Journal of Voice Vol. 6, No. 1, pp. 17-21 © 1992 Raven Press, Ltd., New York

Proposal for Establishing a Degree of Doctor of Philosophy in Arts Medicine

R o b e r t T h a y e r S a t a l o f f

Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A.

Summary: Arts medicine is a new, rapidly developing discipline that includes voice, hand, dance, and other subspecialty areas. At present, there is no or- ganized academic arts medicine tradition. Therefore, it is difficult for inter- ested persons to obtain convenient, high-quality education designed for the special needs of arts medicine practitioners. To meet this need, development of a Ph.D. program in arts medicine appears to be desirable. The structure of such a program is proposed, along with specific requirements for a Ph.D. in arts medicine with a concentration in voice. Key Words: Arts medicine--Voice-- Curriculum--Interdisciplinary education.

Arts medicine is a newly established specialty that poses unique educational challenges. The field involves basic research and specialized clinical care for singers, instrumentalists, dancers, visual artists, and others who place unique demands on their bod- ies and minds and who require function much closer to optimal than virtually any other patients in med- icine. The demands upon some performing artists are extraordinary. For example, in a study of 55 "sports" by a sports medicine center, ballet danc- ing was determined to be the most difficult and chal- lenging (1).

A great deal of information remains to be discov- ered in order to understand the anatomy, physiol- ogy, physics, and other fundamentals that allow ef- ficient, healthy development of artists, and rational clinical management by physicians and teachers of the arts. The research and clinical challenges are made more difficult by the fact that available infor- mation is scattered among diverse professions, each with its own literature, educational traditions, and institutions. Traditionally, even the language used by the various professions is incomprehensible to practitioners of fields now interacting through arts

Address correspondence and reprint requests to Dr. R. T. Sataloff at The Voice Foundation, 1721 Pine Street, Philadel- phia, PA 19103, U.S.A.

medicine. Although recently there has been a sub- stantial increase in basic research, in the opening of clinical "arts medicine centers," in the develop- ment of scientifically based pedagogy courses within music schools, and in the publication of arts medicine literature (2-4), there are few places one can go to obtain the necessary training. At present, there are no academic programs or degrees offered in "arts medicine." In order to educate oneself, it is necessary to either obtain multiple degrees, which frequently require time and information not appli- cable to the student's goals, or to find informal "apprenticeships" to fill in gaps left by traditional educational categorization.

The Ph.D. program in arts medicine suggested in this article is designed to fill the educational needs of scholars in this new field. It abandons traditional educational categories and is flexible enough to ad- dress the special interests and unusual background of each candidate. The degree is designed to assure and promote the development of academic excel- lence in arts medicine, and is specifically geared toward students interested not only in providing top-quality research, clinical care, or artistic train- ing, but moreover in those committed to teaching and the establishment of an academic tradition in arts medicine.

Because of the diversity and complexity of the

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18 R. T. SATALOFF

field, an arts medicine department must offer sev- eral areas of specialization. Despite the fact that all areas of specialization are combined administra- tively under one department of arts medicine, each area of concentration is represented by a distinct curriculum.

Each candidate will choose one of the following concentrations: (a) Ph.D. in arts medicine (voice), (b) Ph.D. in arts medicine (hand), (c) Ph.D. in arts medicine (dance), (d) Ph.D. in arts medicine (other specified concentrations). Although there is some overlap, course requirements are different for each concentration. While minimum suggested require- ments for the degree are listed under each concen- tration, the program recognizes that the advanced status of the candidates considered for this program warrants flexibility. Programs will be designed on an individual basis with the candidate, faculty, and dean, in order to assure that each candidate who graduates from this program meets the most rigor- ous standards and is incontestably an "expert ." However, every effort will be made to educate the student to this level without wasted time or required courses inappropriate to his or her specific needs. Recognizing that most of the candidates in this pro- gram will be established professionals with ad- vanced degrees, the program will be designed so that it interferes as little as possible with the candi- date's practice of her/his arts medicine-related pro- fession.

REQUIREMENTS FOR Ph.D. IN ARTS MEDICINE (VOICE)

Mission statement The Ph.D. in arts medicine (voice) is designed to

provide interdisciplinary training to candidates al- ready advanced in one or more aspects of voice care. The degree is not designed to make each grad- uate an expert in all areas of voice such as laryn- gology, speech-language pathology, voice re- search, voice performance, and voice teaching. Rather, it is intended to enhance skill in his/her pri- mary area of expertise (laryngology, for example) by providing not only additional subspecialty train- ing, but also substantial education in related fields. Such an education is intended to facilitate the op- eration of interdisciplinary teams for voice care, re- search, and training. It should allow the graduate to collaborate more effectively, judge and follow ad- vances in related fields, and improve his/her prac- tice and teaching through a broader base of under- standing. It is not intended to qualify physicians as

Journal of Voice, Vol. 6, No. 1, 1992

speech- language pathologis ts , or v ice /versa . Rather, it is designed to answer the needs of the speech-language pathologist, otolaryngologist, mu- sic educator, researcher, or other specialist seeking advanced education specifically related to voice.

Admission In order to be admitted to candidacy, the appli-

cant shall hold a master's or a doctoral degree in a related field. Such fields include but are not limited to medicine, speech-language pathology, nursing, voice science, physics, computer science, psychol- ogy, music, and music education. The candidate shall have established interests and expertise in at least one traditional discipline related to, e.g., voice. The Ph.D. in arts medicine (voice) will in- volve the following components: basic research, clinical care and assessment, and musical perfor- mance. For example, appropriate candidates may be board-certified otolaryngologists specializing in voice, speech-language pathologists specializing in voice, singing teachers specializing in vocal peda- gogy, physicists specializing in acoustics or voice modeling, computer scientists specializing in voice synthesis, etc. Preference will be given to candi- dates with academic positions and relevant publica- tions. In addition, candidates must demonstrate fa- miliarity with or aptitude for the other areas of this program in which they may not have expertise (vo- cal pedagogy, voice performance, computer sci- ence, physics, etc).

Language requirements include competence in at least one foreign language. This requirement may be satisfied by language requirements of previous degrees.

In light of the requirement for previous degrees, no requirement for cognate courses is imposed.

A preliminary examination is required. A thesis is required. The thesis shall demonstrate

special expertise. It shall be of a stature sufficient for publication in a major national journal. The the- sis shall be defended before an interdisciplinary committee. Musical performance and even com- mercial recording shall not be acceptable substi- tutes for a written thesis. While the importance of performance is recognized in this program, the pro- gram is designed to develop academicians, educa- tors, and researchers. The thesis is expected to rep- resent a substantial contribution to the field. It may be in the areas of basic research, clinical research, education, pedagogy, etc.

In addition to completing the application to grad- uate school and the usual interview process, and

DOCTOR OF P H I L O S O P H Y I N ARTS MEDICINE 19

submitting copies of selected publications, the can- didate shall be required to deliver a lecture in his area of expertise, to audition as a singer (even if the candidate's primary interest is in acting or the speaking voice), and to conduct a short lesson teaching either singing, acting, or speech. It is rec- ognized that many applicants will not have exper- tise in all of the areas tested, but aptitude in each of these areas is necessary to complete degree require- ments.

Comprehensive examination Upon completion of degree requirements, the

student shall be required to pass a comprehensive examination. This shall include (a) a written exam- ination including basic science, research methods, speech pathology relevant to voice, medical care of professional voice users, clinical sciences, and sing- ing methods and pedagogy of speech and singing; (b) an oral examination including, but not limited to, performance of a complete laryngologic examina- tion, visualization of the vocal folds and interpreta- tion of laryngoscopic images, interpretation of ob- jective, clinical measures of voice and pulmonary function, analysis of the singing techniques of be- ginning, intermediate, and advanced singers, and analysis of speaking voice techniques; and (c) pre- sentation of a public solo performance or an ap- proved public performance as a singer or actor. A solo recital will be required in most cases.

SPECIFIC REQUIREMENTS

Specific course requirements include all of the following, plus additional courses selected by the student and faculty, in accordance with his or her special needs: anatomy, biostatistics, care of the professional voice, clinical fellowship, ensemble performance technique, fundamentals of laboratory instrumentation, history of music, introduction to speech pathology and voice therapy, neuroanato- my, objective voice analysis, physical therapy and body awareness, the physics and physiology of voice, psychology and stress management, singing technique, speaking technique, thesis research, and voice pedagogy. A brief synopsis of the content of the proposed courses clarifies further the intent of this degree.

Anatomy A comprehensive course in anatomy of the head

and neck and thorax is presented, along with an introduction to the anatomy of the abdomen, mus-

culoskeletal system, and special senses. Dissection is included.

Biostatistics This course is designed to acquaint the students

with basic statistical methods and experimental de- sign as an aid in understanding the scientific litera- ture and in planning and evaluating clinical and lab- oratory experiments. Specific topics include intro- duction to concepts of sample, population, bias, experimental error, randomization, homogeneity, etc.; properties of frequency distributions with par- ticular emphasis on central tendency and dispersion (mean, median, and standard deviation); logarith- mic transformation of data; random sampling, dis- tributions, and standard errors; null hypothesis and type I and type II errors; x 2 test, and t test for independent samples and for paired data; nonsam- piing misuses of rates and ratios; and introduction of analysis of variance.

Care of the professional voice This course involves a series of didactic lectures

as well as extensive clinical observation of care of professional voice users. Supervised involvement in the diagnosis and treatment of professional voice users will be included. The student is expected to develop competence in the use of instrumentation involved in professional voice care such as the stro- boscope, spectrograph, airflow analysis and pulmo- nary function equipment, and other instruments for detailed voice assessment and documentation. Present and potential clinical applications of re- search laboratory instrumentation will be included.

Clinical fellowship "Care of the professional voice" is a prerequisite

to this advanced course in care of professional voice users. The student will be expected to apply knowledge from the previous course in order to de- velop advanced skills in diagnosis and treatment, under the supervision of a physician, speech pathol- ogist, and singing teacher.

Ensemble performance technique This course provides an introduction to ensemble

performance through didactic lectures on perfor- mance technique, and the technical and stylistic dif- ferences between solo performance and ensemble performance. Regular participation as a performer is required in an ensemble approved by the faculty.

Fundamentals of laboratory instrumentation The theory and application of laboratory instru-

mentation used for clinical assessment and for re-

Journal of Voice, Vol. 6, No. 1, 1992

20 R. T. S A T A L O F F

search in voice science will be presented in detail through didactic lectures and laboratory teaching. Among others, the student will be required to un- derstand strobovideolaryngoscopy with visual and digital analysis, spectrography, acoustic analysis of voice signals, laryngeal airflow analysis, pulmonary function testing, inverse filter techniques, and other instruments and methodologies.

History of music This course will concentrate on the history of

Western music from antiquity to the present day, including a technical study of the significant musical trends. Limited attention will also be given to non- Western music, and especially to its implications regarding performance technique.

Hearing mechanisms and psychoacoustics This course describes the anatomy of the ear and

central auditory pathways, mechanisms of hearing, and techniques for hearing assessment. In addition, causes of hearing loss are reviewed, with special emphasis on hearing problems of musicians. The course also provides an introduction to psycho- acoustics.

Introduction to speech-language pathology and voice therapy

This course is intended for candidates who are not speech pathologists. Through didactic lectures and clinical observation, the principles of speech pathology are presented specifically as they relate to the voice. Techniques for voice modification will be discussed in detail, as well as their theoretical basis. In addition, commonly used techniques un- suitable for professional voice users will be pointed out.

Neuroanatomy A comprehensive course on neuroanatomy of the

brain and cranial nerves is presented through didac- tic lectures. Principles of histologic study are pre- sented. Current theories of neurophysiology are presented, along with specific discussions of neuro- transmitters. An introduction to peripheral neuro- anatomy and anatomy of the spinal cord is included. Emphasis will be placed on neuroanatomy of pho- nation and hearing.

Objective voice analysis This advanced course requires the student to par-

ticipate in recording and analyzing the voices of normal and abnormal subjects. The course stresses

not only facility with the instrumentation, but will also require analysis of the data obtained. The stu- dent will be required to perform validation studies on his/her results and to devise and execute a sim- ple clinical experiment using the techniques he/she has learned.

Physical therapy and body awareness This unique course includes principles of physia-

try, physical therapy, and body movement stage training. It incorporates elements of muscle and ex- ercise physiology, principles of exercise, posture analysis, and practical applications in voice training and stage performance. Each student will also re- ceive personalized body movement and awareness training.

Physics and physiology of voice This advanced course discusses the physics of

sound, acoustics, the interaction between a sound source and the environment, the physiology of voice production, and current theories and tech- niques in voice modeling and computer synthesis of voice.

Psychology and stress management Basic principles of psychology are presented,

with specific emphasis on stress management, preperformance anxiety, and psychological prob- lems and stresses common among performing art- ists. A session on psychologic problems of child prodigies is included, as well as an introduction to music therapy as related to voice.

Singing technique This course requires training in voice perfor-

mance not only through literature, but also through voice lessons on a weekly basis. Objective voice analysis will be performed on each student at the beginning and end of each semester; written and tape-recorded analysis from the singing teacher ap- proved by the faculty will be required, and the stu- dent's progress will be judged by performance be- fore a jury, in the manner standard within music schools and conservatories. This course will be re- peated with more advanced content throughout the candidate's training. When the student is suffi- ciently advanced, it will include education and teaching techniques. Prior to successful conclusion of the degree, each student will be required to an- alyze singing students and to provide voice teaching under supervision.

Journal of Voice, Vol. 6, No. I, 1992

DOCTOR OF PHILOSOPHY IN ARTS MEDICINE 21

Speaking technique Each student will be required to undergo training

for his/her own speaking voice with a speech- language pathologist and an acting teacher. The process of applying theories learned in other courses to one's own speaking voice will be evalu- ated by a reading before a jury. In addition, the student will be required to analyze patients' voices and to apply voice therapy techniques to improve them under supervision.

Thesis research A thesis is required. The topic may be in any area

of voice science and may involve clinical or non- clinical research. The topic and methods must be approved by a thesis committee, and the thesis must be defended at its conclusion. In addition, publication of the thesis in a peer-reviewed journal is expected.

Voice pedagogy An introductory course providing an overview of

the anatomy, physiology, physics, and acoustics of voice production. Their applications to various theories of voice teaching will also be discussed. The evolution of the scientific approach to voice training will be reviewed covering the period from 1600 to the present.

SELECTED ADDITIONAL COURSES

Each student in an advanced program of this sort is likely to have great strengths in certain areas, and weaknesses in others. Additional course require- ments will be designed to correct weaknesses. For example, an experienced researcher with a Ph.D. in physics may need courses that provide additional experience with clinical patient care and/or musical performance. A physician with primarily clinical experience may need additional training in research design and laboratory techniques. Together, the student and faculty should identify "gaps" in the student's arts medicine training and be certain that they are filled prior to completion of the degree.

OTHER CONCENTRATIONS

Degree requirements for arts medicine students with interests in hand, dance, or other areas are designed according to the same principles guiding the program for voice students discussed above.

The requirements will not be discussed in detail in this article.

APPLICATIONS OF THE DEGREE

At present, there are no established academic programs in arts medicine. However, the field is advancing rapidly in clinical and research contexts. People trained in various fields potentially suited to voice specialization have great difficulty in finding fellowship or advanced degree positions to answer their educational needs. It is anticipated that grad- uates holding Ph.D.'s in arts medicine (voice) will be ideally trained to help institutions develop pro- grams to address this growing need. In addition, the education obtained should provide them with ex- ceptionally broad expertise in voice within their pri- mary field (medicine, speech-language pathology, etc.), making them especially desirable in team set- tings.

CONCLUSION

Voice is one subspecialty in a larger field of arts medicine. Advanced, comprehensive training in the intradisciplinary aspects of voice required by the well-rounded arts medicine practit ioner or re- searcher is currently difficult to obtain. Organized programs are necessary to correct this problem, and to begin training the academicians who will evolve and perpetuate this subspecialty of arts medicine. However, voice is only one of many fields in arts medicine, which share the same problems during this early stage of their development. It seems most desirable to address the educational problems of arts medicine as a whole, and to establish academic programs that coordinate the unique needs and strengths of voice, hand, dance, and other arts med- icine specialties under the broader vision of depart- ments or divisions of arts medicine.

REFERENCES

1. Nicholas JA. Risk factors, sports medicine and the orthope- dic system: an overview. J Sports Med 1975;3:243-59.

2. Journal o f Voice, published by Raven Press (New York, NY, U.S.A.).

3. Medical Problems o f Performing Artists, published by Han- ley & Belfus (New York, NY, U.S.A.).

4. Sataloff RT, Brandfonbrener A, Lederman RJ. Textbook o f performing arts medicine. New York: Raven Press, 1991.

Journal of Voice, Vol. 6, No. 1, 1992