Before performing their first virtual recital for an ICU patient, Houston Symphony musicians receive a four-page document providing detailed guidance on repertoire selection. Prohibitions abound: no pieces with “tumultuous climaxes” or “abundant staccatos”; no “heavy accentuation” or “extreme dynamic range”; no “overly contrapuntal complex/dense texture.” Vocal music is discouraged (“too activating/stimulating”), as are dance-inspired works like a polonaise or a rondo—unless the patient specifically asks for something lively. Best are pieces with tempos between sixty to ninety beats per minute, the range of the resting human heart. Suggested composers include Bach, Chopin, Massenet, and Mozart. Off-limits: tumultuous Bartók, stimulating Janáček, and the altogether too extreme Elliott Carter.

The guidelines were written by Dr. Mei Rui, an assistant professor of music-in-medicine at Houston Methodist hospital’s Center for Performing Arts Medicine. Born in China, Rui began piano lessons at the age of three, was accepted into the Shanghai Conservatory of Music at six, and gave her first solo recital—at Vienna’s Hofburg imperial palace, to an audience that included the Austrian president—at ten. In 2001 she turned down a full scholarship to Juilliard to attend Yale, where she continued her music studies while majoring in molecular biochemistry and biophysics. Ever since, she’s maintained a dual career as both concert pianist and research scientist, focusing on the health benefits of classical music.

Rui saw the COVID-19 pandemic as an opportunity to apply and advance her research. In March, to prevent the virus’s spread, hospitals across the country began imposing strict limits on outside visitors. While keeping them physically healthy, the isolation left patients cut off from family and friends, risking their mental health. Could live music help? “There’s real evidence of music’s therapeutic power, its impact on stress biomarkers like interleukin-6 and cortisol,” Rui says. “Even in very sedated or unconscious patients, classical music still has a very beneficial effect.”

Before the pandemic, Houston Symphony musicians regularly visited Methodist to perform recitals for patients and staff. But making those recitals virtual required some adjustment from all sides. The MUSICARE program launched in April, enlisting the services of both local musicians and classical music celebrities like Yo-Yo Ma and Emanuel Ax. To bring that music to ICUs, Rui helped design an iPad Pro rig that nurses take from room to room, setting it up next to a patient’s bed. (The rig can be clamped to a bed rail or stand up by itself.) Using FaceTime, nurses dial the musicians at their homes or studios, where they perform live for between fifteen and thirty minutes. If the patient is lucid, they might be asked what kind of music they prefer; if not, they’re treated to one of the preapproved composers. The program has served nearly four hundred patients so far. 

“I played to one patient who the nurse told me could understand, but couldn’t communicate,” recalls Houston Symphony violinist Christopher Neal. “I played for him for twenty minutes, and he ended up falling asleep, which apparently he was having a lot of trouble doing. I considered that a great, great compliment.” Cellist Brinton Averil Smith once played for a patient who used to be a jazz guitarist and was moved to tears by Smith’s performance. “Sometimes you think people aren’t really all there, and then you see that they’re crying, or you get some kind of emotional response,” Smith says. “It’s very intense, actually.”

Rui also provides the musicians with guidance on how to interact with patients. On no account, for instance, should they ask how the patient is doing. (“Probably not very great.”) Performers must be prepared for a range of medical interruptions, and for the ICU’s ambient cacophony of beeps, buzzes, and alarms. For their part, musicians should strive to avoid the usual work-from-home distractions—screaming children, barking dogs, and the like. “It takes a certain kind of musician to do this sort of work,” explained Houston Symphony executive director John Mangum. “Some are more suited to it than others.”

Through trial and error, the participating musicians have come to their own conclusions about what music works best. Rui leans on Chopin sonatas, while Neal and Smith hew mostly to Bach. “If you think of Tchaikovsky or Chopin, it’s beautiful stuff but in some ways it’s more decorative,” Neal says. “There’s something so simple and so profound about Bach. He was thinking very spiritually in the way he wrote all of his compositions.”

Many of Methodist’s patients have agreed to be part of a study Rui is conducting on how different kinds of classical music affect medical recovery. Studies have shown that slow-tempo music decreases stress in mechanically ventilated patients, and that such music can save $2,322 per patient in ICU medical expenses. But little research has been done on which composers and styles are most efficacious. Rui’s interdisciplinary team plans to use actigraphy watches, which monitor a person’s sleep cycles, along with blood draws to measure the effect of particular pieces on patients’ vital signs. “This field could be interpreted as pseudo-medicine,” she acknowledges, “but that’s what I’m trying to change by providing quantitative, replicable data.”

Todd Frazier, the director of Methodist’s Center for Performing Arts Medicine, which partners with the Houston Symphony, Houston Ballet, Houston Grand Opera, and other performing arts organizations, was initially skeptical about Rui’s research. “I thought it might distract us from the more humanitarian side of what we were doing,” he says. “But then I realized that all these vital signs are already being taken and recorded twenty-four hours a day, so those biological assessments really wouldn’t be anything extra that the patient would have to do.”

Patients aren’t the only ones to receive the benefit of the virtual performances—nurses, doctors, and other hospital staff, who are themselves dealing with extreme stress during the pandemic, occasionally listen in on the recitals. Sometimes the iPad will be set up in one of the nurses’ break rooms, and the musician will take requests. “They’ll ask for a piece by Prince, or something they can sing along to,” Frazier says. “The music parameters are kind of loosened up for that.”