MAASTRICHT, February 19th 2019 – Tinkering is a practice which underlies most medical endeavors, from celebrated inventions such as the stethoscope – which began as a rolled up paper tube and through some experiments on a lathe, soon developed more into the instrument we know today – to everyday work of clinicians in clinics and hospitals. Annemarie Mol, Ingunn Moser, and Jeannette Pols edited a beautiful book on this topic called Care in Practice: On Tinkering in Clinics, Homes and Farms. Clinicians and technologists have teamed together in non-profit organisations like MakerHealth, to celebrate the tinkering work of hospital staff. In the movie The English Surgeon, you can find the neurosurgeon Henry Marsh at work in his workshop, as well as in the operating theatre. In fact, you just have to read any obituary about a medical innovator to learn about the tinkering work that made them famous. Yet amidst all of this talk there is very little about the tinkering of teachers in medicine, and the creativity that goes into their daily educational practices. As I have written before in an article published from this project, the improvisation of teachers is often unspoken of. So when an invitation came from my fieldsite in Maastricht, to hold a workshop for teachers, I thought there was no better topic and expertise to share, than the very creative expertise in the room.
In preparation for the workshop designed to explore the creative possibilities for how to teach physical examination skills, I asked participants to think about the homemade tools they had adapted, copied, invented, used in teaching, or heard of others using, and come with these ideas to share (or bring along). Optionally they could bring some materials to work with, and read an article.
Valentine, the student assistant on this project, and I ran the workshop for the 20 or so teachers who enrolled, arriving at the Skills Lab laden with the materials we had brought. First, I contextualised the theme within the findings of the Making Clinical Sense project and some of the theories and methodologies underpinning the day’s activities – work on critical making, everyday design, creative learning, ethnography and tinkering for example. We emphasized that the workshop was about attending closely to materials, and the creative possibilities of working closely with them. Teachers were sitting around tables piled with balls of wool, plasticine, Fimo, paper, glue, scissors, balloons, pipe-cleaners, balls and elastic bands. Our role was not to teach the teachers anything, but rather to learn from and with them, and basically just allow the time and space for tinkering in their busy work schedules.
Then the teachers shared ideas with each other: how one teacher starts his class on heart murmurs by slamming the door shut, now the mitral valve, and getting the students to imagine they are standing in a ventricle of the heart – he also rubbed his shoes together to simulate the squeaking of pleural rub; how another would pretend to be an atrial arrhythmia with her body – funny another responded, I am a uterus with fimbrae, she said, both standing up and shaking their limbs. Someone had brought in a homemade model of the various angles of the uterus, and another teacher described how she used a balloon to teach ascites, by filling it with water. They discussed how the students paid attention in a different way when they experimented with these methods.
With all this talk of ideas, it was definitely time to work with the materials on the tables and it wasn’t long before the glue gun was being warmed and plasticine being molded in hands. There were some instructions – make a body part to use in teaching physical examination skills, draw a poster to show a skill, make oranges to resemble stages of cervical dilation – but these were soon discarded by most teachers. Balloons were blown up and filled with water to copy the ascites figure, one bursting over all the instructions. Balloons were filled with plasticine to show pitting edema. A series of balloons made a chart of scrotal pathologies for palpation and comparison. Styrofoam balls were turned into eyeballs, with elastics on either side making the muscles of the eye, and little felt tags on fingers showing which cranial nerves pulled them. The inguinal region was made using bits of cardboard and plastic bags. A box holding some of my materials was upturned to allow room for a balloon and scrunched up felt, to practice comparative percussion. Two socks were turned into scrotum by being stitched together, so that they could be pulled for examination.
After an hour of making the medical teachers put their projects on a table and took turns guessing what they might be, with much laughter. They looked at the objects, picked them up and tried to move them. Some textures were surprisingly similar to the body part being simulated – the pitting edema for example – whereas others were poor imitations – the crinkly cardboard. Teachers who had crafted the objects explained why they made them – to try and teach a complicated part of anatomy, like the inguinal region, or complicated neurological processes, like the cranial nerves. There were many models of male genitalia which is of no surprise, considering this is a very tricky examination for the students, and one which currently they do not have very good models for. The teachers observed when existing models might do better, that the tool they just crafted was too complicated, unnecessary, too distracting or the scale wasn’t right. Sometimes they wondered how they might make another version, from different materials. They talked about how sometimes it was the problem that came first, when designing their object, and sometimes they just worked with what materials were to hand. They also wondered what the students might be making themselves?
As education strives for efficiency, standardisation and assessibility, more room is needed for making, every day design and tinkering in medical education. Such activities are not reactions against the digital but can also inform digital technologies in the classroom. It was a privilege to be able to spend a morning working with incredibly knowledgable and inspiring teachers, who make time for tinkering, not only in designated workshops.
Images from the pattern in the Wellcome Library, see more here: http://blog.wellcomelibrary.org/2015/06/how-to-make-a-knitted-uterus-for-teaching/
And for an inspiring essay on winter knitting, read Barbara Kingsolver’s piece here. In the spirit of our interest in materials and their sensuality, I have pasted her thoughts on texture below:
“It starts with a texture. There are nowhere near enough words for this, but fingers can sing whole arpeggios at a touch. Textures have their family trees: cloud and thistledown are cousin to catpelt and earlobe and infantscalp. Petal is also a texture, and limepeel and nickelback and nettle and five-o’clock-shadow and sandstone and ash and soap and slither. Drape is the child of loft and crimp; wool is a stalwart crone who remembers everything, while emptyhead white-haired cotton forgets. And in spite of their various natures, all these strings can be lured to sit down together and play a fiber concerto whole in the cloth. The virgin fleece of an April lamb can be blended and spun with the fleece of a fat blue hare or a twist of flax, anything, you name it, silkworm floss or twiny bamboo. Creatures never known to converse in nature can be introduced and then married right on the spot. The spindle is your altar, you are the matchmaker, steady on the treadle, fingers plying the helices of a beast and its unlikely kin, animal and vegetable, devising your new and surprisingly peaceable kingdoms. Fingers can coax and read and speak, they have their own secret libraries and illicit affairs and conventions. Twined into the wool of a hearty ewe on shearing day, hands can read the history of her winter: how many snows, how barren or sweet her mangers. For best results, stand in the pasture and throw your arms around her.”
July 2nd 2018, MAASTRICHT – It was a beautiful bike ride through the Dutch forests, and for the first time that year we needed sunscreen. We were heading to the Brunssum Blote Voeten Park, a barefoot trail not far from our Faculty, Carla our wayfinding guide.
We started along the trail, shoes left in lockers, chatting and catching up on months apart, finding out about fieldwork adventures, new ideas, holidays. It was easy to get lots in conversation but the trail soon called us to attention. Smooth sand disappeared into woodchips, causing our toes to curl up a little. Soon a muddy trough greeted us, and tentatively we waded, sensing how far we could descend into the cool water, hands out for support. We climbed wooden beams like children, and looked over the park from up high. Down below we could see fellow barefooters inspecting splinters in their usually shoed feet, soft from years of woollen and cotton socks and slippers.
In his much cited article “Culture on the Ground”, Tim Ingold (2004) suggests there has been a bias in scholarship for head over heels and that we need a more grounded approach to human movement that is sensitive to the embodied skills of footwork. Shoes, he suggests, like chairs, are a technology which privilees the intellect over instinct. Ingold argues that:
“The mechanization of footwork was part and parcel of a wider suite of changes that accompanied the onset of modernity – in modalities of travel and transport, in the education of posture and gesture, in the evaluation of the senses, and in the architecture of the built environment – all of which conspired to lend practical and experiential weight to an imagined separation between the activities of a mind at rest and a body in transit, between cognition and locomotion, and between the space of social and cultural life and the ground upon which that life is materially enacted.” (2004, p 321)
While my young son can still squat comfortably, he has quickly adopted shoe wearing as habit as he learns to traverse the cobblestone streets of Maastricht. The first time he encountered grass he begged to be picked up, the first time in sand he tried to flick it off. We become shoe-bound so quickly that it opens up a gap in the market for footwork retraining. Barefoot trails offer the senseless feet of urban dwellers the chance to rediscover mud and woodchips and splinters all over again. The training is not through a guide or signposts but through subtle drawing of attention to change – visitors to such parks are guided by rails, by abrupt differences, by needing to climb or descend. The differences need to be obvious for the rusty foot feeler doesn’t notice subtlety.
We came back from our barefoot trail with our feet tingling. The walk was not only a perfect way to reconnect as a group, but also to disrupt our sensory habits, just for an afternoon.
Image by bark (Flickr), used under the Creative Commons lisence.
During our fieldwork, we all wrote postcards to each other and other members of their research team. The postcards document observations, ideas, dilemmas, puzzles and everyday happenings. They could only ever be thumbnail sketches– a moment or thought caught, a question that arose or a short greeting. But as we have learned in our project, from studying how doctors learn physical examination skills, there is a world of information in a thumbnail.
Through this form of “correspondence thinking”, to paraphrase Tim Ingold (2015, p154), our ethnographies are being crafted not only through individual participant observation with medical students and teachers, but also from lines threading across Budapest, Tamale and Maastricht. Ideas that we circulate on the postcards are becoming important themes in our research. Thoughts, reread weeks later, resonate with our current fieldwork in surprising ways.
Postcards are not the only way we correspond as a research team – we also use Skype, WhatsApp, email and Google Docs. However there is something particularly direct and sensuous about our fieldsites that we can convey in the postcards, in the handwritten vignette. They certainly lack in space for the drawn-out field reflections of the kind that Allaine Cerwonka and Liisa Malkki (2007) engaged in, nonetheless, the postcards help facilitate “an immersion into the ethnographic imaginations of others in [our] team” (Harris, Wojcik and Allison, under review).
Unlike in the best-selling postcard romance from the 1990s, Griffin and Sabine, where the postcard writers seem to exist in parallel and never crossing realities, we all have gathered together again in Maastricht, where our research is based. We bring our own fieldwork to the conversation, but they will not be completely new places, for we have had each other’s postcards on our desks and noticeboards, thumbnails and sketches of these other worlds.
Cerwonka, A and Malkki, L (2007) Improvising Theory: Process and Temporality in Ethnographic Fieldwork . Chicago and London, University of Chicago Press.
Ingold, T (2015) Life of Lines. London, Routledge.
Pandian, A. and S. McLean (Eds) (2017) Crumpled Paper Boat: Experiments in Ethnographic Writing. Durham and London, Duke University Press.
“Teachers also need to be creative when they teach clinical skills such as physical examination. They need to find imaginative ways to describe instructions expressively in protocols and then to improvise with these scripts in class in order to share expertise with students. Yet such practices often go unnoticed in medical education; they are taken-for-granted aspects of teaching and learning.”
I explore these practices with my co-author Jan-Joost Rethans in an article published this week in Perspectives on Medical Education. Entitled “Expressive instructions: ethnographic insights into the creativity and improvisation entailed in teaching physical skills to medical students”, the article, quoted above, draws from my fieldwork this year, as well as my fieldwork in the Sonic Skills project, several years ago. Working with Jan-Joost we draw out some of the themes of creativity and improvisation witnessed in teaching.
Teaching clinical skills in the theatre of medicine”, which expands upon the expertise required in improvisation. As they write, “novice teachers can read a script (clinical textbook content), but expert teachers deliver a script with sincerity that engages an audience and captures their imagination … a recipe book can instruct how to make a dish, but an expert teacher can provide room for creativeness and experimentation to produce a Michelin star meal.”
MAASTRICHT, July 9 – 12th 2018 – Written correspondence takes so many different material forms today, digital and non-digital, and it was precisely this variability in form that we wanted to play with in our first project workshop, July 9th-12th. How is a workshop conversation shaped not only by the verbal discussions that take place during the event, over lingering breakfasts, cooking classes, walking seminars and four-course dinners, but also the written correspondences crafted around it?
Workshopping, as the philosophers Ludger van Dijk and Erik Rietveld reminded us last week, is a situated event that extends temporally and materially. Our workshop invitations were sent early this year, on paper bought at a local newsagency, made at a Belgian paper mill. The RSVPs came back in the form of postcards, each with a different instructional teaching poster printed on one side.
In the lead-up to our workshop last week, over the last weeks and months, we continued the conversation by Skype, FaceTime, telephone, twitter and many many emails. At the workshop itself, participants received a pack with writing paper and a pre-stamped postcard. There was a letterbox for sending mail out.
Each of these forms of correspondence intersected and created not only different spaces for communication but also shaped the communication we had. Conversations co-existed in different temporal realms – an invitation in the post punctuated by emails, a postcard sent out after the WhatsApp message arrived. If we attend to the medium as message, the materiality of our correspondences takes on heightened importance. A love letter sent by pneumatic tube is different from an email written at a office desk, different from a tweet thumbed at the airport, or a postcard written in the sun.
When I was a high school student, there was a university mathematics professor who sent problems to some students around the city where I lived in the mail, photocopied equations which we were to fill out and send back to him. They would soon be returned to us marked up in red pen. We learned maths by correspondence, the teaching and learning a back and forth sent in the mail.
Members of the Making Clinical Sense team used the postal system to correspond about our developing ideas too. Seven of us in a combination of different cities for most of the last academic year, we sent each other postcards often, most arriving, some getting lost in transit, or stuck to other cards, arriving at destinations unthought of. We will be writing more about these postcards on this logbook and these cards will be displayed at the upcoming European Anthropology EASA 2018 conference in Stockholm as part of a project exploring the role of postcards in ethnographic research.
We ourselves still have to explore what it means to workshop, learn, teach, research and collaborate through different forms of correspondence; what different material forms allow space for; what it might to take seriously the message as medium; how written threads take meandering paths, intersecting and branching off as they connect and go off in their own directions.
Notes for a workshop exercise in probing comparison
1. Ask students to form groups of three
2. Each group is given a set of blank postcards.
3. Ask each group to take one postcard and write some keywords or phrases concerning their research interests: e.g. place, senses, belonging etc. They are instructed that this will help another group frame a probing activity for them that is relevant to their interests. [5 mins]
4. Groups swap their topic lists.
Each group now takes another blank postcard and writes a “probe” for the group whose topic list they have, a probe that helps the group interrogate one or more aspects of their topical interests. If this is too difficult, then another stimulating probe activity can be crafted. [15 mins]
The concept of a probe will have been explained in the talk – also examples will be given from my project’s team, of our probing activities – the instructions for the activities we did will also be printed out and available to students while they are brainstorming, if they would like sources of inspiration – also available will be the Dear Data book, and Learning to Love You More, both books having inspired our activities, and which have loads of examples)
5. The rules for the probe are as follows
- Must be possible to do within the space of the workshop grounds
- Must be achievable within half an hour
- Results must be, at least partially, able to be recorded on a postcard
6. Give the postcard with the probe activity written on it back to the other group, along with their topic list.
7. Each group reads their assigned probe and then the group of three splits, so that each person in the group does the probe activity individually, by themselves [30 mins]
8. The group reconvenes and compares their findings, first in the group of three. Group discusses together what they find interesting and insightful in comparing their findings, tacking their postcards (topic list, probe description and any relevant findings) to a large sheet of paper and drawing analytical threads where relevant [30 mins]
9. Each group presents their comparative work to the others [30 mins]
10. Group discussion about activity, focusing on comparative possibilities and limitations of methodology
Last month in our local university paper, The Observant, Thomas Fuller (my husband), describes being involved in a similar trick. He has a wonderful white tattoo of the river Thames, which snakes around his torso. Because of how his skin reacted to the white ink, it is raised a little. When he went for a dermatology check up the doctor saw the potential differential diagnosis immediately. For it also looked like it could be a parasite, winding its way under the skin. So one medical student after another was brought in to ask Thomas questions and to try and diagnosis the mysterious marking on the skin. Not one of them guessed it was a tattoo. It was a trick, designed to help hone the students’ skills of observation and diagnosis.
But tricks aren’t always useful. I interviewed one of the teachers in my fieldsite recently who designs the Multiple Choice Exams for the medical students. He said that the aim of the test is not to trick the student, but rather to help them learn. Being tricked doesn’t tell you much about what someone has learned. He designs the questions so that the students are both being examined, and learning something at the same time, through the range of options they have available. We have much more to examine from this interview, but my initial impression was sheer amazement at how much work went into designing the multiple choice tests, work I completely took for granted (like much of my teaching), when I was a medical student.