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Getting everyone to sing in harmony


This talk, from Clare Skinner, on music, medicine and leadership, comes from our 2022 DFTB conference in Brisbane.

Years ago, before I became a medical student, I heard Professor Michael Field, Associate Dean of Medical Curriculum at the University of Sydney, nephrologist, and an accomplished flautist, being interviewed about his love of music on ABC Classic FM. I have long harboured a dream to do the same.

Thank you for inviting me to present today. I’m a lucky duck and get to speak at many conferences, but this is my dream topic. While ABC Classic is yet to call me, I think a spot on the program at a Don’t Forget the Bubbles conference is even better.

Let’s start with a confession. I don’t drink coffee. I don’t drink Diet Coke. I don’t wear a bike helmet or reflective goggles. In fact, I don’t even own a bicycle. I am the antithesis of Dr Glaucomflecken’s caricature of an emergency physician!

Somehow, I ended up a doctor. But in my heart, I am a writer, an artist, and a musician.

I love music. It’s part of who I am. I can find and make music anywhere. There is always music playing in my head. I have an inner soundtrack, and I walk (and dance) in time to the beat. I can make a musical instrument out of almost anything: a blade of grass, a saucepan lid, or the plastic sheath of a ballpoint pen. I love The Beatles and Crowded House. They mix complex harmonies with storytelling, which gets me right in the feels. But my great musical love is the work of Beethoven.

I thought about playing for you today. My friend, Bec, asked if a piano would be on stage. But this is a medical conference, packed to the brim with over-achievers, so every second person likely has their AMusA, and there are probably at least three former Australian Young Performers of the Year in the audience too.

I know my way around music, but compared to people who do it for real, I am not actually that good. My true skill lies in facilitating, not being the best performer. ‘Facilitator-in-chief’ is my role when leading the ED Musos virtual choir and orchestra, and this also applies to my job in the hospital as Director of the Emergency Department.

So, I don’t ride a bike, but I do like to do a million things at once. I guess that part of the ED stereotype rings true. I love emergency medicine because, as Dan Sandberg once said, it is ‘the most interesting 15 minutes of every other speciality’.

This sums up my approach to music too. I can play the first few grades of a lot of instruments.

Instead of playing for you today, I will tell some stories and, unashamedly, share some personal reflections and photographs.

I play four instruments ‘properly’. In this talk, I will take you through them, one by one, in reverse chronological order of how I learned them. Consider this talk a ‘symphony’ in four movements.

I have learned a lot about life, love, and leadership through my adventures in music. Here goes.

First Movement – Oboe

Taken in the 1980s when an oversized T-shirt was considered a complete outfit – At Band Camp – 1987

I started learning the oboe when I was eleven years old. My grandad, Rob, bought me a second-hand plastic instrument from the newspaper classifieds after I nagged my parents about it for months. I told them that I loved the sound. But I think I was really attracted to the oboe because it was difficult and because I didn’t know anyone else who played it. These were the exact same reasons I later studied medicine.

The oboe opened an important door for me to the world of the symphony orchestra.

The New South Wales Doctors Orchestra ‘Musicus Medicus’ – 2014

An orchestra is a complex system with many moving parts. It’s a bit like the health system. An orchestra has sections and hierarchies, made up of lots of people, with individual strengths and weaknesses.

An orchestra has tribes, each with its own culture and rules. Just like medical specialities, there are jokes and stereotypes, most of which are neither helpful nor accurate. The violins are the goody-two-shoes. They stick together and follow the rules. Maybe they’re the physicians? Or the medical registrars? The brass are loud and unpredictable. Perhaps they’re the orthopaedic surgeons? The percussionists jump around, play multiple instruments, and seem to make stuff up as they go. I think they are probably closest to emergency docs.

And me? I play the oboe—the nerdiest instrument of them all.

When you see and hear an orchestra play, it may seem obvious that the conductor is in charge. To some extent, they are. The conductor’s job is to lead the orchestra, which they do by waving a white stick, making hand gestures, and through the deployment of nuanced facial expressions and body language.

In practice, though, things are more complicated. There is leadership operating at many levels.

Think about the composer. They write the musical score and choose every note, but they have surprisingly little control over how the music is played or interpreted.

Every instrumental section has a leader. The best known is the Concertmaster, who leads the first violins. The players in each section need guidance from their leader to keep them playing tightly together. In time, in tune and in style.

Musicians pick up cues, auditory and visual, from the players around them. Things like when to come in after a rest, how loud or soft to play, and a sense of how the music should feel.

We don’t think enough about the power and impact of behavioural cues in medical leadership.

Just like the health system, chronic tensions are at play in an orchestra. It is very difficult for a large group of musicians to stay together.

Let’s think about tuning, or intonation, as musicians call it. It’s complicated.

If you don’t play an instrument, it might surprise you to learn that playing a few seconds of ‘Concert A’ (440Hz) at the start of a concert is not enough to keep the orchestra in tune. The musicians need to listen carefully to each other and adapt the pitch of every note they play. The winds do this with their lips and through breath control. The strings use their fingers.

Every instrument has different tuning tendencies. Some play sharp, some flat. In most cases, that changes across the range of the instrument and is affected by how warm or cold the instrument is and even by the weather. For example, the upper range of the oboe and the clarinet tend to go out of tune in opposite directions. This makes the famous duet in Schubert’s first movement of the Unfinished Symphony a particular challenge to play.

I have a recording of me playing this symphony while heavily pregnant. I was working hard to keep the long notes in tune – squeezing my diaphragm tight – and in the version played on 2MBS FM, you can hear my baby daughter kicking me on the inside. It was nerve-wracking then, but it is now a very special memory.

The room matters too. Dependent on its size, shape, and acoustic properties, there will be a note that works best, called the ‘fundamental resonance’ or ‘room resonance’, which may somewhat inconveniently clash with the musical key the orchestra is trying to play.

Timing is also tricky. The conductor indicates the beat with their baton, the musicians listen to each other, noise reverberates around the room, and players keep count inside their heads and sometimes tap their toes. There are many versions of the time. Orchestras have predictable tendencies to speed up and slow down. There is a tempo of around 94 to 96 beats per minute, known as the ‘point of indifference’, at which human beings tend to correctly estimate and play in time. It’s the heart rate of a primary school-aged child.

I think these musical forces are a good analogy for change management in a complex system. The orchestra, led by the conductor, must work hard to overcome natural tensions, in the same way that managers in a workplace must overcome cultural or psychological inertia when introducing something new.

Considering all this, it is a miracle that eighty-odd people can make music together at all. This is why I think the symphony orchestra is one of the greatest achievements of humankind.

A good orchestra makes it seem easy. Musicianship, collaboration, and leadership, creating beauty in action.

So, what is the pecking order in the orchestra? Who has the most difficult part? Who is the most important player? Which is the most important section?

There are a lot of string players: first and second violins, violas, cellos, and double bass. Strings tend to play the most notes in the most bars. They give the orchestra body. There are fewer wind and brass players, but they tend to stick out. They give the orchestra colour and shape.

As an oboe player, I have always felt pretty important. The oboe is a technically difficult instrument with a very distinctive sound. Every single note I play can be heard from the back row.

Because of this, the oboe, and particularly the first oboe, has a special role. It often heralds a shift in musical style and helps guide the other players into a new section of the piece. Consider the oboe entry after the iconic Cor Anglais solo in the slow movement of the New World Symphony by Dvorak. Two bars of rapid triplets with lots of accidentals, most of which require alternative fingerings. The first oboe is out there all alone, introducing a new tempo, new mood, and a new key, highly exposed and hugely vulnerable. I rate this my least favourite bar of one of my favourite symphonies. The story goes that the oboe player was having an affair with Dvorak’s wife. That impossible-to-play phrase was pure musical revenge.

There aren’t large numbers of oboe players, so it’s rare for too many to sign up to play with the New South Wales Doctors Orchestra. When we have extras, we take turns to sit a piece out. One of the percussionists was unwell a few years ago, so I was asked to cover the bass drum. We were performing Tchaikovsky’s Symphony number 5, and I had to play a single note. My hands trembled, and I second-guessed myself. It was impossible to get the timing just right.

I have spent twenty years working in Emergency Departments and this was one of the scariest moments of my life.

I learned that there is no such thing as the most important player in an orchestra. There are times when you play the tune, a solo, or when your section takes the lead, called a soli. There are also times when your section backs up other instruments. Let’s talk through a few ways that might happen.

The strings can form what Dr David Banney, doctor-conductor, refers to as a ‘magic carpet. A lovely, light shimmering sound with lots of vibrato, which helps the melody soar. It is also a safety net. The shimmer hides small flaws in tuning and timing and helps make the solo players sound really, really good. Listen to it happening in Princess Leia’s Theme from Star Wars.

The winds can direct traffic. They toot and squeak to accentuate a fast-moving melody in the strings, serving as musical slalom gates, neatly keeping the other musicians in time. They come in when the strings speed up after the introductory section in Beethoven’s Creatures of Prometheus Overture.

The brass? They make what I think of as the ‘superhero’ sound. Rich, round, bronzy low notes that say, ‘don’t muck with me, the big guys are in town’. This lets everyone know when the music is serious business, providing the sort of backup that we all need sometimes. Here they are in Bruckner’s 8th symphony.

These special effects are not just background music. They are acts of facilitative leadership.

There are also times when musicians don’t play in a carefully timed musical sort of way. An orchestral concept I really like is ‘playing the rests’, which is the act of deliberately getting out of the way, musically speaking, to make room for others to take the lead.

Just like a hospital, or a health system, an orchestra needs every player doing their thing and doing it well. You’ve got to know your instrument, learn your part, follow the conductor, be guided by the leader, communicate with the other players, and be engaged with everything that’s going on around you.

That’s why playing in an orchestra is so wonderful. It’s not about you, it’s about the music.

Second Movement – Saxophone

On the front steps – 1985

A change of pace now as we start the second movement. You’ll be relieved to hear that the next three movements are much shorter than the first.

I started playing the sax when I was nine. I auditioned for the school band, and the saxophone chose me. I think I was assigned tenor sax because I was the only kid tall enough to hold it. I subsequently moved to alto, the one in Lily Was Here, which I still play. The Baritone, the curly big sax Lisa Simpson plays, was my main instrument at high school. I also have a soppy sax, the one made famous by Kenny G, in my ridiculously large personal collection of musical instruments.

It was the early eighties, so I taped the sax solo from Your Latest Trick by Dire Straits off the radio, learned it by ear, and played it over and over again. That piece was my dinner party show turn.

The sax is the 1980s epitomised. At the time, it was cool as hell. Through the saxophone I learned to play popular music, how to improvise, and all about jazz.

Chatswood High School Stage Band at Darling Harbour – 1990

A jazz ensemble is a bit like a resus team. It’s small, it’s flexible, and there is nowhere to hide.

Compared to an orchestra, a jazz group seems chaotic and unstructured. From the outside, it can appear that there is no obvious leader or defined roles. But, just like a ‘good’ resuscitation, the secret to a great jam is lots of preparation and finely-tuned teamwork. You need to understand first principles, speak the language, and know the rules – both official and unofficial.

Musical improvisation is not as improvised as it seems. It is all about pattern recognition. You practise scales and chords and learn to understand intervals, keys, and modes.

Cognitively speaking, jazz is Type 1 thinking. Classical music is Type 2.

Like much of medicine, jazz is learned through an apprenticeship model. Players listen to riffs and phrases, usually snippets from show tunes or famous instrumental solos. They learn and adapt them, then practice them in many keys and styles so that they can combine, twist, and bend them and superimpose them on different musical backgrounds.

Playing in a small group is all about good communication. You develop short cuts and scripts to let others know what you plan, or at least hope, to do.

The most important concept I learned playing jazz is ‘the happy mistake’. Whatever you do, don’t stop playing. If you hit the wrong note, then bend it, turn it around, or make a feature out of it. Keep on playing. If you are all working to a shared plan, when something unexpected happens, or you lose your place, the band will meet you halfway, or will catch you if you fall.

And that’s what we do in the resus room. We don’t have a detailed score to follow. We don’t know how the song will end. So, we assess and manage in parallel, use trial and error, know our limits, communicate with each other, and keep an open mind. Our extensive training and shared mental models allow us to do this safely and effectively.

Some of my favourite moments happened playing the sax. Like a concert during my school band’s tour of California in 1990. We improvised to You Can Leave Your Hat On while a hall full of students and teachers sang along and mimed a strip tease, which is probably not so appropriate viewed through a modern lens. I loved jamming with a group of international students in the kitchen at a youth hostel during my elective term in the UK and playing Charlie Parker tunes at a party during a rotation to Lismore Base Hospital.

It’s ancient history now, but I met my first husband at a hospital fundraiser. He’d been hired as the musical act, and I took over on a dare from my friend Pieter and played Misty on his saxophone. We ended up playing subsequent hospital events together. On the day I left, I played Love Never Runs on Time, by Paul Kelly, on high repeat.

Third movement – Piano

At the piano – 1980 – about age six, wearing a skivvy. The seventies were only just over, but still, what was I thinking?

I started playing the piano when I was five. It was suggested by my kindy teacher. I was painfully shy at school and didn’t like to play outside with the other kids during recess and lunch breaks.

My teacher set me up with the piano in the school hall. She thought it would give me a way to express myself and build my social confidence, and she was right on the money. Not long after, following an encounter with maestro Richard Gill, I was having piano lessons at the Sydney Conservatorium.

We’ve been through a lot together, the piano and me.

The piano is where I learned how music works. Chords, scales, and arpeggios. Key signatures, time signatures and dynamics. Sight reading and playing by ear. Melody and harmony.

The piano is where I learned how to solve complex problems. I worked out that if I break a piece into short sections, slow it down, work on the fingering, learn one hand at a time, and count out the timing, I can eventually play even the most difficult piece of music.

Deliberate practise, using auditory, visual, and proprioceptive memory, is a useful habit for improving clinical and communication skills too.

My piano – 2022

The piano is also where I learn all about me.

Here is my piano at home, next to the kitchen, in the space we refer to as ‘the Rock Eisteddfod Zone’. I use the piano to understand and process my emotions. It’s my wellbeing activity, like other people might swim, meditate, or do a so-called ‘fun’ run. Sometimes it feels good. My fingers move smoothly and I reach a flow state. That’s the best feeling in the world. Sometimes it feels really difficult. My fingers are clumsy, nothing clicks, and the notes come out all wrong. Just like real life.

I play a lot when times are challenging. Sad music, angry music, sentimental music. My partner complains that I am very noisy to live with after a bad shift at work.

I play a mix of old favourites, improvisations, and sometimes new pieces, which stretch my skills, test my patience, and require detailed rehearsal.

In the last few years, I have become mindful of the lack of diversity in the composers I play, so I am actively working to remedy that.

Right now, I am working on an old favourite. The slow movement of the Schubert Piano Sonata in B Flat. It’s eight pages long. You can only see four of them in the photo.

My relationship with the piano is spiritual and profound. It is hard to explain. The piano is my lifelong companion. It’s one of my best friends. People who are close to me in real life know that I anthropomorphise everything. Cars, kitchen appliances and even pot plants have human names. But I have never named a piano. Somehow, it doesn’t feel right.

I am never lonely when there is a piano around.

I make friends with pianos wherever I go. When I was a kid, I played pianos in historic houses and museums, and more recently, I’ve played the piano at Adelaide airport, the one outside the volunteer’s shop at work, and the one in the foyer at Gold Coast University Hospital, while on tour for College. I don’t set out to do it, but my fingers twitch, and I can’t resist touching a set of keys. It’s like meeting a new friend.

Fourth Movement – Voice

In the cot – 1975This is the earliest photo of me singing. My mum calls this photo ‘Angel’. My grandfather, John, kept it in a leather-wrapped frame on his desk.

I honestly believe that everyone can sing. And everyone should use how to use their voice effectively.

That doesn’t mean it is easy.

Sometimes you need to find the right words, the right style, the right tune, or the right key.

Sometimes you need to find the right audience.

We all need to get better at listening to a broader range of voices.

It’s okay to sing for fun. You don’t need to be perfect. You don’t need to be a diva, either. Our voices are most powerful when we sing with others. The most loved, revered, sacred sound the world across, is people singing together in a choir. Think about it. In Western culture, the choir is the sound of angels, of heaven. Singing is magical.

I want to talk you through an important concept from opera, Fifth Business. Most operas have five key roles. The soprano and tenor are the leads, usually the romantic lovers. The alto and bass are in support roles, the confidante, and the villain, often troublemakers. There is always another major character and that role is fifth business. The part is usually sung by a contralto or baritone. They are the character that glues the others together. They know everyone’s secrets, make things happen, and ultimately, they reveal the truth.

Let’s try that idea out.

We’ll start with The Pirates of Penzance. I know it isn’t a real opera, but I love Gilbert and Sullivan. Frederick and Mabel are in love, singing the lead parts. Ruth and the Pirate King are creating drama and running interference, and fifth business? That’s the modern Major General.

A more recent example? Grease. Sandy and Danny are the lovers. Rizzo and Kenickie are the support acts, and Frenchie, the beauty school drop-out, she’s fifth business.

Think about this carefully. It’s easy to assume that the lead parts are the leaders. But are they really? I’ve tended to deliberately position myself as fifth business when working in leadership roles. I try to move around in the background, connect people to each other, tell truth to power and make stuff happen.

Let’s get even more modern. Consider the success of Disney’s Encanto. It’s okay; I’m not going to talk about Bruno! Why does Encanto resonate with so many people? Besides the wonderfully catchy score and inclusive casting, Mirabel, the main character, is a facilitative leader. She might look like the star, but she’s actually fifth business.


I’m exceptionally grateful for my music education. I thank everyone who has been a part of it. My parents, teachers, mentors, colleagues, and friends. There are too many of you to name.

Music has allowed me to see, hear and understand the world in a special way. It has developed my leadership, followership, and teamwork skills. It has given me the confidence to tackle difficult problems. It has provided a safe space for solace and reflection. I feel extraordinarily lucky that music is a tool in my kit.

I am aware that not everyone has access to musical instruments, music teachers and the creative arts in the way that I have done. And I do. I acknowledge my privilege.

Why is this important? Because this conference is about children’s health. Music is central to children’s health and music can change lives. I ask you to raise your voices to advocate for access to music education for all kids, especially those who are socially, geographically, and politically marginalised.

Look at me. I’m a kid from suburban Sydney who went to local public schools. And music education is a very big reason that the shy little person singing in their cot grew up to be President of a specialist medical college.

ACEM President – 2022

In medical circles, we talk a lot about learning leadership and teamwork through sports. I think I have learned more about myself through art and music.

I hope I have helped to shatter the cliché that all emergency physicians enjoy extreme sports. Some of us prefer acts of extreme creativity. Please consider including music and the other performing arts in your conference wellness activities for those who don’t feel comfortable in Lycra.

The ED Musos perform Whole New ED – August 2020

I think we overcomplicate leadership and leadership training. To me, leadership is very, very simple. When you are granted the privilege of leading, treat other people like you would hope to be treated yourself.

Here is a summary of lessons I have learned about leadership from my four instruments, which comprise the four movements of this symphony.

Movement I: Understand complex systems. Roles, hierarchies, and tribes. Group dynamics, balancing tensions and managing change.

Movement II: Work as a team. Listen, look, and feel. Interact with curiosity, empathy, and respect.

Movement III: Do the hard work on yourself. Learn, practise, and grow. Whatever you do, don’t stop playing.

Movement IV: Use your voice. Learn how
and when to raise your voice for good.

And, remember it is not all about you.





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