Monday, June 23, 2014

"Mozart's Effect on Us" : A Twenty-Five Year Meta-Analysis of the Mozart effect

(I wrote this as a term paper for the course, The Psychology Of Music, taught at Harvard University in the spring of 2013 by Professor Peter Cariani. The paper has been updated to reflect new research up to 12/2016).
W. Mozart, by Joseph Lange
 Stiftung Mozarteum Salzburg

I. Introduction

For over half a century, cognitive neuroscientists have explored whether there is a causal relationship between listening to music and enhancement of cognitive ability. Reducing this reasoned inquiry to its more simplistic “sound bite” form, does music make one “smarter?”  Can listening to music, especially certain types of music, or perhaps the music of certain composers, lead to greater mental capacities of memory and intellect?  Is music hard-wired in the human brain, and in turn, does music hard-wire the brain?  Or, is this “music-mind- stuff” just hype, a persistent neuromyth, nothing more than anecdotal and uncontrolled pseudoscience, marketing ploy rather than hard science. This paper reviews the context surrounding one aspect of the inquiry: does listening specifically to the music of Wolfgang Mozart improve cognitive ability over listening to other types of music or silence, evaluates the published research, and draws conclusions on the validity and utility of the findings. 

II .  Overture 

Researchers have long thought that there might exist in the brain a neural network“music box”, analogous to the so-called  “language box” of Noam Chomsky, that music might be subserved by a similar neural network as language, and that entraining these networks could lead to improved cognition.

The field of music psychology has arisen out of findings in structural neurology. Mountcastle, in 1957, was the first to posit that the cerebral cortex has a columnar organization, with the trion as the basic structural unit (1).  A trion is an idealized mini- column of neurons with three levels of firing activity. (1)  In 1990, Leng et al examined histological sections of temporal lobe auditory cortex with Cajal staining techniques, and discovered that the neuroanatomy of the auditory system has a columnar architecture similar to the trionic neural architecture hypothesized by Mountcastle (akin to that of the visual system as first described by Hubel and Wiesel). (2)   Leng hypothesized that this vertical stacking of auditory neurons predisposes them to fire in certain patterns, that these patterns of firing were quasi-stable, and that this was a logical and mathematical outcome of its columnar cortical architecture, representing a form of “basic exchange of mental activity.” (2)  Utilizing computer modeling and computational symmetries to create a one-to-one correspondence between neuronal firing patterns and discrete musical pitches, they found that the output, rather than being random noise or unorganized sound (which is what one might intuitively expect), actually sounded more like actual music, organized sound with the  "flavor,” to use their term,  of new age music, “Eastern” music, or music of the early Baroque (2).

Leng hypothesized that if brain activity can sound like music, could working in reverse and observing how the brain responds to music? (2, 3)  Might patterns in music stimulate the brain by activating similar firing patterns of nerve clusters? (2, 3)

At the same time, a different line of research was ongoing in Paris which would eventually align with the research of the Leng team. Alfred Tomatis M.D. was a French-born otolaryngologist who in the late 1980s founded the specialty of “audiopsychophonology.” His thesis was that “the voice cannot produce what the ear cannot hear.” (4)  Using Gregorian plainchant and several of Mozart’s five violin concerti, Tomatis used his techniques to treat patients who could not properly vocalize, declaim on theatrical stages, or sing in concert halls. Thomatis’ concept of “auditory processing integration” retrained the voices of, inter alii, Maria Callas, Gordon Sumner (Sting), Gerard Depardieu and Benjamin Luxon, resuscitating their careers. Tomatis reported on his findings in 1991, arguing for a Mozart “effect” to explain the improvement in these patients.(4) This was the first time the term “Mozart effect” had been used, though Tomatis did not copyright the term.

III. Prelude 

Frances Rauscher, Gordon Shaw and Ky, of the department of psychology at the University of California, Irvine, published a one-page paper in the October 14, 1993 issue of the journal Nature, entitled, "Music and Spatial Task Performance." (5)  They found that short-term listening to the complete first movement and the first three minutes of the second movement (10 total minutes) of the Mozart two- piano sonata in D (K.V. 448/375a) led to a short-term improvement (~ 9 points, for about 15 minutes) in spatial-temporal tasks on a Stanford-Binet Test (paper folding/ cutting), over the same group tested after sitting in silence, and then after listening to “relaxation music.” (5)  The Rauscher team did not give this finding a name, nor did they extrapolate their findings to state that Mozart’s music improved any other aspect of cognition.  

Mozart Sonata for two pianos in D,  KV 448
Frontispiece of the Breitkopf Edition

IV. Sonata 

What is so special about the two-piano sonata in D (K.V. 448) of Wolfgang Mozart that it was chosen for the Rauscher study? In September 2012, in preparation for some remarks on the Mozart effect that I presented at an October 2012 Music and Medicine Symposium at Weill Cornell Medical College in New York City, I interviewed Professor Frances Rauscher about this topic. Professor Rauscher, who is now at the University of Wisconsin-Madison as an emeritus professor of psychology, told me that when she and her team were organizing the Nature study at UCI in 1993, she had asked a musicologist at her institution for a composition that was relatively upbeat, had some repetition and was melodically relatively straightforward, and that this was the piece chosen. Rauscher stated that. “we used the first movement of the Mozart two-piano sonata because it has very few musical motives that interweave in various forms throughout the movement; that it was a two-piano sonata helped reinforce the symmetry in the music.”

I asked Dr Rauscher why her team used both the first movement of KV 448, marked Allegro con spirito (lively and with spirit), but also part of the Andante (a slow talking tempo) second movement. Her response was that “we included a portion of the second movement as a sort of "cool down" period.” (Frances Rauscher, personal communications, 9/12/2012) The Mozart selection the researchers chose was purposely not of one tempo, because they wanted music that was both fast and slow. The first movement of the two-piano sonata, in D major (two sharps), is largely comprised of tonic and dominant chords, and has six distinct repetitive motifs. The two pianos not only echo each other, but often play the same melody in octaves. I asked Professor Rauscher about this seeming overkill, and she said they purposely wanted some chordal redundancy to emphasize certain melodic themes as that would potentially entrain better.  

V. Development

In 1996, Don Campbell, a professional musician, successfully petitioned the United states Copyright and Trademark Office to obtain a copyright for the term “The Mozart Effect” (note the capitalization of both “Mozart” and “Effect”), and subsequently published a 1997 book entitled, The Mozart Effect: Tapping the Power of Music to Heal the Body, Strengthen the Spirit and Unlock the Creative Spirit. (6)

Campbell followed that up with another book, The Mozart Effect for Children, along with dozens of related cassettes, CDs and related workbooks. In his 1996 book, Campbell defined "The Mozart Effect" as "an inclusive term signifying the transformational powers of music in health, education, and well-being. It represents the general use of music to reduce stress, depression, or anxiety; induce relaxation or sleep; activate the body; and improve memory or awareness.”  (6)   Campbell went on to claim that “innovative and experimental uses of music and sound can improve listening disorders, dyslexia, attention deficit disorder, autism and other mental and physical disorders and other diseases.” (6)

The response to the Campbell books was overwhelmingly positive. If YouTube had existed then, it could hve been said that the books and the term The Mozart Effect had gone "viral".  The Mozart Effect was so popular as a concept that it became a political call- to-arms for the arts, reaching, among other places, the Georgia state legislature, when in 1998 then governor Zell Miller apportioned funds to buy every child born in Georgia either a tape cassette or CD of classical music. (7)  

At the same time that Campbell was reaping profits from the cottage industry he spawned popularizing the notion of some kind of Mozart Effect, the Rauscher study was being subjected to an enormous amount of scrutiny, most of it negative.         

VI. Theme and Variations 

On 3/1/13, I performed a Medline search of all titles containing the terms “Mozart effect,” "The Mozart Effect,"  “Mozart + spatial,” or “Mozart + cognition.”  A total of 107 distinct articles were retrieved and analyzed as to:  peer-review, accepted methodology, controlled trial, and rigor of data analysis. Most of the articles were reviews of other works, hypotheses, single case studies, anecdotal opinion, or did not meet all of the four critera; of the 107 articles, only six qualified for the meta-analysis

A 1994 study by Stough et al from Auckland, New Zealand, failed to find any relationship between the Mozart sonata and spatial reasoning. The researchers employed Raven’s Advanced Progressive Matrices, an accepted tool for analyzing spatial reasoning, whereas the Rauscher group used Stanford-Binet testing. This study, while meeting the four inclusion criteria, could not be definitely analyzed given the different testing methodologies. (8)

In 1995, a group from SUNY Albany replicated the Rauscher study and increased the study group to 114 subjects, with a slight older mean age than the college students in the Rauscher study (SUNY mean age 27.3 vs Rauscher mean age 20.8). The SUNY group found no increase in spatial-temporal reasoning, and no correlation to higher scores and any type of classical music preference. (9)

A study by Steele et al, the so-called Appalachian Study, also found no correlation between the music of Mozart and increased spatial-task performance. Steele’s conclusions were that “any cognitive improvement was transient” and more likely represented a “practicing’ effect and a familiarity with the paper-cutting test on multiple trials to different pre-treatment stimuli (10).

However, two separate studies by Rideout et al, one employing EEG data and both reproducing the methodology of the 1993 Rauscher study, confirmed the findings of a temporary increase in spatial-task performance scores in the groups “pre-treated” with Mozart’s music. (13, 14)

Rauscher and Shaw responded to the spate of studies, some of which confirmed, but most of which refuted their 1993 findings, by repeating a Mozart effect  study on laboratory rats, confirming that rats pre-treated with Mozart, learned to navigate a T- maze significantly better than rats exposed to minimalist music (Philip Glass), white noise, or silence, and that this increase was retained for several months. Rauscher stated that the inconsistent results of the Mozart effect in other studies was a result of those studies utilizing diverse subjects and different methodological designs, such as musically disparate compositions, listening conditions, and measures. Rauscher also reiterated that her team's 1993 Nature study specifically identified its limitations: that the effect was transient, and limited to spatial cognition. (12) 

VII. Coda

By 1999, six years after the Rauscher study, the scientific community had pronounced the Mozart effect anecdotal and non-reproducible. Two articles in Nature, both entitled “Prelude or Requiem for the Mozart effect?,” one by Kevin Steele and coworkers (15), and the other by Christopher Chabris (16), came to the same conclusion: that the results of the Mozart effect were transient, and that there was no difference in spatial-temporal skills after being pretreated, in their studies, with Mozart’s two-piano sonata, the minimalist music of Philip Glass or silence. (15, 16)  Chabris maintained that “this (Mozart) effect, if indeed there is one, is much more readily explained by established principles of neuropsychology, in this case, an effect on mood or arousal, than by some new model about columnar organization of neurons and neuron firing patterns" (16)

This could have been the coda and the end of the interesting saga of the Mozart effect. However, further rigorous lines of inquiry have followed, examining specific circumstances in using Mozart’s music, and music similar to the music of Mozart: in epilepsy in some studies, and in cardiovascular health in others. These new avenues of research have reopened the related inquiry of whether there is a biological underpinning to the Mozart effect.

Epileptic patients who listened to the music of Mozart, and the music of two other composers whose style resembles that of Mozart (Johann Christian Bach and Johann Sebastian Bach), had a statistically significant reduction in the frequency of epileptiform activity, in comparison to the same patients when they listened to the music of 58 other composers, including the works of Beethoven, Chopin, Brahms and Stravinsky. (17) The authors, John Hughes and John Fino of the University of Illinois, examined 81 musical selections of Mozart, 67 selections of Johann Christian Bach, 67 of Johann Sebastian Bach, 39 of Chopin, as well as 148 selections from 55 other composers. The compositions were computer analyzed to search for any distinctive aspect and to determine if there was a dominant periodicity.  Long-term periodicity (mean = 10-60 sec, median = 30 sec) was found most often in the music of Mozart and the two Bachs, which was significantly more often than the works of the other composers. Long-term periodicity was found to be absent in the control music that had no effect on epileptic activity in previous studies. Short-term periodicities were not significantly different between the music of Mozart and the two Bachs, versus the music of the other composers. However, at least one distinctive aspect of the music of Mozart and the two Bachs, specifically their long-term melodic periodicity, may resonate within the cerebral cortex and also may relate to brain coding.” (17)  Thus, the Mozart effect could also be termed the “J.S. Bach effect” or the “J.C. Bach effect."

More recent evidence for the efficacy of Mozart’s music on epileptiform frequency has confirmed the Hughes and Fino data. In a 2011 series of experiments by Lin et al, the researchers looked at long-term listening of Mozart’s two-piano sonata KV 448 and epileptiform activity in children, and found that there was a significant reduction in activity in the group “treated” with Mozart’s music. (18) The Lin group re-confirmed their findings in 2015. (19)

Trappe et al looked at the effect of the music of Mozart, Beethoven, and Verdi, as well as heavy metal music played by several groups, on their effect on heart rate variability. They found that the music of these composers, but not heavy metal music, lowered heart rate and reduced the variability of heart rhythm. (20)

There have also been peer-reviewed articles on the use of Kv 448 in tinnitus (21), cognitive rehabilitation in the aged (22), and on the central nervous system. (23)

Pauwels et al looked into whether there is a link between music-generated emotion and higher level cognition. Positron emission tomography and functional magnetic resonance imaging show that listening to pleasurable music activates cortical and subcortical cerebral areas where emotions are processed. (24) These neurobiological effects of music suggest that auditory stimulation evokes emotions linked to heightened arousal, and result in temporarily enhanced performance in many cognitive domains. Music therapy applies this arousal, offering benefits to patients by diverting their attention from unpleasant experiences and future interventions. Music therapy has been applied to cardiovascular disorders, cancer pain, epilepsy, depression and dementia. Music may modulate the immune response evidenced by increasing the activity of natural killer(NK) cells, lymphocytes and interferon-γ, as many diseases are related to a misbalanced immune system. There is moderate level of evidence that listening to known and preferred music decreases burden of disease and stress by  enhancing the immune system .(24)

Verrusio and colleagues evaluated, by electroencephalography (EEG), the effect of listening to Mozart's KV 448 2-piano sonata or Beethoven's Für Elise piano bagatelle, in separate groups of healthy adults, healthy elderly, and elderly with mild cognitive impairment (MCI).(24) EEG recordings were performed at basal rest conditions and after listening to Mozart's music or Beethoven's music. There was an increase in the alpha band and median frequency index of background alpha rhythm activity, (a pattern of brain wave activity linked to memory, cognition and open mind to problem solving), with the Mozart KV 448 in the adult group and in the group of the elderly. No changes were observed in MCI. After listening to Beethoven’s Für Elise, no changes in EEG activity were detected in any of the groups. They concluded that Mozart's music is able to "activate" neuronal cortical circuits related to attentive and cognitive functions. (25)

Studies demonstrating the effect on Mozart's music in autistic children have demonstrated improved language skills, augmenting their ability to communicate, participate and express non-verbally, and develop appropriate expression of their emotions. (26)

VII. Summary

What conclusions can be drawn from analyzing the data on the Mozart effect?

1. If there is anything that could be called a Mozart effect, it is transient and it is specific to spatial-temporal reasoning.

2. The Mozart effect cannot be extrapolated to other cognitive abilities nor cognitive enhancement over longer periods of time.

3. There is not just a Mozart effect; there is also a  "J.C. Bach effect”, a “J.S. Bach effect," and likely, an "effect" by other composers in classical and popular genres, whose melodic themes happen to “align” with the periodicities of  neuronal network activity.

4.   Certain types of music with  specific rhythms and periodicity, create an arousal effect, and it is this arousal that creates  temporary enhancement in cognitive capacity. Whether or not this effect is a consequence of  the “aligning of neurons" is unknown. This hypothesis needs further research.

5. Studies examining Mozart’s music and epileptiform discharge, Mozart's music and tinnitus, and Mozart's music and heart rate and rhythm regularity, have found a salutary and direct correlation with Mozart's music more than silence, random noise, and the music of other composers.

6. Despite the varied interpretation of  the findings, the data underpinning the Mozart effect has been positive, calling attention to the ability of certain genres of music, to lower disorganized brain activity (decrease epileptiform discharge), decrease stress, blood pressure and heart rate.

In a world increasingly fraught with stress, anger and anxiety, the use of music, especially Mozart's music, as both therapy and for pleasure, has been one of calmness and healing, centering us in a sonic world of consummate and felicitous harmony.


1. Edelman G. and Mountcastle V., The Mindful Brain: Cortical organization and the group selective theory of higher brain function, Cambridge, MIT Press , 1978 

2. Leng, X., Shaw G., and Wright, E., Coding of music and the trion model of cortex. Music Perception (1990) 8: 49

3. Lerch, D., The Mozart effect: A Closer Look
4. Tomatis, A., Pourquois Mozart?  (1991) Paris, Hatchette Diffusion Books

5. Rauscher, F., Shaw G., and Key,K., Music and spatial task performance. Nature . 1993; 365: 611

6. Campbell, D., The Mozart Effect: Tapping the Power of Music to Heal the Body, Strengthen the Mind and Unlock the Creative Spirit, New York, Avon Books, 1996

7. Sack, K, Georgia’s governor seeks musical start for babies, New York Times. Jan. 15, 1998,Sec A, pg. 12

8. Stough C, et al, Music and IQ Tests. The Psychologist . 1994; 7:253                           

9. Newman J et al, An experimental Test of "The Mozart Effect": Does listening to his music improve spatial ability? Perceptual and Motor Skills. 1995; 81: 1379

10. Steele K, et al, The mystery of the Mozart effect: Failure to replicate. Psychol. Sci. 1999; 10: 366

11. Rauscher F., and Shaw G., Key components of the Mozart effect. Perceptual and Motor Skills. 1998; 86, 835

12. Rauscher F, et al, Improved maze learning through early music exposure in rats. Neurol. Research. 1998; 20:427-32.

13. Rideout B, and Laubach M., EEG correlates of enhanced spatial performance following exposure to music. Perceptual and Motor Skills. 1996; 82: 427

14. Rideout B., Taylor J, Enhanced spatial performance following 10 minutes exposure to music. A replication. Perceptual and Motor Skills. 1997; 85: 112

15. Steele, K., et al, Prelude or Requiem for the Mozart effect? Nature 1999; 400: 827

16. Chabris, C., Prelude or Requiem for the Mozart effect? Nature. 1999; 400: 826

17. Hughes, J., and Fino, J. The Mozart effect: Distinctive aspects of the music as a clue to brain coding.  J. Clin. Electroencephal. 2000; 31: 94

18. Lin L., et al, Mozart effect decreases epileptiform discharge in epilepsy, Epilep. Behav. 2011; 4: 420-424

19. Lin, L. et al., Mozart's music in children with epilepsy, Transl Pediatr. 2015; 4:323-6. doi: 10.3978/j.issn.2224-4336.2015.09.02

20. Trappe H, The effects of music on the cardiovascular system and cardiac health, Heart. 2010; 96: 1868

21. Attanasio G, Cartocci G, Covelli E, et al. The Mozart effect in patients suffering from tinnitus. Acta Otolaryngol. 2012; 132: 1172–1177

22. Cacciafesta M, Ettorre E, Amici A, et al. New frontiers of cognitive rehabilitation in geriatric age: the Mozart Effect. Arch Gerontol Geriatr. 2010; 51: e79–e82

23. Lin, L-C., Listening to Mozart K.448 decreases electroencephalography oscillatory power associated with an increase in sympathetic tone in adults: a post-intervention study, J Roy Soc Med. Open. 2014; 8;5(10):2054270414551657. doi: 10.1177/2054270414551657. eCollection 2014

24. Pauwels, E., et al., Mozart, music and medicine. Med Princ Pract. 2014; 23:403-12. doi: 10.1159/000364873

25. Verrusio, W., et al., The Mozart Effect: A quantitative EEG study, Conscious Cogn. 2015; 35:150-5. doi: 10.1016/j.concog.2015.05.005

26. (Kathleen Terani:  "Music, movement and the Mozart effect" Omni-Intelligencer, March 2016.

Vincent P. de Luise, M.D. F.A.C.S. is an assistant clinical professor of ophthalmology at Yale University School of Medicine, and adjunct clinical assistant professor of ophthalmology at Weill Cornell Medical College, where he also serves on the Music and Medicine Initiative Advisory Board. A clarinetist, he performs chamber music,  was the director of the Connecticut Mozart Festival in the bicentenary year of the composer's death, co-founded the annual classical music recital of the American Academy of Ophthalmology, is president of the Connecticut Summer Opera Foundation, and writes and blogs about music and the arts at A Musical Vision

Thursday, June 5, 2014

Teachable Moments, Learnable Moments: Medical Rounds as a Paradigm for Education

Mind, Brain, and Education                                         
Journal of Mind, Brain and Education Volume 8, Issue 1 March 2014, pp. 3-5.                                                             
Teachable Moments, Learnable Moments: Medical Rounds as a Paradigm for Education

Vincent P. de Luise MD, FACS  (1,2)
Corresponding author: 1. Harvard University 2. Yale University School of Medicine


The medical profession has for almost a century employed various types of “Rounds” as pedagogical tools to engage physicians, physicians-in-training, and their health care teams, in the clinical diagnosis and treatment of patients. This validated paradigm of medical rounds (MR) has recently been extended to the field of education, where it is being used as an effective strategy for administrators to better understand their own domain. There are four distinct types of MR which can be further analyzed to find commonalities and parallels with the domain of education. The four types of MR are (1) Morning Rounds, (2) Chart Rounds, (3) Grand Rounds, and (4) Ongoing Collaborations—each have unique pedagogical characteristics and serve different functions. They are, however, unified by common threads of dynamic and interpersonal interactions wherein teacher (physician) and learner (physician-in-training) share leathe now outmoded theory of the “empty vessel” and corroborate the concerning and fluidly exchange roles in the pedagogy. MR models supplant pt of the teaching brain. A formal analysis of MR underscores its ongoing utility in education both for its pedagogical innovations and for the Interactive and inherently human attributes that are required between teacher and learner for its efficacy.


        Docendo discimus (“By teaching, we learn”)   Seneca (4 BCE-65 CE)

For almost a century, the medical profession has employed various types of “rounds” as pedagogical tools to engage physicians and physicians-in-training in the diagnosis and treatment of patients, and in the learning and teaching of medicine and surgery. The older, static notion of the physician “doctor” (Lat. doceo, docere = “to teach”) as teacher and the physician-in-training as the “empty-vessel” learner has been supplanted by Dynamic Systems Theory (DST) (complexity) models extended to education and brain development and the synchrony and synergy between teacher and learner and the teaching brain (Rodriguez, 2012). It has been discovered that, as a function of the interrelationship between teaching and learning, the development of the teaching brain occurs in spurts, with each cluster of spurts producing a new level of skill and understanding (Fischer et  al., 2007), a development that also occurs in medical rounds (MR). In recent years, the validated paradigm of MR has been extended to the field of education, where it is being used as an effective strategy for administrators to better understand their own domain (City, Elmore, Fiarman, & Teitel, 2009). Are there deeper insights that can be gleaned from an analysis of MR that can be extended to education? Are there parallels between the two disciplines that are foundational and that exemplify aspects of the teaching brain? Is it even possible to tease out those aspects of MR that are distinct from education, when MR is itself, in its essence, a consummate pedagogical exercise?
Answering these questions requires an analysis of the four types and functions of ME which can be translatable to education. Each of these types of MR represents a unique opportunity for teaching and learning, and provides insights into the teaching brain.

Morning Rounds (“Walking” Rounds)
Morning Rounds, the archetypal MR, are the daily episodes of teaching and learning that occur in virtually all hospital settings. An attending physician or hospitalist (hospitalists are physicians specialized in hospital-based medical care)—a more experienced physician or surgeon who has the ultimate medical responsibility for the team's patients—is accompanied by a group of physicians-in-training which includes interns (Post Graduate Year 1, PGY 1), residents (PGY 2–4), and medical students. Morning rounds is a community effort: it also includes nurses, social workers, pharmacists, and quality improvement specialists, all of whom play an ever-increasing role in patient care and resource utilization (Cooper & Elnicki, 2011).

The team “walks” the floor of the medical unit, surgical unit, or specific area of the patients for which they are responsible. The team goes to the bedside of each patient on that team's watch, where each patient represents a “classroom episode” of teaching and learning pedagogy. One of the physicians-in-training, usually the intern or resident, presents to the team that patient's history, laboratory testing and diagnostic imaging results, as well as a differential diagnosis of possible disease entities that could explain the patient's illness and reason for admission. At one time, these presentations had to be delivered from memory, to underscore to the physician-in-training that they had to have complete mastery of knowledge and understanding of the patient's condition before they could opine a treatment strategy. A discussion then ensues, often in the presence of the patient and in the form of a dialectic using the Socratic method, of the most likely diagnoses and best treatment options. If there are pertinent physical findings (e.g., a mass lesion, a heart murmur, a skin rash), the attending physician will identify and discuss them, ask permission of the patient to examine them, and then lead the physicians-in-training in the physical exam by palpation or auscultation of those physical findings as appropriate. This experiential, heuristic model of pedagogy inures not only to informing the physicians-in-training, but continually shapes and transforms the teacher's mind in response to the dialectic.
Within the Morning Rounds model, there are not only distinct differences between teacher and learner, but also, as a result of the fluidity of the dialectic at any given moment, the teacher may become the learner and the learner a teacher. As the attending physician teaches an aspect of the patient's condition, or describes a particular clinical sign or finding, the physicians-in-training also participate in the pedagogy by asking deeper questions about those findings. This fluidity has parallels to the concept of synchrony in the DST model of the teaching brain (Rodriguez, 2012). A recent study has found that physicians-in-training (medical students in this particular study) actually learn differently, depending upon who is doing the teaching. At times, medical students acquire and understand a topic more fully if the intern or resident is doing the teaching than if the attending physician is doing so (Bodnar, Fowler, & Saint, 2013).
The syllogism that the physician-in-training represents the student, that the attending physician/hospitalist is the teacher, and that the patient is the object of the “teachable moment”—comparable in the educational setting to a classroom learning experience such as a book chapter reading or a science experiment—is far too simplistic. The pedagogical episodes in Morning Rounds are both top-down and bottom-up, as the data that are initially presented to the team by the physicians-in-training are then evaluated and modified not only by the attending physician, but by the whole team. Thus, the dialectic in MR is not just dyadic but rather remarkably fluid; observations and inquiries by the physicians-in-training, and the changes in laboratory test and imaging results over the course of the patient's hospital stay, modify the original diagnostic hypothesis and, as a direct consequence, alter suppositions about therapy.

Afternoon Rounds (“Chart” Rounds)

This episode of learning/teaching usually occurs at the nurses' station, or in a private room or a quiet area, away from patients. In these episodes of learning/teaching, the attending physician, hospitalist, or resident usually leads a discussion of each patient's lab test results and imaging results obtained during the day (i.e., since the end of the Morning Rounds). The “on-call” intern and/or resident are present to ensure that they understand each patient's diagnosis and current status for their responsibilities on the evening shift, as the other physicians go off-duty.

“Grand” Rounds

Grand Rounds are a form of top-down pedagogy which almost invariably take place in an auditorium venue, away from the patient bedside. The venue is physically located in the teaching hospital itself, or at the medical school with which the teaching hospital is affiliated. With the dramatic changes in health care delivery that have occurred, the auditorium maybe at a distance from the teaching hospital. Tele-videoconferencing allows members of the patient care team associated with that Grand Rounds case to be present in real-time, even if physically distant from the teaching hospital at the time of the presentation, as well as allowing physicians and physicians-in-training from satellite locations to participate.
In Grand Rounds, the pedagogy is usually delivered by a physician from a podium to a receptive audience of physicians and physicians-in-training, one of the latter of whom begins by presenting a patient case. Following the presentation, a physician expert in that patient's illness, discusses the case, bringing in relevant peer-reviewed data and literature. There is then an open forum of questions, answers, and alternative opinions exchanged between the physician expert and the physicians and physician-in-training in the audience, providing another example of the fluidity of MR pedagogy.
Technology now allows the archiving of Grand Rounds presentations, which then make these pedagogical episodes available as online videos. These can be viewed by physicians and physicians-in-training at a later date, enabling them to improve their knowledge and patient care, while accreting to one of the core ideals of the Hippocratic Oath: Medical education should be transparent and open, and physicians should actively share their knowledge without compensation in order to improve patient care (

Ongoing Collaboration

Ongoing collaborations between physicians and basic science researchers are a separate yet crucial aspect of the teaching hospital–medical school model. These daily, ongoing teaching/learning episodes are harder to quantify, but which could be classified as a form of rounds. In these episodes of pedagogy, often taking place within the cafeteria or lounge of a teaching hospital, physicians and researchers tackle ongoing scientific challenges. These informal “chat” sessions have become essential as incubators for the cross-fertilization and transfer of ideas, so much so that a number of medical schools have purposely built common spaces easily accessible to both researchers and physicians to convene and discuss topics of mutual interest and inquiry. A result of these interactions and chats is often the birthing of a scientific breakthrough.
While these four identifiable types of MR are distinguishable based on either geographic or temporal grounds, the overarching aspect that unites them is that each is characterized by both dyadic as well as more complex and fluid interactions between teacher and learner. These are the synchronous, synergistic, and mutually beneficial relationships within the process of MR that inform the teacher as much as they impart knowledge to the learner.
Educators in general tend to have autonomous ideas about educating. In the domain of medicine, there are numerous disparate teaching styles in different pedagogical venues, the top-down lecture format of Grand Rounds being a prominent example. However, these individual styles of pedagogy are all subsumed in the context and structure of MR.
Teaching systems can be stratified into those capable responses: instinctual, higher-order student-centered teaching, or using more complex teaching brain teaching. At this most complex level, exemplified by the various types of MR, the teacher and student engage in a synchronistic teaching flow that achieves an optimal teaching and learning experience (Kent, 2013; Rodriguez, 2013). MR activities are inherently synchronistic and demonstrate teaching flow in the dynamic and complex interchange of teacher as teacher/student and student as student/teacher (Rodriguez, 2012, 2013).
The teaching brain is not subordinate to the learning brain; rather, the two are in a dynamic cycle of synergy and synchrony with each other (Rodriguez, 2012). The ultimate measure of effective teaching is not to assess whether an individual has learned a specific piece of knowledge, but rather to evaluate whether the learner and teacher come closer together in thought and skill, that they should flow together successfully within each other's context (Rodriguez, 2013). MR are pedagogical episodes that exemplify this point. MR maintain physicians, physicians-in-training, and researchers in a constantly engaged and challenged environment, continually pushing them to refine their understanding of their patients' condition by being informed by the most recent medical knowledge that supports their diagnosis and care. In an increasingly technological world, with laptops and PDAs at once essential to education (as learning tools, not as teachers) but also serving as further barriers to direct human contact, MR remain the most human and enduring of pedagogical activities. At the core of all of these dynamic pedagogical episodes is the observation that MR hinge upon, indeed require, face-to-face interactions between physicians, physicians-in-training, researchers, and their teams, and conversely, without these critical human interactions, that would be little if any pedagogy (Yano, 2013) and suboptimal patient care.
MR are not just about learning; they are also very much about teaching and about the synergies and effective outcomes that result. Educators need to employ many of the strategies found in MR to enhance their own ability to diagnose the problems that occur in their areas of responsibility and expertise, and in a collaborative fashion find the most effective solutions. These teachable moments and learnable moments need to become as essential in education as they have been in medicine.