In this paper we explore a site of work and learning that is rarely investigated ethnographically and to which few applied linguists have gained access: the operating theatre. Taking up the 2011 BAAL Annual Meeting’s theme, ‘The Impact of Applied Linguistics’, we argue that linguistic ethnography, through detailed analysis of situated, embodied interaction (Maybin & Tusting 2011), can and should make an important contribution to research on and improvement of the quality and safety of health care.
Surgical trainees learn to operate through participation in numerous operations. Clinical research has shown that the complication rates of cases performed by trainees under supervision are comparable to those of cases performed by consultants (Acun et al., 2004). However, ‘process variables’, such as the (variation in) the communicative features of the supervision that was provided, have received little attention. Our study was aimed at rendering these features visible and placing them in the wider social-pedagogic context of the operating theatre, highlighting the dynamic, embodied interaction between consultant-supervisors and surgical trainees.
Data and method
Observations were carried out in a major teaching hospital in London by a linguist and a clinical researcher. 35 cases were observed (equivalent to 82 hours of operating time), 10 of which were audio and video recorded (22 hours of operating time). A wireless microphone was worn by one of the surgeons, and in-built video cameras were used to capture the operative field. Field notes of all operations were kept by the researchers. All staff in theatre and all patients involved have given informed consent to collect the data. Ethical approval was granted by the UK National Health Service Research Ethics Committee (ref nr 10/H0712/1). Video clips were transcribed multimodally, detailing use of speech, instruments, and hand, arm and head movements.
Linguistic-ethnographic analysis of interaction at the operating table shows how surgical trainers and trainees coordinate their actions using all communicative resources available to them (see also Svensson et al 2009; Bezemer et al. 2011a, 2011b). These include speech, gesture, gaze and posture, as well as their use of instruments. Each of these resources offer distinctly different potentialities and constraints for instruction. For instance, on one occasion a trainer may use speech to describe to the trainee the operative manoeuvre to perform (cf. “Do you see that white line there? That’s where you need to dissect”); on other occasions the trainer may point to anatomical structures (giving meaning to deictic elements such as ‘here’ and ‘there’), reposition the hands of the trainee, or take over control over the instruments to demonstrate the next action. Trainees display embodied responses to this guidance, and trainers adjust their guidance in accordance with these responses and the unfolding operation. Thus the degree of guidance can vary significantly from moment to moment: some operative manoeuvres may be performed by a trainee without any visible or audible guidance, whereas others are strongly mediated by multimodal instructions.
The variation in the degree of guidance given to trainees who ‘perform’ an operation under supervision raises important questions about how operations are recorded, analyzed and assessed in professional surgical discourse. The number of times that surgical trainees have ‘performed’ or ‘done’ a procedure is often taken as a reliable indicator of their surgical experience. For instance, the randomized control study discussed above compares operations ‘performed by’ trainees with operations performed by consultants. Our study shows that such classifications wrongly suggest that trainees classified as ‘(operating’) ‘surgeon’ have had equal control over the operation. Operating surgeons are not necessarily primary ‘agents’ throughout an operation: they don’t always ‘do’ or ‘lead’ the operation; nor are they merely passive ‘recipients’ of instruction. To measure participation in operations adequately more sophisticated categories will need to be used, detailing changes in the degree of guidance.
Our study shows that linguistic ethnography and applied linguistics more generally can contribute to an important research agenda from which it is currently noticeably absent. By rendering visible the moment-by-moment unfolding of surgical operations and the training embedded within it we have drawn attention to the complexities and contingencies of clinical work and patient safety in situ, thus complementing generalized pictures of ‘what works’ (Iedema, 2009) and ‘what is safe’ (as in randomized control trials). These insights are crucially important as linguists, ethnographers, clinical researchers, policy makers and health care professionals work together to improve health care.
The paper was part of a colloquium, The Impact of Applied Linguistics: Using Linguistic Ethnography to Study Health Care, organized by the UK Linguistic Ethnography Forum (www.uklef.net). The other speakers were Jamie Murdoch, Deborah Swinglehurst, Sara E Shaw, Celia Roberts (chair) and Rick Iedema (discussant). The research reported in this paper was supported by the Royal College of Surgeons of England, who funded a research fellowship (2009-2010), and the London Deanery, who granted an award under the Simulation and Technology-Enhanced Learning Initiative (2009-2011).
Zeki Acun et al. (2004). A Randomized Prospective Study of Complications Between General Surgery Residents and Attending Surgeons in Near-Total Thyroidectomies. Surgery Today 34(12): 997-1001.
Jeff Bezemer, Alexandra Cope, Gunther Kress and Roger Kneebone (2011a). “Do You Have Another Johan?” Negotiating Meaning in the Operating Theatre. Applied Linguistics Review 2: 313-334.
Jeff Bezemer, Ged Murtagh, Alexandra Cope, Gunther Kress and Roger Kneebone (2011b). “Scissors, Please” The Practical Accomplishment of Surgical Work in the Operating Theatre. Symbolic Interaction 34, 3, 398-414.
Rick Iedema (2009). New approaches to researching patient safety. Social Science & Medicine 69(12): 1701-1704.
Janet Maybin and Karin Tusting (2011). Linguistic Ethnography. In: James Simpson (ed), The Routledge Handbook of Applied Linguistics. Routledge, London (pp. 515-528).
Marcus Svensson, Paul Luff and Christian Heath (2009). Embedding instruction in practice: contingency and collaboration during surgical training. Sociology of Health and Illness 31(6): 889-906.
Please refer to this paper as: Bezemer, J., A. Cope, G. Kress, & R. Kneebone (in press). “How many lap choles have you done?” A linguistic-ethnographic take on counting surgical experience. In: The Impact of Applied Linguistics. Proceedings of the 44th Annual Meeting of the British Association of Applied Linguistics. London: Scitsiugnil.