If you've had surgery under anesthesia in the last couple of decades, your doctor was probably listening to her favourite music while operating. There's growing debate in the medical field about whether music in the operating room really helps surgeons focus or creates a potentially dangerous distraction.
Imagine you're in a busy restaurant. People chatter, silverware and dishes clatter, noise spills out from the kitchen. The noise around you is loud; it measures around 94 to 100 decibels, which is the auditory equivalent of walking behind a running lawnmower -- and an especially loud one, at that. You have to raise your voice to keep up a conversation, and some words are hard to understand clearly against the background din.
You've got a headache just thinking about it, right? Now imagine you're in an operating room with that same level of background noise, only now it's the clatter and clang of metal tools and the louder whirring of electric or air-powered instruments. Monitors beep, alarms blare, and there's an unconscious patient lying on the operating table. The surgeon asks you to hand them something, but you can't quite make out the words. You ask her to repeat herself, raising your voice to be heard over the noise. Another alarm goes off on a monitor.
That's a normal day for surgical staff at most hospitals around the world. Operating rooms are noisy places. About 40% of the time, the noise level in the operating room is over 100 decibels. And when alarms start going off or someone strikes a bone chisel with a mallet, that volume can shoot up to 120 or 130 decibels (the average volumes of an ambulance siren and a shotgun blast, respectively). In fact, noise levels in operating rooms are so high that surgical staff run an increased risk of hearing loss.
And yet, in many operating rooms around the world, someone's iPod and Bluetooth speakers are playing classic rock or the latest pop songs as a soundtrack to surgery.
"Music is a special type of noise," wrote anesthesiologist and researcher Jonathan Katz in an October 2014 paper in the journal Anesthesiology. Proponents of music in the operating room say that it helps mask the more stressful noises of the operating room, which is helpful for patients and surgical staff alike. Listening to music also helps surgeons stay calmer and work more efficiently, at least according to some studies.
Soundtracks for Surgery
Music has been part of surgeries since at least 1914, when physician Evan O'Neill Kane brought a gramophone into his operating room to help calm his patients before and during anesthesia. The practice became even more common during the 1930s, and it was a popular topic in medical journals of the time, which recommended "soft, soothing, melodious music" as best for patients and advised surgeons to avoid jazz or "sentimental tunes."
Today, music is nearly ubiquitous in operating rooms around the world. Over half of operating room staff in India described playing music in the operating room as "commonplace" in 2011; 63% of doctors and nurses in Israel said they regularly listened to music during surgeries in 2008; and as early as 1997, 72% of anesthetists in the UK regularly heard music in the operating room. But today's operating room tunes aren't for patients, but for staff.
While patients lie unconscious on the operating table, surgeons and operating room staff listen to everything from classical music to heavy metal. "Generally, most people listen to upbeat music," Andrew Zhang, assistant professor of surgery in the division of plastic and reconstructive surgery at the University of Texas Medical Branch, told Gizmodo. Zhang himself prefers pop music, and he listens to the same Pandora station -- a blend of Rihanna, Justin Bieber, Michael Jackson, and others -- in the operating room, at the gym, and in the car. Others listen to rock and roll, hip hop, or Latin music, and one participant in a recent study even chose to sew up an incision while listening to Broadway show tunes.
Pandora and Spotify are popular sources of surgical soundtracks; staff members use the apps on their personal iPods or smartphones, plugged into operating room computers or even Bluetooth speakers. Some newer operating rooms even have built-in docking stations.
Helping Surgeons Get in the Groove?
"I believe listening to music does really help with the surgeon actually focusing and doing the cases more efficiently and better," said Zhang. "I think it does help with focus and muscle memory and overall decreasing the stress that a person is feeling," he said.
Earlier this year, Zhang, working with UTMB chief resident Shelby Lies, found that plastic surgery residents closed up incisions more efficiently when they got to listen to music they liked. Residents worked 8% to 10% faster when accompanied by their own music, and faculty members at UTMB said that their stitches looked better than those of a control group working without music. Zhang and Lies published their findings in the Aesthetic Surgery Journal in August.
"When we are doing our jobs, a lot of the time we're doing the same thing over and over and over again -- like a repetitive motion, almost, especially during closing. Some of the plastic surgery cases that we do involve a lot of wound closure, which we do so often, and it's very, very routine, and listening to music really does make a person go faster and be more efficient," said Zhang.
But there's still some debate about whether music in the operating room is a good thing. Despite Zhang's findings earlier this year, other studies have had mixed results on whether listening to music on the job actually helps or hinders surgeons' focus.
A 1994 study in the Journal of the American Medical Association (JAMA) found that surgeons performed better on arithmetic problems (meant to simulate difficult mental tasks in surgery) and solved the problems more quickly when they listened to music they had chosen, compared with working in silence or with generic background music. Surgeons listening to their own music also showed much lower stress levels during the test, reported researchers Karen Allen and Jim Blascovich.
Of course, as Katz pointed out in his 2014 paper, "It is important to note that the volunteers in this study were all self-reported music enthusiasts, the music was self-selected, the study was conducted in a sound-proof laboratory, and the task tested was an arithmetic exercise." That's a far cry from dealing with a complication during an actual surgery in a noisy operating room. Then again, closing up an incision is, as Zhang explained, a relatively simple, routine task for experienced surgeons.
Music might help reduce stress and improve efficiency at such repetitive tasks, but what about more complex procedures? In 2008, Danilo Miskovic and his colleagues tested how music affected junior surgeons performing a laparoscopic procedure on a virtual simulator. Surgeons who listened to a piece of music by composer Richard Wagner scored much lower on performance ratings than those listening to a more relaxing selection, and the group working without background music outperformed the others.
Miskovic and his colleagues concluded, "Music in the operating theatre may have a distracting effect on novice surgeons performing new tasks." Clearly, context makes a difference.
Talking Over the Music
Even if music helps surgeons work with greater speed and accuracy, it seems to be a distraction for other members of the surgical staff. Surgeons have gotten most of the attention in studies on the effects of music in the OR, but a successful surgery is a coordinated effort that also relies on anesthetists, nurses, and technicians. Recent papers in professional journals of nursing have raised concerns about how music in the operating room affects communication and teamwork during surgery, and anesthetists and anesthesiologists have also weighed in on distraction and communication issues.
Anesthesiologists are especially sensitive to noise in the OR, it turns out. And in a 1997 survey, 54% told researchers that music was distracting when a problem came up during surgery. Another 26% said it reduced their own vigilance and impaired communication with the rest of the surgical staff.
In fact, music does seem to make it harder to communicate in the operating room. Earlier this year, when Sharon-Marie Weldon, senior research officer and nurse in the Department of Cancer and Surgery at Imperial College, London, and her colleagues reviewed videos of 20 surgeries at a London teaching hospital, they found that surgeons had to repeat requests to nurses five times more often in surgeries where music was playing. "The impact of loud music on communications seems to be clear," wrote the authors. "It hinders the nurses' ability to hear the surgeon's speech. When music masks the audibility of speech, it often results in the surgeons having to repeat themselves, and consequently, it takes longer for nurses to respond with assistance."
How much longer? Delays ranged from a few seconds to just over a minute -- and if there's an emergency in the middle of an operation, seconds count.
Zhang says his staff turns the music down immediately if trouble starts. "If something is not going right or is going unexpectedly, usually we turn the music down. If there's some anesthesia problems or anything like that, we just turn the music off completely," he said.
But according to Sheldon and her colleagues, turning down the music doesn't always go quickly enough. "Sometimes it took a while to reduce the volume on the sound system," they wrote, "for instance, when a nurse was trying to find the volume control on an anesthetist's iPod." That few seconds of fumbling could be critical in an emergency.
A Matter of Taste?
There's a common thread running through all of these studies on music in surgery: personal preference makes a big difference. Surgeons consistently perform better when the music is something they have chosen. 78% of the anesthesiologists responding to the 1997 survey said that music they disliked was especially distracting, and in a study a year later, CR Hawksworth found that when anesthetists selected their own music, it didn't hinder their performance.
"For all personnel in the operating room, it is apparent that the selection of the music and the manner in which it is delivered play a key role in its effect," wrote Katz in his paper.
But because there's a definite hierarchy in the OR, it may be hard for nurses and technicians to speak up about their preferences. In their observational study at the London teaching hospital, authors observed that the surgeon, and occasionally the anesthetist, usually chose the soundtrack for each operation, with little or no input from nurses, residents, and other staff members.
That may be a matter of culture; nurses responding to a staff survey at another UK hospital earlier this year reported much more democratic control of iPods in the operating room. About a third said that surgical staff chose the music, but another third said the whole staff had a say, and the remaining third thought it was up to the nurses. 15% of the surgeons surveyed agreed that the nurses had control over the music.
And that survey, in the Journal of Perioperative Practice, is also one of the few papers that describes a positive opinion about music in the operating room from nursing staff. "The majority of both nursing and medical staff felt that they enjoyed their work more and performed better when music was played in theatre. The study concluded that the majority of theatre staff found listening to music while they work a positive experience," wrote lead researcher A.A. Faraj and colleagues. That's probably no coincidence.
Communication is Key
At UTMB, Zhang, who says he usually works with the same group of nurses, anesthesiologists, and scrub techs, picks the music, but he checks with his operating staff to be sure no one objects to his choice. So far, according to Zhang, no one in his operating room has ever asked him to change the music, or to operate with no music at all.
"I have had a couple of nurses who didn't want to hear the music next to them, so we moved the speaker closer to where we sit so they don't hear much of the music at all," he said.
"I do feel like in the surgical field, after the patient is under anesthesia, when you're doing the surgery, the surgeon is the most important person in that room who needs to be doing the best job there," said Zhang, but he added, "It's a team effort; everybody's on board when we do something, including playing music. I think the surgeon should communicate with their staff, obviously. And obviously, if they're playing something that's really offensive to somebody, then that is potentially an issue, but I definitely advocate better communication, first, with your staff."
Weldon and her colleagues in London agree. They advocate adding a discussion about music to the pre-operation safety checklist recommended by the World Health Organisation. After all, part of the goal of the checklist, which WHO introduced in 2008, is to improve communication among surgical staff and encourage junior members of the team to speak up about safety concerns.
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