Making meaning from sensory cues in the operating room – an important content area of post-graduate surgical learning

PURPOSE: The authors aimed to map and explicate what surgeons perceive they learn in the operating room.

METHOD: The researchers used a grounded theory method in which data were iteratively collected through semi-structured one-to-one interviews over a 24-month period. A four-person data analysis team from differing academic backgrounds quantitatively analyzed the content of the transcripts employing an immersion / crystallization approach.

RESULTS: Participants were 22 UK surgeons, some of whom were in training at the time of the study and some of whom were surgeon trainers. Major themes of learning in the operating room were perceived to be ‘factual knowledge’ ‘motor skills’ ‘sensory semiosis’ ‘adaptive strategies’ ‘team-working and management’ and ‘attitudes and behaviours’. 277 data points (short paragraphs or groups of sentences conveying meaning) were classified under these major themes and sub-themes by the analysis team. A key component of learning in the operating room that emerged from these data was ‘sensory semiosis’, learning to make sense of visual and haptic cues.

DISCUSSION: Whilst the authors found that learning in the operating room was across a wide range of domains ‘sensory semiosis’ was found to be an important theme that has not previously been fully acknowledged or discussed in the surgical literature. The discussion then draws upon the wider literature from the social sciences and cognitive psychology literature to examine how professionals lean to make meaning form ‘signs’ making parallels with other medical specialties.

See Cope, A., Mavroveli, S., Bezemer, J., Hanna, G. & Kneebone, R. (in press). Making meaning from sensory cues in the operating room – an important content area of post-graduate surgical learning. Academic Medicine.

Surgical decision making in a teaching hospital: a linguistic analysis

Background: The aim of the study was to gain insight in the involvement of non-operating surgeons in intra-operative surgical decision making at a teaching hospital. The decision to proceed to clip and cut the cystic duct during laparoscopic cholecystectomy was investigated through direct observation of team work.

Method: 11 laparoscopic cholecystectomies performed by consultant surgeons and specialty trainees at a London teaching hospital were audio and video recorded. Talk among the surgical team was transcribed and subjected to linguistic analysis, in conjunction with observational analysis of the video material, sequentially marking the unfolding operation.

Results: Two components of decision making were identified, participation and rationalisation. Participation refers to the degree to which agreement was sought within the surgical team prior to clipping the cystic duct. Rationalisation refers to the degree to which the evidential grounds for clipping and cutting were verbalised.

Conclusion: The decision to clip and cut the cystic duct was jointly made by members of the surgical team, rather than a solitary surgeon in the majority of cases, involving verbal explication of clinical reasoning and verbal agreement. The extent of joint decision making appears to have been mitigated by two factors: trainee’s level of training and duration of the case.

Bezemer, J, G Murtagh, A Cope, K R Kneebone (in press). Surgical decision making in a teaching hospital: A linguistic analysis. ANZ Journal of Surgery.

Touch: A resource for making meaning

In this article we attempt to provide some ways of thinking about touch. Our aim is to develop new insights in ‘touch’, as well as in meaning making and communication more generally, by bringing into ‘explicitness’, meanings which, at present are referred to by labels such as ‘implicit’, ‘tacit’ or ‘embodied’. We wish to show that this discussion needs to happen, and it needs to become more precise before we can attempt to settle various issues in connection with touch, such as the implications of touch-screens and other touch-technologies. The frame for our discussion is Social Semiotics. Taking examples from different domains and communities of social practice, ranging from shoulder tapping and clinical examination in hearing and sighted communities, through to tactile signing in deaf-blind communities we explore ways in which touch is used as a resource for making meaning, and unpack the multiplicity of meanings attached to the term itself. One question that is central to our discussion is whether and if so, how, touch can represent and communicate meanings and develop into a ‘mode’ that can serve a ‘full’ range of semiotic functions within a community.

Bezemer, J. & G. Kress (in press). Touch: A resource for making meaning. Australian Journal of Language and Literacy. Read a pre-print version.

Communication in the operating theatre

Background: Communication is extremely important to ensure safe and effective clinical practice. A systematic literature review of observational studies addressing communication in the operating theatre was conducted. The focus was on observational studies alone in order to gain an understanding of actual communication practices, rather than what was reported through recollections and interviews.
Methods: A systematic review of the literature for accessible published and grey literature was performed in July 2012. The following information was extracted: year, country, objectives, methods, study design, sample size, healthcare professional focus and main findings. Quality appraisal was conducted using the Critical Appraisal Skills Programme. A meta-ethnographic approach was used to categorize further the main findings under key concepts.
Results: Some 1174 citations were retrieved through an electronic database search, reference lists and known literature. Of these, 26 were included for review after application of full-text inclusion and exclusion criteria. The overall quality of the studies was rated as average to good, with 77 per cent of the methodological quality assessment criteria being met. Six key concepts were identified: signs of effective communication, signs of communication problems, effects on teamwork, conditions for communication, effects on patient safety and understanding collaborative work.
Conclusion: Communication was shown to affect operating theatre practices in all of the studies reviewed. Further detailed observational research is needed to gain a better understanding of how to improve the working environment and patient safety in theatre.

Weldon, S-M, Korkiakangas, T, Bezemer, J & Kneebone, R. (in press).
Communication in the operating theatre.
British Journal of Surgery.

Multimodal Transcription as Academic Practice: A Social Semiotic Perspective.

With the increasing use of video recording in social research methodological questions about multimodal transcription are more timely than ever before. How do researchers transcribe gesture, for instance, or gaze, and how can they show to readers of their transcripts how such modes operate in social interaction alongside speech? Should researchers bother transcribing these modes of communication at all? How do they define a ‘good’ transcript? In this paper we begin to develop a social semiotic framework to account for transcripts as artefacts, treating them as empirical material through which transcription as a social, meaning making practice can be reconstructed. We look at some multimodal transcripts produced in conversation analysis, discourse analysis, social semiotics and micro-ethnography, drawing attention to the meaning-making principles applied by the transcribers. We argue that there are significant representational differences between multimodal transcripts, reflecting differences in the professional practices and the rhetorical and analytical purposes of their makers.

Read the full article: Bezemer, J. & D. Mavers (2011). Multimodal Transcription as Academic Practice: A Social Semiotic Perspective. International Journal of Social Research Methodology 14, 3, 191-207. DOI

Selected excerpts


Transcription is a common academic practice. In social research investigating language and communication, a ‘transcript’ usually refers to a distinctive genre associated with turning a strip of ‘naturally’ occurring talk – e.g. a job interview, a conversation at the dinner table – into writing. This genre has analytical as well as rhetorical purposes: to develop insights into the moment-by-moment and in situ construction of social reality and to provide evidence in developing an argument for an academic audience. With the increasing use of video recording in social research, methodological questions about multimodal transcription are more timely than ever before. How do researchers transcribe gesture, for instance, or gaze, and how can they show to readers of their transcripts how such modes operate alongside speech? Should researchers bother transcribing these modes of communication at all? What are the epistemological implications of choices of inclusion and exclusion? What does one gain from inclusion of modes other than speech if the aim of transcription is to focus on a selection of the vast amount of data collected? In this paper we investigate how some researchers, including ourselves, have dealt with these issues. We discuss the emergence of multimodal transcripts in social research, review the theoretical perspectives on transcription adopted in conversation analysis and linguistics and develop our own, social semiotic take. We then use this framework to analyse and compare a selection of multimodal transcripts which have appeared in recent academic publications.


In this paper we have analysed and discussed a small number of ‘multimodal’ transcripts from a social semiotic perspective with the aim of gaining a better understanding of the methodological implications of this changing academic genre. We have suggested directions along which to investigate transcripts: how common principles (framing, selecting and highlighting) and modes of transcription (writing, image and layout) are differently used in video-based social research. Whilst these principles operate in all modes, each mode provides distinctive potential for re-constructing video data, and these choices shape the account of social interaction in significant ways. Such reconstructions are inevitable and essential outcomes of any video analysis, and it is through reconfiguring video data that researchers and their audiences can see the observed interaction in the categories appropriate to their discipline(s) and position themselves in relation to that discipline(s).

We have identified some significant methodological differences between the various transcripts. We can see, for instance, that their makers have chosen to represent strips of interaction ranging from a few seconds (Heath et al.) to a couple of minutes (Erickson). Their transcripts also point to different units of analysis, such as: ‘turns’ (Erickson), ‘actions’ (Heath et al.), ‘higher level actions’ (Norris), and ‘modes’ (Mavers). These differences reflect the professional interests of the makers, and their analytical and rhetorical concerns. As conversation analysts Heath et al. are particularly concerned with the temporal unfolding of action, and they tend to look for more detail in shorter clips than for less detail in longer clips. They want to show that interaction is sequentially organized, and that this interaction unfolds in different forms of action. As social semiotician, Mavers calls these forms of action ‘modes’, and highlights the modal organization of interaction. Norris wants to discern ‘simultaneously performed higher level actions’ (2004: 101) in a 30-second clip, and so frames the moments where new ‘higher level actions’ are added to what is going on. Bezemer identifies ‘types’ of bodily configurations in a 5-minute clip, thus like Norris he moves beyond the ‘micro’ actions which are in focus in Heath et al.’s transcript. Another difference between the transcripts is their treatment as a ‘source of evidence’. In conversation analysis evidence for an argument ought to reside in the transcript, and other, ethnographic sources of evidence may be considered as ‘supplementary’. In the ‘micro-ethnographic’ approach adopted by Erickson such sources of evidence are given more equal weight. Thus the transcripts have different positions in the originating analysis and rhetoric.

In this paper we have looked at transcripts as finished products, as professional artefacts. We treated these artefacts as mediating social interaction between the ‘makers’, the represented materials, and the (imagined) ‘readers’. The framework set out here is not only useful from the perspective of the sociology of science, but can also be applied by individual researchers undertaking video-based social research to reflect on the methodological and theoretical implications of choices around transcription. Such reflection, we believe, should not focus on representational ‘accuracy’. Rather, transcripts should be judged in terms of the ‘gains and losses’ involved in re-making video data. It is crucial to make those gains and losses transparent, for example, which modes of communication used in the observed activity have been excluded from the transcript and why, and what the effect is of that exclusion on the analysis and subsequent reader interpretation? It also promotes reflection on the effects of transduction: how use of the mode of transcription shapes what is re-presented. Transcription conventions accommodate such transparency and consistency, but are currently utilized only in transcribing speech to writing. Contemporary practices in multimodal transcription may require information, for example, on how images were constructed. Such conventions cannot and need not be standardized beyond the study/project/publication for which they are used, but they need to be made transparent to readers.

We have discussed only a small number of transcripts in this paper, and so our conclusions are provisional. We are in the process of expanding our data set, so that we will be able to systematically analyse a broader range of multimodal transcripts. This corpus will increase the variety of transcripts we have worked with so far, to include, for instance, musical notation as a mode of transcription showing the relative temporal locations of vocally stressed syllables in talk (e.g. Erickson, 2004), ‘laban’ script as a mode of transcription for movement (Duranti, 1997, p.149) and geographical maps detailing the direction of gaze (e.g. Haviland, 2003). Further research will also need to involve interviewing the makers of transcripts, as well as observations of transcription activities (c.f. Vigouroux, 2007) to gain more insight into transcription as a situated practices (Mondada, 2007) and ‘effects’ on readers. Transcripts, like any form of representation, are not only socially and culturally shaped, they are also situated (Mondada, 2007), that is, they are produced in a local, social, physical context in which certain representational resources are available and others not. Increasingly, computer software technologies are part of those resources, and they shape ‘transcription’ (Plowman & Stephen, 2008). Transcription may also be a collaborative activity, involving a number of participants who are engaged in a ‘data session’. It would be particularly interesting to compare different versions of a transcript, made in different situations, involving different participants, and the processes of review and reformatting. The interactions between transcribers, and between transcriber and computer, and the local ecologies within which these interactions unfold need to be researched ethnographically. So does the ‘reading’ of transcripts: to our knowledge, no one has observed how people engage with transcripts. We do not know what they attend to, in what order, or indeed if they read the transcript at all. In short, our paper is only a very modest theoretical and empirical contribution to important methodological questions.

How to transcribe multimodal interaction?

transcriptexcerptThis working paper looks at some of the key issues to consider when transcribing multimodal interaction. Making a transcript is an invaluable analytical exercise: by forcing yourself to attend to the details of a strip of interaction you gain a wealth of insights into the situated construction of social reality, including insights in the collaborative achievements of people, their formation of identities and power relations, and the socially and culturally shaped categories through which they see the world. In this paper I reflect on the process of making a multimodal transcript. I discuss the following steps: (1) Choosing a methodological framework (Reviewing multimodal frameworks and Considering rhetorical status of the transcript); (2) Defining purpose and focus of transcript (Selecting episode and features to transcribe and Defining questions to address; (3) Designing the transcript (Creating a template, Defining transcription conventions and Filling in the template); (4) Reading the transcript (Annotating and Recounting the transcript); (5) Drawing conclusions (Addressing research questions and Making connections with other studies and theoretical constructs).

Bezemer, J. (2012). How to transcribe multimodal interaction? Read it on NCRM EPrints.

Multimodal Analysis: Key issues.

This chapter discusses multimodal approaches to the study of linguistics, and of representation and communication more generally. It draws attention to the range of different modes that people use to make meaning beyond language –such as speech, gesture, gaze, image and writing – and in doing so, offers new ways of analysing language. The chapter addresses two key questions. First, how can all these modes be handled theoretically? What are ‘modes’? How do people use them? Second, how can all these modes be handled analytically? What are the methodological implications if one or more modes are excluded from the analysis? The chapter fi rst highlights the ways in which multimodality is taken up in social linguistic research. It then describes a social semiotic approach to multimodality. The steps taken in such an approach are described and exemplified with case studies of classroom interaction and textbooks. It concludes with a discussion of the potentials and constraints of multimodal analysis.

Read a pre-print version of the full chapter: Bezemer, J. & C. Jewitt (2010). Multimodal Analysis: Key issues. In: L. Litosseliti (ed), Research Methods in Linguistics. London: Continuum. pp. 180-197.

Learning in the operating theatre: A social semiotic perspective

Learning has become a key issue across different disciplines. The school is no longer seen as the only significant site of learning, and learning is no longer seen as a matter of the ‘mind’ alone (Lave and Wenger 1991; Säljö 2009). The approach put forward in this chapter embraces these changes in the theorisation of learning. The starting points of our approach are, first, that teaching and learning are social practices. Hence our theory is a socially based theory, concerned with the interaction between people and the identities and social roles they take up across different sites, including clinical work places. Our second starting point is that teaching and learning are instances of communication, so that a theory of learning and teaching is set within the general frame of a theory of communication. We study communication not to identify ‘communication failures’ in clinical work (cf. Lingard et al. 2004) but to draw attention to the resourcefulness of clinicians as communicators and the complexities of their encounters with patients and other clinicians, whether as teachers or as learners.

Our theory of communication – and by implication, of learning – is a social semiotic one. Its focus is semiosis, that is, how people ‘make meaning’; how they make sense of what other people say and do, and what they themselves say and do ‘to make things happen’. To help develop this theory further, and to address specific questions about clinical learning, we have analysed audio and video recordings of interactions in the operating theatres of a teaching hospital in London. We used a wireless microphone worn by one of the surgeons, and in-built video cameras, allowing us to capture that to which surgeons typically orient themselves, that is, their hands, their instruments, and the parts of the patient’s body that they operate on. In addition to these recordings we kept detailed field notes of all operations observed, particularly noting changes in the spatial configuration of participants around the operating table, and we made photographs of the screens, books and other media that are used in the operating theatre (see Bezemer et al. 2011 for more methodological details).

Video recordings are indispensable for our social semiotic research, not least in clinical settings, since communication and learning are instantiated in the fine grained detail of subtle body movements. For instance, in an operating theatre, surgeons shifts in their direction of gaze from operative field to scrub nurse may suggest the onset of a request for an instrument. These shifts occur in split seconds. They cannot be captured on-the-spot and in field notes by researchers, let alone recalled in interviews by the research participants after the observed event. A video record allows us to begin to analyze these practices. Detailed analysis of video recordings of work places and educational settings is now well established in social research (Heath et al. 2010; Kissmann 2009), including social research in clinical settings (Iedema et al. 2006). The theoretical and methodological assumptions underlying these studies vary somewhat. Most video based studies of the operating theatre and its adjacent rooms, such as the anaesthetic room, are based in Conversation Analysis. These studies highlight the ‘practical accomplishment’ of  clinical work (Bezemer et al. in press; Hindmarsh and Pilnick 2002; Koschmann et al. in press; Mondada 2003; Svensson et al. 2007). Looking at what people say and do, millisecond-by-millisecond,  they show that seemingly simple interactions such as the passing of an instrument actually requires significant fine-tuning and careful monitoring of the body movements of colleagues. The social semiotic take we propose in this chapter adopts a similar analytical approach, taking seriously the details of different forms of communication, but its theoretical framing is different. Connected with critical discourse analysis and educational studies (Kress and van Leeuwen 2001), our theory highlights the power relations that shape people’s engagement with the world.

The chapter is organized as follows. In the next section we outline our social semiotic theory of communication and learning. In the following two sections we expand on some of the key concepts, using examples from clinical and non-clinical sites of learning. We conclude with discussing the implications of our take for learning and assessment in and through clinical practice.

Read the full chapter: Bezemer, J., G. Kress, A. Cope & R. Kneebone (2012). Learning in the Operating Theatre: A Social Semiotic Perspective. In V. Cook, C. Daly & M. Newman. Work-based learning in clinical settings: Insights from socio-cultural perspectives. Abingdon: Radcliffe (pp. 125-141).

Partnerships in research: Doing linguistic ethnography with and for practitioners

In this chapter I reflect on linguistic-ethnographic research I conducted in partnership with surgeons. My focus is twofold: I explore how the partnership has shaped my research; and I illustrate how linguistic ethnography can contribute to public and professional debates about health care. Three joint research projects on learning and communication in the operating theatre form the backdrop of the chapter. In each of these projects I worked closely with two surgeons: Roger Kneebone and Alexandra Cope. In the first project, ‘Mapping Educational Activity in the Operating Theatre’, we looked at on-the-job surgical training (funded by the London Deanery, the organisation responsible for postgraduate medical education; and the Royal College of Surgeons of England). In the second project, ‘Digital Technologies in the Operating Theatre’, we explored the role of video technology in surgery (funded by the Economic and Social Research Council (ESRC)). In the third project, ‘Transient Teams in the Operating Theatre’, we investigated communication between surgeons and nurses during operations (funded by the ESRC). The chapter is based on my field notes, email exchanges with my research partners and memos I wrote after field work. The chapter follows different stages in the partnership. First, I discuss the field work I did in a London hospital. Second, I outline the theoretical and methodological perspectives that guided my initial engagement with the data. Third, I present two case studies that illustrate how I built on these perspectives to address the concerns of surgeons, health care professionals and the public more widely, which focus on the pertinent and timely question of how to improve the safety and quality of health care.

Bezemer, J. (in press). Partnerships in research: Doing linguistic ethnography with and for practitioners.
In F. Copland, S. Shaw and J. Snell (eds). Linguistic Ethnography: Interdisciplinary Explorations. Palgrave Advances Series. Read the manuscript.

Holding the Scalpel: Achieving Surgical Care in a Learning Environment

Dana Event Simulated Surgery at Science MuseumIn this article, we show what surgical training looks like in situ. Drawing on fieldwork in a London hospital, we explore how a trainer and trainee jointly achieve surgical care when the trainee holds the scalpel. We make this common pedagogic arrangement visible through transcription and analysis of audio- and video-recorded interaction in the operating theater. Through moment-by-moment analysis of the temporal unfolding of action and speech, we show that the actions performed by the trainee with the scalpel serve as mini-gestures, signaling to the trainer where and when the trainee is going to cut. The trainer “reads” these gestures and prompts the trainee to continue or change his course of action through spoken utterances. We use our ethnographic account as a detailed empirical point of reference for reflecting on the challenges and possibilities of surgical education and patient safety in the operating theater.

Bezemer, Jeff, Alex Cope, Gunther Kress and Roger Kneebone (2014). Holding the Scalpel: Achieving Surgical Care in a Learning Environment. Journal of Contemporary Ethnography 43 (1), 38-63. Read a pre-print version.