August 7, 2013 | 2
Every field of expertise becomes routine to those who work in it. The first time I went into the operating theatre as a medical student, everything was strange and scary. I had no idea what to do, how to behave, what I could or couldn’t touch. But this strangeness didn’t last long. A couple of weeks later and things were already becoming pretty routine. By the time I finished my surgical training ten years later, I’d stopped noticing most of what seemed so strange. It was just part of everyday life.
Of course familiarity is an essential part of any expertise. We can’t stand open-mouthed and marveling forever, or we’d never get on with the job. And we need to focus on what we’re there to do. But there’s a danger of taking for granted things that need to be questioned. I’ve been wondering how I can make myself see things differently, how I can develop new perspectives on what I think I already know. Because looking differently changes what you see. So I’ve been looking outside medicine.
In one phase of my career I trained as a trauma surgeon, operating on people who had been stabbed and shot. In the process I became pretty good at sewing. So I searched for other people whose job involves joining things together. Joshua Byrne is a leading bespoke tailor in London. Every time he makes a suit he starts from scratch, designing and building something unique for each person. When I asked Joshua to show me what he does, he demonstrated a simple task – joining a sleeve to a jacket. Simple to him, that is. Because although in his hands it looked completely effortless, things were very different when I tried it myself. I felt completely at sea – struggling to manipulate layers of cloth, to put in stitches with a straight needle, to coordinate different tasks. I joined the wrong layers together, I pricked my finger, I had to unpick what I’d just done. I was all thumbs and felt completely clueless.
At first I couldn’t understand what the problem was. After all, I’ve spent years doing delicate complex operations – joining tiny blood vessels, sewing intestine, shaping skin. So why couldn’t I put the sleeve on a jacket? Then I realised that the crux was not the sewing, but the context. As a surgeon I always operated as part of a team. A theatre nurse would hand me instruments and take them away when I’d used them; an assistant would position the organs and hold them in the right place; someone else would cut my stitches when I’d tied them. The environment was quite different too. I’d be scrubbed up, wearing a gown and gloves; I’d be standing; and everything would be brightly lit. But in Joshua’s studio I was sitting on a stool with no team around me, no assistant holding the jacket in position, no theatre nurse handing me a threaded needle or adjusting my thimble, no technician focusing the light. It was just me and the material, and I was out of my depth. It took me right back to my first time in the operating theatre. So by shifting my perspective, a whole lot of things I had come to take for granted suddenly became visible again. I began to remember what it was like when I was a novice, when the strange had not yet become familiar.
I started to explore other ways to make the familiar strange. A meeting with some ceramicists made me think about surgery as craft, and about the complex relationships between materials, tools and the craftsman’s hands. And I began to wonder if we could talk at an abstracted level that moved beyond technique, that involved the essence rather than the details of what we both do.
An expert potter (Duncan Hooson) showed me what happened when he deliberately thinned out the neck of a vase he was throwing to the point where it crumpled and fell in. His description of ‘thin materials on the verge of collapse’ made me think about operating on frail and elderly patients whose tissues scarcely hold together. And I realised that although our skills were very different, our experiences had a lot in common. We both need to know how to identify that point when our material is about to fail, to break or tear apart, and take steps to avoid it. That isn’t something you can learn from a book or even from hearing someone talk. You have to experience it yourself. You have to ‘know it with your hands’. But how can we experience one another’s worlds when our starting points are so different? How can we develop a shared language for describing the indescribable?
An obvious point of intersection is to watch and participate in one another’s work. But there are practical difficulties here. A surgeon visiting a potter’s studio or a tailor’s workshop is one thing. A potter or a tailor taking part in a real operation would be quite another. So I’ve been exploring how simulation – realistic representations of surgery which don’t involve actual patients - can provide a proxy for the real thing.
Simulation is a mainstay of training in many occupations, and medicine is no exception. It’s now possible to create highly realistic ‘operations’ where full teams can perform complex surgery using sophisticated mannekins and technology. But until recently, this kind of simulation has been restricted to clinicians and has taken place out of public view.
I’ve been exploring how simulation can work in the other direction – how it can open up the closed world of surgery and invite non-clinicians to participate. With colleagues at Imperial College London I’ve developed a lightweight inflatable operating theatre which can be set up almost anywhere. Prosthetic models recreate the look and the feel of human organs, even bleeding when you cut them.
This allows people with no medical expertise to join a surgical team, taking part in operations performed by expert clinicians but with no risk of harming a real patient. I’ve been taking these simulations to museums, science fairs, art galleries – even music festivals. And each time I learn new things from the people who take part.
Opening up a familiar world to outsiders can be both exhilarating and disturbing. Outsiders bring ‘eyes of newness’. Outsiders aren’t afraid to question what insiders no longer see. And outsiders sometimes point out that the emperor is wearing no clothes. A sculpture designer came to one of our simulations – a brain surgery operation for head injury – and asked an craftsman’s questions about how neurosurgeons drill into the skull. Why, he asked, don’t we approach the skull as a carpenter or engineer might? Why don’t we redesign our technique rather than doing it as we’ve always done it? As insiders, that’s the kind of question we seldom think to ask. By throwing down a challenge, this outsider made us re-examine our practice and ask if there are better ways.
Becoming an expert takes years of practice. At first this needs intense focus, eliminating distractions as we hone and perfect our skills. But there’s a danger of becoming insular. All around are rich and complex worlds of craft and performance, full of extraordinary skills. We can learn much from such worlds, but most of the time we don’t even notice them. So from time to time we need to open what we do to outsiders and invite them to join us, letting in some fresh air and seeking new perspectives. Looking differently at what has become familiar helps us see things we didn’t know were there.