In praise of seams
CAIPE 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
+
ontology
Della 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
respect
dignity
kindness
gentleness
touch
imagination
curiosity
shared 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 Dickens
Bleak 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 Gioia
The 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 Eliot
Middlemarch, 1872