Addressing questions from health care with linguistic ethnography

Case study I: Surgical training

Since we had done fieldwork in a teaching hospital we had hours of video-recordings of operations performed by surgical registrars under supervision of consultant surgeons. Alex, being a registrar herself, was particularly interested in this. Detailed transcription and interactional analysis seemed to be a good way to go about gaining new insight into the role of language and communication in providing surgical care and teaching safely.

Take Transcript 1. This is an excerpt from an interaction featuring a registrar (who had been in specialist training for about ten years) working under the supervision of a consultant surgeon. They had worked together for six months. Looking back on the episode, the consultant told us that he knew this trainee well and that he therefore felt comfortable handing the scalpel to him. In the episode they perform a keyhole operation, which means that they access the patient's abdomen through a number of keyhole incisions. They then insert a camera (a 'laparoscope') into the cavity, gaining a view which is magnified and projected on screens around them. Other instruments are then inserted to operate inside the patient's abdomen. In the focal episode, the trainee is dissecting an attachment to the abdominal wall. To achieve that, they need to identify 'planes' where they can separate tissue without damaging surrounding - and often vital - structures. For instance, the gonadal vessels and the ureters are delicate structures that run close to the colon and remain difficult to spot when dissecting the colon out. Surgeons therefore treat these structures as 'danger points' (Goffman 1961) which, if exposed to 'unskilled action', result in significant 'costs'. I selected the episode for close analysis as it is here that the trainer orients to a danger point (the trainer warns the trainee in the first line of Transcript 1), providing an opportunity to investigate how consultants see and deal with risks when they let their trainees operate.

In the focal episode the consultant holds the camera. He sets the frame, zooming in and out and changing the camera angle as and when he feels appropriate. The trainee is in control of the Harmonic, a laparoscopic scalpel that surgeons use to cut and coagulate tissue by burning it. Both direct their gaze at one of the screens that display what the camera captures. To make a cut the trainee grasps tissue, closes the instrument, and then presses a pedal to activate the electric circuit that runs through the grasper, so-called 'diathermy'. In Transcript 1 these actions

Transcript of interaction between supervising consultant and operating registrar are marked on

Figure 11.1 Transcript of interaction between supervising consultant and operating registrar are marked on (vertical) time lines alongside the spoken utterances produced by the trainer. Every second is marked with a short hairline. The first vertical line marks the moments that the trainee keeps the scalpel in contact with tissue; the second line the moments that he lifts tissue up; the third line the moments that he grasps tissue; and the fourth line the moments that he actually cuts tissue (Figure 11.1).

The transcript helps us deconstruct - 'dissect' - what happens in this strip of interaction. As the trainee makes the first contact in this episode, the trainer tells the trainee to 'just be a bit careful with the planes there'. The trainee then withdraws the instrument from the tissue he was touching and the trainer explains why he wants the trainee to be 'careful' in the area he was in: 'there are the ureter and things'. The prompt change in the trainee's course of action suggests that the trainee is responding to what the trainer says, perhaps taking his comment as an indication that he had better find a different, 'safer' plane. Note that the trainer's 'there' in the first two utterances refers to a broad area, including but not specifically pointing to where the trainee had placed the scalpel.

In the next four seconds or so the trainee makes the first cut. As the trainee is approaching a different plane the trainer tells him to 'go superficially'. Staying superficial is a way to avoid getting in contact with structures such as the ureter, which are hidden further into the body. The latter part of the utterance overlaps with a grasping and a lifting action by the trainee. Then, just after the trainer has said (a very short) 'yeah', the trainee starts cauterising. As the trainer's 'yeah' is preceded by a lifting and grasping action and followed by a cauterising action we suggest that the trainer has interpreted the lift and the grasp as an indication of the trainee's commitment to cut at the point where he is grasping; and that the trainee has interpreted the trainer's 'yeah' as a ratification to cauterise. After the cauterising the trainer says, 'as you're doing', acknowledging that the trainee has indeed gone 'superficially', as he had suggested. As the tissue that is cauterised separates, the trainee withdraws the instrument.

We used this form of analysis of teaching episodes to make two points. First, we proposed that the analysis shows how patient safety is actually achieved. We noted that the trainee's actions signify to the trainer a trajectory of actions. This is an important resource for achieving surgical care in a learning environment where the trainee holds the scalpel: trainers can read and anticipate, and trainees can signal what they are up to. We also explored the potentials and limitations of using speech to give instructions. We saw what the effects were of the trainer's spoken utterances: they prompted the trainee to withdraw his instrument, start a new contact, or proceed to cut. In other words, speech is an important resource for achieving surgical care in learning environments, allowing the trainer to prompt the trainee to act or to cease to act. We also rendered visible some of the challenges in using speech. Surgeons do not have names for everything they see inside a body, so you'll often hear them saying something like, 'that stuff there', for instance, when directing a trainee where to act. At these moments pointing is an essential semiotic resource, yet supervising surgeons often do not have a spare hand to point with at these moments as they hold the camera in one hand and provide traction with the other (Bezemer et al., 2014). This challenge could be addressed, for instance, by introducing head mounted laser pointers.

Another point we were able to make with this analysis was to do with the limitations of more common qualitative and quantitative medical research. For instance, we pointed out that the kinds of teaching strategies made visible by the transcript are not articulated in interviews and they would be difficult to note on-the-spot in structured observation sheets, yet they play a key role in safely training up the next generation of surgeons - and in training them how to support the training of others. We also drew attention to the way in which operations are reported. In research and assessment, surgeons often distinguish between 'doing' an operation, either independently or under supervision, and 'assisting in' an operation. Classifying participation in that way enables surgeons to calculate 'how many' cases of a procedure they 'have done' ('I've assisted in 100 and did 50'). Using examples such as the one above we highlighted that operating is always a joint achievement. Trainees do not simply 'do' the operation, nor are they merely passive 'recipients' of instruction: control over operations is distributed, and this distribution (the degree of guidance) varies significantly from moment to moment: some actions are performed by trainees without any visible or audible guidance, whereas others are strongly mediated by instructions. In a paper for the World Journal of Surgery (2012), we therefore concluded that the common classification of participation in operations is 'an oversimplification of a complex picture'.

That paper didn't get accepted in its original form. In the first version we didn't include any numbers; it focused entirely on a transcript. As noted in the previous section such a focus on a small excerpt was highly unusual for a surgical journal. The response from our reviewers was that we had an important message, but not the numbers to back it up. In the mean time, Alex had done additional fieldwork for her PhD, observing 122 operations (Cope 2013); and together we had audio- and video-recorded another 12 operations. Using these materials we were able to sandwich the transcript between tables. One table showed how many of the 122 operations Alex had classified as 'done' by trainees in her fieldnotes, and another table showed our classification of who 'did' which phase in the 12 video-recorded operations. Thus we looked at 'participation' at three levels: at the level of an operation, at the level of a stage within the operation, and at the level of situated interaction. That 'mixed method' approach ('coding' 122 operations, plus transcribing a small excerpt from one operation) proved successful: the next version of the paper was accepted.

Case study II: decision making

Another area of the research focused on decision making. Decision making has received ample attention in social studies of medicine. Much of that work explores how doctors discuss treatment options and reach decisions with the patient and other specialists. Other research in this area is on how doctors make decisions as they 'do' clinical work, such as performing a surgical procedure. While some research on decision making involves micro-analysis of interactions (see for instance Sarangi and Roberts 1999) the work on intra-operative decision making is dominated by psychological research. These studies describe decision making as an important cognitive skill that enables surgeons to consider and choose between multiple courses of action in situations of uncertainty and high time pressure. They draw on observations, think aloud sessions and retrospective interviews (Fioratu et al. 2011). Each of these sources has limitations. Think aloud sessions and interviews only capture decisions that the surgeon is aware of and able to articulate verbally. The observational studies (which usually do not involve video-recordings) only capture decisions that the observing researcher notices on the spot.

That provides a strong rationale for a linguistic ethnographic contribution to research on decision making during operations. First, decision making is recognised by the medical world, including surgeons, and connects with current debates about transparency and 'speaking up' in clinical teams when important decisions are being made (see for example Reid & Bromiley 2012). Second, we had relevant data: videorecordings of laparoscopic operations, which we can play back alongside the audio to produce a detailed picture of how the operation unfolded. Third, we render decision making visible and audible in interactions between surgeons, moving beyond the notion that decision making is lodged inside a single surgeon's mind.

Consider the next example, taken from another keyhole operation: a gall bladder removal operation. A registrar (Registrar 1) is operating, assisted by another registrar (Registrar 2). Alex (Registrar 3) and I are observing. Transcript 1 details a small strip of interaction from about 5 minutes into the operation (Figure 11.2).

Using a special type of grasper the operating registrar separates tissue, rendering anatomical structures visible. He then says, 'there you go'. The assistant responds to this by saying, 'nice'. The operating surgeon then sweeps his closed instrument up and down the structure he has

Transcript of interaction between operating

Figure 11.2 Transcript of interaction between operating (1), assisting (2) and observing (3) registrars just freed up, while asking, 'Agreed?' The assistant responds affirmatively. He then asks Alex if she's happy, Alex responds that she is, and he then closes the exchange by saying, 'very good'.

So what is being decided here, and how? We might say that the operating registrar's 'agreed' and 'happy' serve as proposals, which are accepted by the assistant and by Alex. However, it is not clear from the spoken interaction what they agree on. For that we need to look more closely at the unfolding anatomy and the actions they perform. What they are looking at here is the cystic duct, which they need to clip and cut before they can remove the gall bladder. When the operating registrar says, 'agreed' he makes a sweeping movement alongside this duct. To them, this gesture and question marks a decision point in the operation that surgical textbooks also highlight: the decision whether or not to proceed with the clipping and cutting of the duct. The textbooks insist that surgeons need to obtain a 'critical view' of the anatomy. They need to have freed up the cystic duct from surrounding tissue, such as fat, in order to ascertain that it is indeed the cystic duct, and not the main, 'common bile' duct from which it branches off. Accidentally taking down the common bile duct would lead to serious complications, which would only become manifest when the patient is already out of the operating room. In light of that, the operating registrar's question - 'agreed' - signifies that he is proposing to proceed to clip and cut the structure that he is drawing attention to with the sweeping gesture. Indeed, immediately after this exchange he cuts this structure.

This analysis can feed directly into questions about surgical care. We rendered something visible which some audiences may see as illustrations of 'good practice', suggesting, for instance, that surgeons should always seek agreement from other surgeons co-present prior to making important decisions such as this one. We were keen to look at a collection of examples of the same decision point from a number of different operations. Looking across 12 gall bladder removal operations we were able to notice, for instance, that only on some occasions did the operating surgeon make a verbal proposal to cut prior to cutting the cystic duct. Yet on all occasions they made a gesture with their instrument to exhibit that the structures are 'clean' and sufficiently freed up prior to cutting. We also noticed that only registrars got involved in this decision making: house officers never reply to a question such as, 'Agreed?'.

The case studies illustrate one version of linguistic ethnography. Using video-recordings I explored, not only the role of language, but also the role of gesture, gaze and body posture in operating theatres. Through micro-analysis of social action in all these modes I was able to address a range of different 'issues' in surgery, including surgical training and decision making. Approached in that way linguistic ethnography can be used to shed light on what happens in any site, even on activity which is not always organised around spoken interaction, such as operations. Exploring language and communication ethnographically meant that I also looked beyond my video-recordings. For instance, the first case study was informed by explorations of how operations are recorded by the surgical community themselves, for example in the portfolios of surgical trainees. The analysis in the second case study is informed by explorations of how the surgical procedure in focus is presented in surgical textbooks. These documents provided useful insights into wider institutional and professional discourses, respectively, which I linked to the micro-analysis of small excerpts of video-recorded interaction. This form of trans-contextual analysis is one the distinctive features of an ethnographic approach to language and communication.

The case studies also illustrate how I produced linguistic ethnographic accounts that resonate with the concerns of surgeons. My strategies for achieving that can be summarised as follows: (1) translating linguistic- ethnographic perspectives into pertinent questions (for example, 'How do surgeons mark the decision to proceed to perform a highly consequential action in their interaction?'); (2) problematising and complementing categories circulating in the surgical community by showing how interaction unfolds in situ (for example showing that 'doing' an operation can refer to many different degrees of control by operating and assisting surgeons); (3) combining detailed analysis of data excerpts with coding of larger samples; (4) building up categorical collections of interactional data (for example looking at a decision point across multiple cases of the same procedure). These strategies were helpful ways to bridge my theoretical and methodological stance with that of the majority of the surgical community.

As I was making an effort to reach out to the wider surgical community I again benefited greatly from the partnership. As co-authors of most papers my partners helped mediate the linguistic ethnographic perspective through detailed track changes and comments such as, 'surgeons won't understand this'. Having published extensively in medical journals they were much more familiar with the standard formats of these journals, such as its background-aims-methods-results-conclusion structure, and the expected writing style (for instance, concise and with no active constructions). To make a 'real' impact the analysis needs to be pushed further still, leading to actual proposals for change. At the time of writing we have not reached that point, but we are getting close.

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