Musings & Meditations on the intersections between clinical care and audiophilia.

The "Monastery" of Petra (Jordan); carved out probably around 1st Century CE. Harder to get to, but I thought this was just as awe inspiring as the "Treasury" made famous in "Indiana Jones and the Last Crusade".

In the last month, I had the pleasure of travelling through Jordan and Israel. As I pondered on some of the sights and sounds of the ancient civilizations, I wondered among other things, perhaps not surprisingly, on the audiophile pursuit for the purposes on this blog. :-)

Regardless of culture, we as humans share the same universal hopes, fears, and desires as we carve out a place in this world for our families and ourselves. Whether it's with a street vendor in Amman or some guy in a Shanghai night market, haggling over the best price for a souvenir T-shirt is essentially the same process. Nobody wants a bad deal, or items below expected quality.

We can discuss academically about the mechanisms of price discovery, study the complex verbal and nonverbal negotiation techniques, or explore macroeconomic determinants of supply and demand. Whether it’s getting a decent T-shirt or purchasing "high-fidelity" audio products, as consumers, value is always a core consideration as I've discussed many times over the years as a recurring theme (including here, here and here).

Coincidentally, a few weeks prior to leaving on vacation, I had a discussion on Audiophile Style with Andrew Quint who writes for The Absolute Sound. Like him, I work as a doctor and engage in the art and science of clinical care of and with people every day while pursuing the audiophile hobby in my free time. Over the years, I have virtually met some of you on forums and through E-mails also coming from clinical backgrounds whether as pharmacist, psychologists, therapists, nurses, etc. This article germinated during my travels as I thought about the complexity of clinical care and likewise some of the complexities that arise in audiophile discussions. Thankfully, related themes are nowhere as complicated or potentially perilous for us audiophiles and the epistemological debates among us seem safely parabolical of more significant ideological differences beyond just this little hobby sandbox

Since clinical care is a huge topic, permit me to talk somewhat loosely about some points of intersection since I think these factors have affected my attitudes toward the audiophile hobby and informed the judgments I make when reviewing products contained in these pages. These ideas may resonate with your own thinking as an audiophile.

(Along the way in this article, let me show you some pictures I took during the vacation!)

Timna Valley, Israel - mineral deposits site (especially copper) of the ancient Bronze Age - since 6th-5th millennium BCE.

I. Idiosyncrasies and diversity of character

While overseas, the old joke about "2 Jews, 3 opinions" came up a number of times but always with respect that divisions among us are to be expected and debates need not degrade into ad hominem attacks. While extreme positions like beliefs in conspiracy theories, gross misinformation on social media of various forms, or the political divides we see expressed and magnified in media are common, most of the time, and with most topics, I trust we agree with each other much more than differ, and most disagreements in normal life are trivial.

What I have found amazing after more than 20 years of work in clinical medicine is how humans can maintain sometimes highly incongruent ideas. A person can come across as seemingly logical throughout an interview until certain topics are brought up, subsequently opening up islands of unusual, inconsistent beliefs that deviate in devastatingly odd ways against all that was spoken and even agreed on prior to that point.

Thankfully, even unusual ideas can still remain within the broad spectrum of niche culturally acceptable or at least understandable beliefs. I love working with people, so exploring that diversity of beliefs and viewpoints (generally) can be a lot of fun and often will add to insights in my own life. Most people also can tolerate a bit of prodding and challenging as well.

I think most clinicians can appreciate those with unusual beliefs without great difficulty most of the time. What is more troublesome to deal with unfortunately are disagreeable characters. Those with abrasive egos who refuse to communicate openly, seemingly have no curiosity to learn/change, unable to debate without getting offended, those who stubbornly hold on to indefensible positions as common examples we might see in audio forums. [I am reminded of a classic paper from 1978 from Groves on "Taking Care of the Hateful Patient" when thinking of those with severe characterological disorders in clinical settings.]

Over the years, admittedly as a clinician, I have learned to appreciate the presence of other strengths in most individuals even if I might have experienced initial negative countertransference feelings. In fact, studying people - these “characters” – has become one of the most fascinating part of the job experience. Learning to deal with certain characters is an art often poorly taught in medical school and plays a huge part in the “bedside manner” of clinical work. There's no shame in admitting that this is an art form that’ll take a lifetime to master - if even possible!

Reflecting on this in the audiophile realm, I think we have seen some rather interesting “egos” in audiophilia over the years, the names of whom I will refrain from mentioning here. I suspect sometimes what comes across in articles or on videos are just personas maintained as part of the roles some have to play (for example, reviewers who basically act as sponsored advertising spokespersons for companies to derive their income). As discussed previously, there are also broader psychological factors and philosophies at play in the audiophile industry we need to be mindful of. 

Dome of the Rock at dusk. Jerusalem, Israel. Built and rebuilt since ~690 CE.

While difficult to change, like in any good novel or biography, it’s nice to see when character growth happens. True maturity I believe finds a person achieving balance in his thoughts and temperaments over time.

“The first principle is that you must not fool yourself - and you are the easiest person to fool."

-- Richard Feynman (Caltech Commencement, 1974)

Character traits play a pivotal role in subjective evaluations. This is important when we talk about “hi-fi” and the countless subjective opinions we read, watch or listen to. With today’s technology where sonic differences are often tiny, I believe the mature audiophile needs to integrate knowledge of his own perceptual and cognitive limits and watches his ego when expressing opinions. I think most audiophiles appreciate the truth that qualitative differences of the ephemeral audio experience are more likely than not modest between most “hi-fi” products and should be likewise expressed without dramatics for the most part save for those times when one is truly surprised to hear distorted sound. I have certainly heard some rather poor sounding yet very expensive - supposedly "hi-fi" - devices that have been reviewed highly over the years; surely if we were to measure those devices, the results would be poor.

Square Bucks coffee, anyone? I saw a number of these scattered throughout Bethlehem in the West Bank so I assume the coffee must be good and with adequate air conditioning on hot days. ;-)

II. Power of placebo

Seasoned clinicians appreciate the "ritual" power of the placebo effect. It’s strong but the effect’s outcome varies depending on the situation. In acute care when we’re dealing with urgent conditions, psychological benefits of placebo would be doubtful. However, these days as medical care has improved, with average life expectancy around 80 years in many developed nations, we are increasingly dealing with chronic medical conditions and not aiming for a “cure”. Maintenance of optimal functioning, reduction of pain and other distress to improve the subjective quality of life, becomes the primary goal. It is here particularly that the placebo effect can be highly significant.

While there are clear ethical issues with prescribing a placebo pill without consent (these days there are also "open label placebo" studies that overcome this issue), clinicians know when we see such conditions with strong psychological overlay that there are ways to utilize the benefits of that effect. So long as treatments are not financially difficult for patients and are unlikely to cause harm, it’s common that doing so will result in clinical improvement even if the hard science doesn’t give us clear evidence of very significant efficacy.

Sea of Galilee (aka Lake Tiberias), Israel. Tourist boat seen.

Many patients these days want to try “natural” remedies and supplements instead of pharmaceuticals, and for me that’s fine. In fact, since we often will run into conditions with strong psychological elements, I actually recommend that patients try what they have “faith” in first and if that fails, then come back and we can look at medical options. Again, so long as the proposed non-scientifically proven treatment remains inexpensive and would not result in physiological harm. The patient’s engagement in self-agency with a treatment he has faith in, even if the treatment is unlikely to be physiologically potent can be potentially beneficial.

Last year, I touched on this as a response to the ridiculous article in Stereophile talking about lyme disease referencing unscientific and expensive therapies I think are scams and unethical to be promoting.

This recognition of the placebo effect is why in medicine, we demand that research be done rigorously. Why studies are assessed based on the strength of the methodology in order to make “Level 1” recommendations with the “gold standard” based on placebo-controlled, double-blinded designs of adequate power where both patients and clinicians are unaware if the treatment is an active agent or placebo.

I know, as audiophiles, we are interested in experiencing “fun” or aiming to deepen our sense of “joy” in musical (or just plain sonic) experiences. Some extreme subjective writers emphasize this and disparage the “boring”, “academic”, “intellectual”, parts of audio device evaluation and design as if disciplined evaluations do not apply to the hobby. Of course, this is nonsense!

To disparage the importance of employing the scientific method in clinical medicine is regressive. We must maintain a distinction between scientifically verified treatments from the claims of quacks, shamans and witch doctors. In the same way, an audio reviewer should be able to distinguish companies engaged actively in building devices with good R&D as opposed to opportunistic snake-oil salesmen and their companies.

Nehushtan - Serpentine Cross - Memorial Church of Moses, Mt. Nebo, Jordan

While I think we should be open to understanding and testing the hypotheses in indigenous health practices and “complementary” care, we must obviously realize that traditional health knowledge, many thousands of years old, did not improve life expectancy to what we enjoy in the developed world these days. For examples, estimates of life expectancy among indigenous New World inhabitants was somewhere around 35-40 years prior to the arrival of Europeans. This was about the same even to the mid-1800's until the recognition of Pasteur and Koch's “Germ Theory” for causality of illness by the late 1800's. Since then, life expectancy has improved markedly thanks to the scientific method applied to good general sanitation and in medicine (including simply using aseptic techniques):

Statista Source.

Not surprisingly, "complementary", "naturopathic", and "homeopathic" remedies are best reserved for chronic conditions most amendable to the power of placebo.

So it is with much of audiophilia. I applaud companies that develop new and better ways of pushing the frontiers of high-fidelity production and playback. Ethical clinicians would not want to see patients being taken advantage of, spending thousands of dollars on inefficacious remedies - I’ve seen families literally bankrupted with bills spent on questionable treatments. In a universal health care system like here in Canada, there is a duty to be responsible with public tax dollars when tests and prescriptions are written that they be beneficial and efficacious. In the same way, I hope audiophile reviewers, influencers, and publications can recognize the importance of seeking evidence and speaking truth about the things that make no fidelity differences especially when some of these snake-oil products demand high MSRPs as a matter of conscience.

Furthermore, I believe that knowingly promoting “faith” whether in questionable treatments or ineffective products will actually “do harm” because this will award questionable companies, potentially disincentivizing those that are doing good work, and miseducates the consumer. Especially in medicine, this could result in "opportunity costs" such as wasting time and delaying urgent treatments (eg. for cancer) while the patient tries things like "psychic surgery" and other such quackery.

St. Jerome - Church of the Nativity (originally built ~325 CE) in
Bethlehem, West Bank, Palestine.

III. Science with art

While there are elements of science in clinical care (demonstrable effects beyond placebo), let me be clear that much of the work of a clinician is subjective, artistic, and appeals to the emotional needs of patients.

There is art in those “bedside manners”: calming anxieties, projecting confidence, communicating in respectful ways, demonstrating care, etc. mixed into the science of medicine which allows us to understand pathology, use diagnostic techniques, and plan treatments. The science part is primarily built on objective empirical measurements of disease, controlled treatment trials, and longitudinal quantification of treatment progress.

I agree with the subjectivists that the ultimate goal of the hardware audiophile is that of enjoying the sound systems we build. Obviously, we must inherently acknowledge the emotional aspects of this hobby. Beyond the sound quality, there is also beauty in the design of those boxes we buy. Speakers in a room add to the ambiance of the space and can be just as much a statement piece as a beautiful grand piano in a living room. Appearances, brand names, pride of ownership - all are legitimate subjective "non-utilitarian" reasons to buy whatever audio products we want.

Caesarea Maritima - ruins from the time of Herod The Great ~20-10 BCE. Caesarea, Israel.

Like the clinician with an understanding of the science behind diseases/disorders, as hardware audiophiles, we need to remember also that historically, we achieved “good sound” based on the ideal of high-fidelity playback, true to the source material. The accuracy of devices can be measured. Our perceptual limits can be tested either corporately (like say the recent 16-bit vs. 24-bit blind test) or individually. And the sound quality achieved by the system can be measured in the room we listen in, not just measurements of individual components.

Between art and science, I would argue for the primacy of science for the hardware audiophile pursuit. Just as without science there would not have been the significant increase in life expectancy since the late 1800s in the graph above, there would really be no such thing as "high fidelity" technology without science for audiophiles even though the primary gain ultimately is the expression of music as art. Acknowledging that we must find a balance between science and art does not imply that they're exactly equivalent. Sometimes, science is what we must appeal to primarily, other times it might be more artistic, more subjective especially once we've reached a state where the sound quality is beyond the threshold of "good enough" for music enjoyment.

Be careful of the people who claim measurements don’t correlate to how something sounds. In my experience it generally does. But again, only to a certain extent depending on the quality of our rooms, the ambient noise level, and our hearing abilities - the confluence of factors that tells us we've achieved a "good enough" threshold. (Most of the time, the more important question is "Which measurements matter?".)

Oh yeah, as in clinical medicine, for many conditions, there’s no need to spend excess money if less expensive generic options achieve the same effect as newer or fancy brand name meds. Sure, idiosyncrasies like sensitivity to side effects or allergic reactions could happen, but typically, drug effects are predictable and measurements will correlate with treatment efficacy (whether it be change in blood pressure, reduction in tumor size, nerve conduction efficiency, cognitive improvement, etc.). So too the sound quality between expensive and much less expensive brands. There's nothing wrong with spending more money on high quality parts, beautiful enclosures, impressive brand names; hopefully this correlates at least with better reliability and excellent sound quality. But if objectively there are no measurable differences, and there is no evidence using blind listening tests of audible superiority, make sure to take that into consideration as audiophiles assessing value.

One more thing before moving on. Socioeconomic status is often not an issue for many audiophiles. Speakers, DACs, amps marketed at ever-increasing, sky-high, MSRPs to me seem foolish to "invest" in if there are no verifiable utilitarian sonic benefits regardless of one's net worth. Sure, one can purchase nice looking luxury speakers to grace the mansion if that's what one wants, but usually, I don't think audiophile hobbyists are primarily focused on appearances as the reason to buy something. When we watch shows like Dragons' Den (or the American Shark Tank), do millionaires and billionaires just throw money at anything or do they come across as shrewd investors? ;-)

Some devices like DACs for example, IMO, can be easily tested. I honestly see no benefit in say a US$20k DAC when clearly something at $1k often bests those objectively and provides customizations like filter settings already if you want to vary the subjective sonics (see discussions on "perceptibly perfect"). Furthermore, the savvy audiophile can do all kinds of other things like use HQPlayer or implement room DSP for further tweaking. Price is not the issue if there are simply no utilitarian benefits for the "investment" and there's no need to feel envy for another audiophile who owns a very expensive product if it makes him/her happy.

An early morning view of the Dead Sea, Israel.

IV. Necessity of expressing judgments

I recently saw this IMO unwise Michael Lavorgna article. Notice the way he villainizes those he deems to be “hifi extremists”. He’s concerned about the “level of certainty coupled with bullying bravado” expressed by some - about what exactly, or who he's talking about is unknown. While I don’t think there’s ever a need for “bravado”, he seems a bit sensitive and insecure in that post.

As a pure (extreme?) subjectivist, he apparently has no clear foundation of knowledge to build a cogent argument upon in that article. What’s wrong with accepting that some people like a certain level of distortion if that's the charge (this is probably true for tube amps)? What’s wrong even with accepting that some might prefer the subtle effects of “lossy” encoding (for example we saw a preference in MP3 blind testing for the lossy heavy metal track)?

This is why ultimately, his summary that (emphasis mine):

“There is no wrong way to listen to music on the hifi because it’s a personal matter.” 

might sound nice superficially, but it’s a meaningless statement because:

1. I don’t think many of us care what “way” anyone else chooses to listen to music (be it vinyl, CD, streaming, or whatever hardware you use).

2. He seems to have thrown the word “hifi” in there forgetting what it actually means! Is he still referring to “high fidelity”? Because if so, then there are core technical implications that transcend just “personal matter”. If I personally like the sound of music played through a cheap AM radio, does that make the radio "hifi"? I don't think so. 

I use this Lavorgna article out of convenience, but he's just one of many audiophile reviewers out there we can point to who appear to be making very superficial comments (and superficial articles) as if hi-fi is just based on personal feelings. It's also a comfortable position to take because he doesn't make any judgments and I guess this makes people feel good; not "bullied" or anything horrible like that. (A lot of people seem "triggered" these days, eh?)

In clinical care, while it’s important to be nice to people and show respect to inherent basic rights we all should enjoy, there are times we need to be blunt, to point out errors, to challenge incorrect opinions, to advise against unwise courses of action. Expressing disagreement with some people can get unpleasant, but must be done if we are to show care for others. To not express disagreement around potentially serious matters is literally a dereliction of duty; a form of malpractice even if the patient might not appreciate the gesture.

"I attack ideas. I don't attack people. And some very good people have some very bad ideas."

-- Antonin Scalia (2008 interview)

In general, it’s good to be nice. However, it’s unlikely that universal niceness equates to adequate honesty. Assertiveness, while remaining open to listening and engaging with the arguments of others, is not bullying. I hope individuals like Lavorgna can learn to appreciate that.

Jerusalem - Temple Mount, Dome of the Rock. From Mount of Olives.

In Closing...

"Wisdom is not a product of schooling but of the lifelong attempt to acquire it."

-- Albert Einstein (1954)

While my writings here over the years have been highly critical of audiophile magazines, reviewers, and portions of the Industry, I trust the words have not come from a place of mean-spirited animosity. As linked at the start of this article, I discussed the contentious (ahem… bankrupt) MQA with Andrew Quint of TAS and I don’t think there were any hard feelings between Andrew and myself by the end of that exchange. As a general principle, I think it's good not to hang on to interpersonal negativity as much as possible even if we do have to be assertive in our comments. There are enough stressors in daily life and there's no need to add anything else when enjoying a hobby!

Like in clinical care, if we can understand the diversity of opinions even if we might not agree with them, the power of psychological processes (like the placebo effect), and apply a balance of science with appreciation of the art not just in audiophilia, but also in many other areas of life, we probable will be a step closer to being wiser men and women. It might seem ironic given the reputation audiophiles have among hobbyists, but I do think that among our quarrels and battles, we can elevate each other using these conflicts for a higher level of enlightenment as this hobby evolves.

The Internet has expanded free speech and access to information in ways unfathomable to previous generations. As with all technologies, there will be positive and negative sides to it. Widespread claims and statements of mistruths certainly when it comes to opinions in health care are rampant especially through social media; these are much more dangerous than the irrational beliefs of audiophilia. Whether one is a knowledgeable, experienced professional in some field or serious audiophile, there's no need to be meek if one has evidence to back up one's beliefs as this is the only way to promote truths within the free marketplace of ideas in cyberspace.

Church of the Holy Sepulchre, Jerusalem. First sanctuary on this site from 4th Century CE as per Constantine.

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Flag at half mast: National day of mourning (Tuesday April 25, 2023) -
before the 75th Anniversary of the State of Israel.
Prayers at the Western Wall behind, remnant of the Second Temple up to 70 CE.

Thanks to those who submitted responses to both the recent "SURVEY: What audio playback system and/or streaming music service are you using in 2023?" and "Internet Blind Test: 24-Bit vs. Dithered 16-Bit Part Deux - Daft Punk Edition!".

Just in case there are any last minute stragglers, I'll keep the posts open for final submissions for a couple more days since I have to catch up on work and other duties anyways. Definitely last chance to be counted.

Back to home sweet home, friends. ;-)

Beautiful British Columbia, Canada. Sunset over Horseshoe Bay, looking north.