 136} are cited by MacDonald and Saarti⁸⁵ and by Cheng.^{88, 89} Evidence also supports offering music to enhance the teaching and learning process through affective engagement (see 3.3 above); however, further evidence is needed to substantiate the use of music for other kinds of learning in medical education, particularly experiential learning, which is often invoked to justify the use of music to develop skills for clinical practice (see 3.5 below).

3.5 Develop skills for clinical practice

The use of the arts to teach ‘instrumental' skills has been criticised by medical humanities scholars, who rather value the arts for their ‘disruptive’ or ‘transformative’ potential.^{99, 120, 137, 138} Nevertheless, the idea that engagement with music may develop skills also useful for medical practice has been theoretically developed in the literature; for example, Nemoy cites Woolliscroft and Phillips¹³⁹ and Evans¹⁴⁰ to describe how doctors, like musicians, must combine technical and interpersonal skills in the ‘performance’ of their roles (art of performance).¹⁰⁹ Haidet et al.,¹¹⁰ evaluating a four-week course on jazz improvisation offered to fourth-year medical students, employed in addition to pre- and post-test student surveys an external measure of student performance and blinded assessors in a controlled experimental study (n = 30), through which they were able to demonstrate a statistically significant increase in students' adaptability and listening abilities. However, while several studies have sought to evaluate the hypothesis that music may support development of skills such as communication,^{110, 113, 123} empathy,¹²⁰ leadership¹¹³ and reflection,⁹³ a pattern of small sample sizes, reliance upon self-report measures and lack of longitudinal data collection to evaluate whether the use of music has led to sustained outcomes in practice, means that evidence for the efficacy of music to develop skills for clinical practice is thus far considered weak.^141-144

3.6 Humanism in medicine

Humanism in medicine is a stated aim of the ‘medical humanities’, which rather than being an agreed set of interests, practices or approaches, are an evolving discipline characterised by ‘heterogeneity’ and ‘dissent’.^{137, 138} With this in mind, the categories in this theme must be considered as signposts only and located within a broader debate about the value of the medical humanities and how their outcomes might be evaluated.¹⁴⁵ Empathy (affective engagement), developing skills for clinical practice and identity are often considered integral parts of the medical humanities,¹⁵ while also having meaning outside of this context. Although some interpretivist studies have explored how participation in music may support reflection,^{99, 107} empathy¹²⁰ and identity (see 3.7 below), more work in development of theory is needed to understand how music may support humanism in medicine.

3.7 Creative expression (identity)

A number of interpretivist studies, for example by Segal,⁷² Ledger and Joynes,¹¹⁴ Nemoy,¹⁰⁹ Larsen et al.¹¹³ and Kumagai,⁹⁹ provided evidence for how students' participation in music supported personal and professional identity formation. Interestingly, extra-curricular music programmes usually associated creative expression with well-being,^{72, 109, 114} while within medical curricula and the medical humanities creative expression was often viewed rather as an ideal site or medium for ‘disruption’,⁹⁹ ‘resistance’ or ‘transformation’.^{114, 120} An intrinsic relationship between creative expression and other rationales for using music such as wellness, affective engagement and self-reflection is suggested in the outcomes of the study by McBain et al.¹⁰⁷

4 DISCUSSION

This synthesis presents the first comprehensive picture of how and why music has been offered in medical education, based on the analysis and evaluation of reports describing music-focused programmes and activities. Although previous studies sought to evaluate the benefits of music in medical education through thematic analysis of phenomenological data^{51, 109} or literature review,^{7, 17-20} variously emphasising the use of music for well-being,^{18, 19, 51, 109} affective engagement,^{51, 109} identity,^{51, 109} self-expression,^{51, 109} as a teaching and learning resource,¹⁷ to improve academic performance,¹⁹ to improve communication skills,¹⁹ for developing humanism^{17, 18} or to modulate the (healthcare) environment,¹⁷ this synthesis is the first to consider all of these rationales together and as interrelated.

Consistent with prior reports, high-quality evidence for including music in medical education is scarce.^{7, 16, 18-20, 109, 114, 146} Relevant articles (particularly those published prior to 2015) are largely descriptive and exploratory, characterised by weak evaluation methodology, poor quality evidence to justify judgements about efficacy^{141, 142} and the assumption that changes in attitudes will lead to changes in behaviour,¹⁴³ and were not longitudinal. Moreover, with only a few exceptions,^{103, 104, 109, 114, 120} theoretical constructs from social psychology and music sociology that might offer a more nuanced understanding of how people engage with music have yet to be integrated in medical education research,¹⁴⁷ while only a very few studies have tried to integrate evidence from both neuroscientific and sociological perspectives.^{103, 104, 114} A recent systematic review of articles published between 2015 and 2020 on how music might ‘improve learning’ in medical education reported positive effects of music upon well-being, performance, communication skills and empathy.¹⁹ However, consistent with our finding that there is a paucity of research relevant to this question, only five articles were assessed as being of acceptable quality and were reviewed in full by the authors. Notably, evidence for increased empathy was based on a single cross-sectional study (not meeting criteria for inclusion in this CIS) that measured empathy and agreeability in students with and without music education using an empathetic tendency scale.⁸ Our data, generated from a much larger number of articles and including nine judged to be of sufficient quality to enable a high level of confidence in results, show that evidence for offering music is strongest in relation to the aims of well-being, facilitating a supportive learning environment, affective engagement, memorisation and creative expression (identity). That engagement with music might enhance development of humanist values, such as empathy and social justice, or skills for clinical practice are ideas that require more evidence to be substantiated.

We reflexively note that within the research team, our disciplinary alignments are with music therapy and cultural studies (AO), medicine (JS), medical biochemistry and medical education (AW) and medical education (MM); all authors are classically trained musicians and three authors (AO, AW and MM) have been involved in establishing and teaching a music elective at an Australian medical school. The epistemological position of this CIS is informed by critical theory and could be described as ‘deconstructivist’,¹⁴⁸ by which it is acknowledged that there is a (Kantian) ‘sublime’ essence always exceeding the ability of language to capture the phenomenological experience.^{149, 150} Consistent with this epistemology, the categories and themes identified are not presumed to indicate a stable, timeless logos but are rather viewed as dialectical concepts, which acquire meaning only in relationship to one another. A limitation of this position is that the categories and themes identified must remain open to re-interpretation. However, in taking this stance, we can agree that, in line with recent reviews not exclusively focused upon music but the creative arts and health humanities more broadly, the affordances of music in medical education may be ‘multiple’ and not effectively represented by linear models.^{146, 151} As music therapist Even Ruud cautions, we limit music's possibilities when we think of it as a ‘stimulus leading to predictable responses’.¹⁵² The experience of engaging with music appears rather to exceed the intentions of those who offer it with a specific outcome in mind, as shown in the ‘unexpected’ or ‘surprising’ effects sometimes reported by researchers.^{91, 107, 114, 119}

Music is a resource both familiar and accessible to the majority of medical students.¹¹⁴ We echo other researchers in recommending that educators seek to increase opportunities for medical students to engage in music programmes and activities.^{114, 153} However, like Ledger and Joynes¹¹⁴ (with whom we share the possible bias of including in our research team a music therapist) and Cao et al.,¹²⁰ we suggest that this be accompanied by shifting agency to students,¹²⁰ for example, through opportunities to explore the reflexive use of music as a personal resource affording both ‘benefits and risks’,¹¹⁴ inviting students to select their own music as background and for sharing with peers, or enabling participatory activities such as improvisation, playing or singing familiar songs, songwriting and recording and performing music for an audience, all activities that are often used in music therapy with participants who do not have specialist musical training.^{69, 154} The influential work of music sociologists such as Tia DeNora¹⁵⁵ and community music therapists such as Brynwulf Stige¹⁵⁶ and Gary Ansdell¹⁵⁶ (as cited by Ledger and Joynes¹¹⁴ and by Nemoy¹⁰⁹) could help to frame how students themselves have agency in responding to the multiple affordances offered by music. This agency is often ignored in the literature, where a minority of music programmes or activities were described as student-led, although we note that published articles may exhibit a bias towards faculty-led music programmes⁷ and that this may not be representative of the reality. That agency in engaging with music may enhance its benefits is supported by Anyanwu et al.'s report of a positive association between students' music genre preferences during leisure with their preference for background music during private study time (where students' preference for background music volume, tempo and genre during study were found to vary markedly),¹⁰⁴ and accords with theories of empowerment from music therapy.¹⁵⁷

The results of this synthesis demonstrate that there remains a gap between what is claimed about the affordances of music and what has been explicitly addressed in medical education research. As such, the question of how music might best serve the aims of medical education can only be partially answered based upon the available evidence and requires further investigation, particularly in relation to the development of humanism. Accounting for student agency and the ‘multiple’ affordances of music will ensure that future teaching and research are best positioned to benefit medical students' well-being and personal and professional development.

AUTHOR CONTRIBUTIONS

Alice Rae Orchard: Conceptualisation (lead); data curation (supporting); formal analysis (lead); writing—original draft preparation (lead); writing—review and editing (equal). Janell Sitoh: Data curation (lead); formal analysis (supporting); writing—original draft preparation (supporting). Amy Wyatt: Conceptualisation (supporting); data curation (supporting); formal analysis (supporting); writing—review and editing (equal). Maxine Moore: Formal analysis (supporting); Writing—review and editing (equal).

ACKNOWLEDGEMENTS

Open access publishing facilitated by Flinders University, as part of the Wiley - Flinders University agreement via the Council of Australian University Librarians.

CONFLICT OF INTEREST STATEMENT

The authors do not have any conflict of interest to declare in the writing of this article.

ETHICS STATEMENT

This review article was undertaken in relation to the research project, “Experiences of medical students who participate in a music elective”, which received ethics approval from the Flinders University Human Research Ethics Committee (project number 2720).

Open Research

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available in the public domain, accessed via electronic databases MEDLINE, PubMed, PsycINFO, ERIC, SCOPUS and Google Scholar.