In praise of seamsCAIPE Annual General Meeting

21 June 2012

As soon as certain topics are raised, the concrete melts into the abstract and no one seems able to think in turns of speech that are not hackneyed: prose consists less and less of words chosen for the sake of their meaning, and more and more of phrases tacked together like the sections of a prefabricated henhouse.

Orwell G. Politics and the English Language. In The Collected Essays, Journalism and Letters 1945-

1950.

epistemology+

ontologyDella Fish

what you know

+who you are

Della Fish

Transactional care

•Patient is cared for•Focus on efficiency and effectiveness

•Predetermined protocols•Reflection on facts and figures

Relational care•Patient is cared about•Focus on quality of the moment

•Emergent creativity•Reflection on feelings and ethics

… its fierce ethic of personal responsibility for errors is a formidable virtue. No matter what measures are taken, doctors will sometimes falter, and it isn’t reasonable to ask that we achieve perfection. What is reasonable is that we never cease to aim for it.

Gawande A.Complications: a surgeon’s notes on an

imperfect science, 2002.

… we are interested in not only the professional’s visible behaviour , but also the motivations that drive it. These we see as shaped by the practitioner’s underlying humanity and self-knowledge, and underpinned by moral and ethical sensitivity to the individual patient and particular context.de Cossaert L, Fish D.

Developing the Wise Doctor, 2007.

… endlessly create, negotiate and develop meanings …; engage all the time with multiple activities, factors, and perspectives; ceaselessly formulate problems and solutions; and learn to live with the insoluble, the ephemeral, the tentative, and the incomplete. de Cossaert L, Fish D.

Developing the Wise Doctor, 2007.

Patient-based learning

respectdignity

kindnessgentleness

touchimagination

curiosityshared biomedical

knowledge

intimate physical care

He knows that by touching her with his skilful and accustomed hand, he can soothe her yet more readily.

Charles DickensBleak House, 1852-3.

bricolage

In its old sense the verb ‘bricoler’ applied to ball games and billiards, to hunting, shooting and riding. It was however always used with reference to some extraneous movement: a ball rebounding, a dog straying or a horse swerving from its direct course to avoid an obstacle. Lévi-Strauss C.

The Savage Mind, 1962.

Weick’s sources of resilience:

•improvisation and bricolage

•the attitude of wisdom•respectful interaction

… generalists – such as a bricoleur who are able to do many different things - … notice more options and enact a greater variety of designs than specialists see and do.

Weick KE.Making sense of the Organization,

2001.

Bricoleurs remain creative under pressure, precisely because they routinely act in chaotic conditions and pull order out of them. Thus, when situations unravel, this is simply normal natural trouble for bricoleurs, and they proceed with whatever materials are at hand. Weick KE.

Making sense of the Organization, 2001.

The improviser may be unable to look ahead at what he is going to play, but he can look behind at what he has just played: thus each new musical phrase can be shaped with relation to what has gone before. He creates his form retrospectively.Ted GioiaThe Imperfect Art: reflections on jazz and modern

culture, 1988.

Gioia’s description suggests that intention is loosely coupled to execution, that creation and interpretation need not be separated in time, and that sensemaking rather than decision making is embodied in improvisation. Weick KE.

Making sense of the Organization, 2001.

Weick’s sources of resilience:

•improvisation and bricolage

•the attitude of wisdom•respectful interaction

... wisdom is an attitude rather than a skill or a body of information.

Weick KE.Making sense of the Organization,

2001.

Wisdom is an attitude taken by persons toward the beliefs, values, knowledge, information, abilities, and skills that are held, a tendency to doubt that these are necessarily true or valid and to doubt that they are an exhaustive set of those things that could be known. Meacham JA. Wisdom and the context of

knowledge. In Kuhn D, Meacham JS eds. Contributions to Human Development 1983;

8: 111-134.

Weick’s sources of resilience:

•improvisation and bricolage

•the attitude of wisdom•respectful interaction

A patient-professional encounter is a discourse; a dialogue is an interpersonal mode of being which at its best may be called authentic interaction. The “magic” of authentic interaction is that we do not completely control it as individuals, but are caught up in it and give in to its own movement. Nessa J, Malterud K. Tell me what is wrong with me: a discourse

analysis approach to the concept of patient autonomy. Journal of Medical Ethics 1998;24:394-400.

You must be sure of two things: you must love your work, and not be always looking over the edge of it, wanting your play to begin. And the other is, you must not be ashamed of your work, and think it would be more honourable to you to be doing something else. You must have pride in your own work and in learning to do it well.

George EliotMiddlemarch, 1872