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Please review our Terms and Conditions of Use and check box below to share full-text version of article. Get access to the full version of this article. View access options below. You previously purchased this article through ReadCube. A relaxed atmosphere and light-hearted banter often referring to shared experiences from the past showed a strong sense of team awareness. To us as observers, a striking characteristic was the ability of the team to integrate multiple tasks with no apparent effort, and to incorporate other team members such as trainees and students into both practice and teaching.
These impressions were confirmed in post-re-enactment interviews, when participants commented that although the setting was not completely authentic, it allowed them to work with their colleagues very much as they had on previous occasions. The theatre sister scrub nurse played a crucial role in assisting the work of the surgeon, thereby demonstrating the distributed nature of surgical expertise. Standing at his side, she arranged her tray of instruments neatly at the outset, positioning them in accordance with their likely usage, and ensuring that handles were aligned.
She responded quickly to his requests for particular instruments or simply knew from his gestures what was required. At other times, she would glance at the operative field and pick up an instrument which had not yet been asked for, holding it in readiness for up to two minutes. Sometimes she had several such instruments to hand, able to move instantly to the one required. As the operation proceeded, she deftly pulled the instruments and swabs that he had discarded away from the operative field.
Instruments that would be needed again she repositioned so that the handles were ready for him to grasp. The anaesthetist was also a crucial part of the dynamic. Physically, he was somewhat removed from the surgeon and nurse, standing by the head of the patient and taking frequent measurements of pulse and respiration. In both teams he exchanged banter with the surgeon though seldom the theatre sister scrub nurse , reflecting their longstanding professional and sometimes social relationship.
He also insisted — somewhat jokingly given the lack of a real patient — on his right to say when the operation could begin. He assumed the role of lead actor in a play, dominating the discourse, ordering other team members around, and looking to his nurse to affirm some of his observations.
Although he remained the focus of discussion and action, he did not perform to his team but rather chatted with them. In showing that there was no single template for team working, these differences highlight the impossibility of deriving general insights from individual case studies.
Nevertheless, we believe that our observations have a wider applicability. Historians have observed that surgery was a highly personality-driven field, and that through the system of hands-on training of junior staff, surgeons ensured that their methods and ways of working were disseminated to subsequent generations. Ellis and Black were just two of the wider population of surgeons moulded by their respective teachers. In turn, as highly successful, influential surgeons, each had multiple opportunities to mould the next generation.
This suggests that the patterns of working that we observed were not unique to them, but were more widely distributed throughout the profession. This impression has been confirmed by the responses of numerous surgical team members current and retired with whom we have shared our findings.
For the historian-observer of SBR, the technical nature of surgical expertise was particularly difficult to decode. Both surgeons conducted the operations confidently and without hesitation, handling tissues and manipulating instruments in a manner informed by experience and anatomical knowledge.
However it was not until they began to train junior surgeons in the procedure that they articulated the skills and actions involved, thereby making them accessible to the external observer. Some of this teaching was verbal, involving direct instruction in where to cut or dissect. Students were also quizzed, especially about the anatomy of the structures being operated on at the time. At times this was designed to put the trainee on the spot. Surgeons also passed on practical tips, demonstrating subtleties of technique which resisted description in words.
Sometimes they used instruments as didactic tools, to point out anatomical features or to trace their course in the air above the operative site. Fingers could also become surgical instruments. The nurse participated in the training process by anticipating the instruments needed and holding them ready. Much teaching related to general aspects of operative technique.
Specific aspects of the operation were used to address such fundamental matters as operative posture; how to hold, manipulate and use instruments; how to handle and manipulate tissues; how to tie a suture; and how to assist the primary surgeon, thereby becoming a fully functioning member of the surgical team. At the same time, the surgeons gave advice distilled from their own experience or from that of their own mentors, thereby revealing how expertise passed down the generations.
Sometimes they offered personal anecdotes and sometimes more general guidance on how to avoid complications or anticipate and circumvent disaster. We have argued that the tacit and embodied nature of surgical expertise is impossible to capture from traditional sources such as texts and interviews. Yet these aspects are central to the practice of surgery. We believe that SBR is capable of achieving this goal.
In post-enactment video review sessions, they repeatedly identified aspects of their behaviour of which they had been wholly unaware at the time, and which they had not mentioned during pre-enactment interviews. Such behaviours included anticipating the needs of other team members; passing instruments unprompted; assisting with surgical techniques; communicating in a variety of verbal and non-verbal ways; and using banter, humour and challenge for educational purposes while operating.
At the same time, our ability to recreate a real operation was limited by the nature of simulation. The deliberate construction of the event was probably most evident in the absence of bleeding in the hybrid model, coupled with anatomical differences between the pig and the human. At other levels, however, participants described feeling completely immersed in the situation and responding authentically as they perceived it to the operation and to one another.
Our observation of their behaviour endorses this belief.
Only later did she remember that the procedure was a simulation and that sterility was not required. This perceived authenticity is in line with simulation research across a wide range of domains, most notably perhaps in the reliance placed upon simulation by both civil and military aviation.
One question raised by our use of SBR to recreate the technical and social aspects of surgical expertise is the extent to which this method can capture the practices of a particular period. Since memories are constructed rather than being retrieved, questions arise about the correspondence between practices enacted now and experienced then. At the very least, we argue that SBR provides a documentary record of practices which by their nature elude description by other means, and which would otherwise go unrecorded.
So far as we are aware, this is the first time such an approach has been adopted within the history of surgery. Our work to date has focused primarily on the development and refinement of the method. Further research is now required using the documents we have created. This will enable us to build on the above observations about the team-based social and technical nature of surgical expertise. The novelty of this methodological approach brings challenges. For example, how can we make this rich data accessible to other scholars, and how should data analysis be approached?
Since social practices in the operating theatre are complex, layered and mediated through multiple modes, written transcripts alone are inadequate. At this stage we do no more than highlight the issue and open it for debate. Our own view is that video recordings could be mapped against a written summary, chronicling the key steps of the operation and providing time codes for specific events and transition points. Further analysis at a micro level could be conducted at a later date, perhaps drawing on the growing body of work around ethnomethodological approaches within the operating theatre.
While this paper has focused on the value of SBR to historians, we believe that it also has potential benefits to contemporary surgery. This means that many shared tacit and embodied behaviours are in danger of vanishing, and that valuable skills and expertise may disappear. The almost complete eclipse of open cholecystectomy by laparoscopic surgery has resulted in a generation of consultant surgeons who have rarely performed the open technique.
In such taxing circumstances, the requirement to perform a technique of which they have little background knowledge or experience is likely to result in considerably poorer outcomes than were achieved a generation earlier, to the ultimate detriment of the patient. Such concerns are not new. This problem is even more urgent two decades later. SBR may offer a partial solution, by preserving an endangered set of technical skills which could be drawn upon by surgeons of the future.
We have demonstrated that it is still possible to bring together members of longstanding multidisciplinary surgical teams for the purposes of SBR, despite the considerable age of their members. Such opportunities cannot last forever, however, and soon it may no longer be possible to reconstitute full teams from long ago. We believe there is an urgent need to carry out this work while there is still time. The speed of change in contemporary surgery, and the rapid disappearance of primary source material from the relatively recent past also make it important to capture present-day operative procedures for future historians.
Although, at one level, these procedures are becoming widely accessible online, the social practices of surgery with which we are concerned are seldom captured. Consequently, there is a strong argument for the periodic recording and archiving of present-day surgery for analysis by future historians.
Kneebone trained as a general and trauma surgeon in the s, learning to perform open cholecystectomy in the manner described below. After completing his specialist training he changed direction and became a general practitioner, then moved to academia to develop the field of surgical education.
Woods trained as a veterinary surgeon and worked in general practice before retraining as a historian of medicine. These topics feature heavily in overview accounts of the history of surgery. They have also been subjected to dedicated analysis. Key accounts include: A. Pickstone ed.
Lawrence ed. For an early sociological analysis of surgical teamwork, see R. Its contemporary dimensions are discussed by: S. Timmons and J. Wilde and G. Julie Anderson, Francis Neary and John Pickstone, Surgeons, Manufacturers and Patients: A Transatlantic History of Total Hip Replacement Basingstoke: Palgrave Macmillan, situates the development and use of hip replacement techniques within the context of health care costs and priorities, industrial development and patient perspectives.
See also the responses to Collins by N. I bid. Bezemer, A. A phased approach progressed through familiarization with the data, generation of initial codes, searching for themes, reviewing themes, defining and naming themes and generating a report. Data were subjected to repeated listening and review. Thematic analysis was performed initially within each data set magicians and puppeteers.
Data were collated and initial coding was carried out. A provisional thematic structure identifying selected themes and sub-themes was developed and refined through repeated review. Each data set magic and puppetry was treated separately at first. In the later stages of the process the data sets were examined against the surgical context and discussed with surgical colleagues, identifying areas of similarity, and difference and shaping concepts relating to performance in the context of surgical practice. The aim at this stage was to identify aspects of these performances that might resonate with surgery, without pre-judging what might emerge.
Discussions within the author's research group and with wider groups of colleagues and publics general and selected honed and narrowed the themes Appendix in Supplementary Material. Results from each case study are presented below, using selected verbatim quotations to support primary and secondary themes from the thematic analysis.
Key quotations are provided in the body of the text in order to contextualize the themes, while more extensive and additional quotations are provided in the Appendix in Supplementary Material using the same thematic structure. The Discussion section explores connections between these data sets and the practices of surgery. Over a 60 month period, eight professional close-up magicians took part in the study. A total of Phase 2 June to December : In depth exploration with an international group explored similarities and differences between magic and surgery.
A full-day closed-door meeting in London in December between six magicians, three clinicians including the author , a semiotician and other researchers provides a primary reference point for this study. The participating magicians all members of the Magic Circle or its American equivalent are highly regarded professionals in their field with successful careers in the field of magic, and all are recognized by their peers as outstanding performers.
Discussion took place under the Chatham House Rule to ensure confidentiality. Phase 3 January to Present : Eight formal discussion events both private and public in the succeeding months investigated in more detail issues that had emerged from the initial group meeting. These included further educational events with surgical consultants, trainees and other clinicians, and two public discussions with magicians and surgeons held at the Wellcome Collection in London.
Member checking through further interviews with participants allowed emerging understandings to be tested and refined. Verbatim quotations within the themes are used to ground and contextualize the discussion. Quotations are anonymized, referring to experts by number. A key characteristic of close-up magic was the need continually to engage with audience members as individuals, integrating performance with their responses. The performance itself is highly designed and constructed and its essence is a live encounter where unpredictability is a key element.
This requires high levels of skill in establishing and shaping relationships with audience members. The following elements can be identified. Successful magicians have developed precise and reproducible techniques for establishing rapport with their audience and generating a conducive atmosphere. This starts by creating a personal connection. That does two things. One, it says we're equal.
In addition to gaining their audience's attention, magicians must be able to direct that attention precisely. As a magician I need to know what's happening with the eyes. I have to know what you're thinking and to know that you know what I'm thinking at any moment. Magicians emphasize that, contrary to popular belief, their art does not involve hiding things.
Rather it requires the building of alternative perceptual worlds. Beginning magicians think it's about taking stuff away. But you can't really hide stuff. What you can do is build things. Performers are aware of the fragility of the relationships they construct and the need to perform with integrity. Magicians pay close attention to creating a shaped and constructed perception in their audience. This recollection may not correspond with what was actually said or done by the magician, since recollections are notoriously plastic and subject to subsequent refashioning.
One version is the thing that the person actually gets. Highly developed fine motor skills are an essential element of close-up magic. Acquiring these skills entails years of unremitting effort. The hands have to know how do to that, so that you have maximum opportunity to be doing the occupation stuff. For successful magicians, gaining and maintaining such mastery is a satisfying experience in its own right. These skills must become so much second nature that nobody watching is aware that they even exist. Magicians develop approaches to practice which allow them to maintain high levels of motor precision and accuracy.
Kind of unconscious practicing that results in muscle memory. These manipulative skills are only part of the wider context of performance—an awareness which comes with maturity as a performer. Becoming a magician as opposed to someone who can perform tricks involves maturation and requires a perspectival shift that does not always occur. They think it's more about how they're doing it, or it's about themselves. The creation of a shared frame between performer and audience requires collaboration whose essence is a personal relationship. Magicians are processing information on many levels at the same time, and taking action accordingly.
Close-up magicians in particular recognize this, developing the ability to make and act on rapid social judgments. Have to know who's head of the table, who's flirting, who's arguing …You're potentially interrupting five conversations. So you've got go over there as if you've got something more important to say or do than the people who're sitting there, having a very nice meal, didn't ask for a magician—so you have pick your exact moment, where you're going to stand—so if you are head of the table and I stand next to you—all of those geographical things—in seconds.
This requires constant awareness of audience dynamics and interaction. Magicians are in a state of high alertness as they perform, registering minutiae of audience response.
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Over a 30 month period, 11 puppet professionals including a director and dramaturg, puppeteers and performers, makers, and wranglers took part in the collaboration. Phase 1 : May to August : Explorations using surgical simulation demonstrated clinical practice in the consulting room and the operating theater. Surgical team members demonstrated open and laparoscopic keyhole surgery, using Distributed, and Sequential simulations in the author's research laboratory as described above to show individual and team work and explore its relevance to puppetry.
Surgeons subsequently visited puppet theater space and workshops. Phase 2 : February to Present : Evolving ideas were explored with invited groups of professionals from fields related to, though distinct from, puppetry. Ten further events each between 1 and 3 h include simulation-based clinical education and a range of crafts involving the management of threads marionettes.
In-depth discussion with surgeons continues to explore parallels. Member checking through further interviews with participants allowed emerging understandings to be tested and further refined. As above, verbatim quotations within the themes are used to ground and contextualize the discussion. This process is underpinned by high levels of awareness of others in the team, and an ability to respond collaboratively to the unexpected during performance.
Puppetry highlights performance aspects of a shared activity based around dextrous manipulation. This sensitivity to the bodies and intentions of other performers has to be deliberately developed. Puppeteers often expected to form newly constituted groups composed of unfamiliar colleagues. Physical preparation plays an important role. This is accepted as normal within the puppetry community. Puppeteers take pains to establish an effective group relationship, even perhaps especially if they do not know one another.
Preparatory exercises are seen as especially important in a performance genre where fine motor control is of primary importance and where performers are expected to maintain unnatural postures for extended periods Video 3. Exercises may include passing a puppet or an imaginary shape from person to person. Puppeteers deliberately foster a sensitivity to the physical signals they receive from one another while performing,. Team-working is clearly understood by all performers in a group. This is especially evident in Bunraku, an ancient Japanese form where three performers manipulate a single puppet.
In contrast to marionettes, which are manipulated by strings, Bunraku requires the puppeteers to move their puppet directly. One traditionally the most experienced controls the puppet's head; another its back and arm; while a third controls the feet Video 4. Although the puppeteers make no attempt to hide, remaining in plain view throughout, their focus as a group creates a powerful illusion for the audience that the puppet is alive and its manipulators are invisible.
Although all three puppeteers are indispensable, there is an understood hierarchy within the trio. Traditionally, the puppeteer controlling the head is in overall charge. Hand and feet puppeteers follow. Though the actual action may be led by another like the feet when walking , the intention to act is determined by the head puppeteer. Puppeteers expect and rely upon critique to improve and refine their work, taking it as entirely normal.
Such feedback forms an integral part of the performance culture of puppetry. And that can actually be really hard, because it can be very personal, very direct, very cutting. We have feedback during our rehearsal process. And that feedback is generally speaking from a director; often amongst yourselves; anybody who comes in and watches the work; and your self-criticizing things of course—you're your own worst critic […] There's constant feedback. A focus on dexterity and sensorial awareness highlights the intersection between hands, instruments and materials and the ability to respond to subtle physical signals.
In this case warming up is seen as essential for achieving the highest levels of fine motor control by hands and fingers over strings, rods or other objects Video 3. They'll focus on back or legs or whatever. But for puppeteers very particularly it's hands […] Same way as a sportsperson will warm up for a race, so they don't pull a muscle and they're ready to perform.
Although no single area of performance exactly mimics or reflects the world of medicine, each of the studies highlights aspects which are relevant to clinical practice and have been highly developed outside it. The following discussion explores how the themes and sub-themes identified above illuminate the practices of surgery and constitute a case for including it within the canon of performance science. The discussion addresses the consultation and the operation as distinct yet mutually dependant domains of performance. The clinical encounter can be viewed as an instance of close-up performance.
When successful, each patient is wholly convinced by the effortlessness of the encounter and the authenticity of the clinician's attention. Both involve an encounter which does not appear to be scripted but evolves naturally within a conversational setting. Both require performance within a range of contexts, often outside the control of the performer a hospital outpatient department, say, or a hotel ballroom where table magic is to be performed after dinner.
Yet both are in fact meticulously designed, presenting an illusion of spontaneity through painstaking practice. This is a complex process which takes place on multiple levels. This entails a shift in focus by the performer, moving from an internal to an external locus of attention. Continual recalibration is needed, acknowledging the audience rather than the performer as the central point.
The consultation can therefore be framed as a jointly constituted performance with a very small audience often of only one between clinician and patient s. It requires commitment by all parties in the construction of a shared experiential world. As with magic, medicine happens in a space between patient and clinician. If there is no patient, there is no consultation. It is not enough to have medical knowledge or skill. Such knowledge only becomes meaningful through performance. This process is not a simple transfer of information but requires a tailor-made account to be constructed with each individual patient, highlighting some aspects and downplaying others.
Magicians, like clinicians, pay close attention to such construction. As highlighted above, magic is not about concealing but about building an alternative universe—not hiding what is there so much as building up an experiential world. Experienced clinicians too are well-aware of their role in shaping expectations and of the consultation as an additive, not a subtractive, process. Although in clinical practice the aim is not deliberate misinterpretation, there are clear similarities in terms of performance intention and technique Wilson, To be successful, each phase initiating, continuing, concluding of the consultation entails specific performance techniques which can be learned and taught.
In all of these, attention management is key Macknik and Martinez-Conde, The ability to connect with every patient, whether new or already known, is a core skill, and constructing a successful engagement space requires high levels of self-awareness by a clinician. In surgery and in magic, then, the first few moments of any encounter exert a profound effect upon the rest of the performance. Initial contact and establishing rapport are crucial. In the surgical context this involves assessing each patient's state of mind and responding appropriately from the outset, a process which requires close observation and high levels of alertness.
Although seemingly natural and unforced, effective consultations embody consummate skill based on years of practice Lamont, Successful magicians have developed precise and reproducible techniques for establishing rapport with their audience and directing attention where they want it. Yet clinical training, especially in its early stages, is dominated by the need to acquire and recall factual knowledge, overshadowing the need to embed such knowledge with effective performance. The consultation requires rapid interpretation of non-verbal cues and immediate reaction to the nuances of a patient's response—all within an apparent relaxation and informality that belies the complexity of what is going on underneath Launer, Underlying this relationship between audience and performer is a process of collusion between performer and audience, whether conscious or not.
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In the case of a clinical consultation, this aims to reach a shared understanding of the patient's problem and a shared consideration of options for treatment. In the case of a magic performance, unspoken expectations are similar.
Gray, Henry. Anatomy of the Human Body
In both, the performer is aware of the fragility of the relationship Lamont and Wiseman, Finally, though all stages of a consultation are important, the closing moments have a critical impact on a patient's retrospective perception. Shaping an audience's final impression is a key skill, but the significance of this phase is often overlooked.
Clinicians are often preoccupied by the demands of the system in which they work, such as seeing a requisite number of patients, entering data onto the computer system and dealing with unexpected contingencies. Many consultations come to an abrupt halt without attending to this final impression.
Magicians, on the other hand, are expert at constructing a shaped and constructed perception in their audience. Comparing clinicians' and magicians' techniques for ending a performance offer a rich area of performance science enquiry. This is an effortful process underpinned by years of preparation, prolonged practice and continual recalibration. This requires many functions to become automatized so that they can be subsumed into the wider performance without conscious effort or even awareness.
Although the extensive literature on reflective practice within and beyond medicine addresses some of these issues, their implications have not been fully explored Schon, ; de Cossart and Fish, Although many consultations take place between one clinician and one patient, additional social, performative, and judgment skills are required when dealing with family or social groups.
In some areas, such as pediatric surgery, this can be especially challenging. A clinician has to make an immediate assessment of complex family dynamics, connecting with adults and children at the same time and gathering information about relationships between them.
This assessment requires continual review as the consultation evolves, and clumsiness can disrupt delicate dynamic structures.
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Magic performance requires similar skills. Close-up magicians recognize this and develop the ability to make and act on rapid social judgments. Performing successfully under such conditions involves recognizing when to step back as well as when to take center stage. Judgment is key, and such judgment only comes through long experience. A good surgeon knows when to operate. And a really good surgeon knows when not to operate.
The discussion so far has focused on interaction between clinician and patient. The focus during operative surgery is rather different, requiring a balance of individual and group skills within an ensemble. Operative surgery is a shared performance par excellence. It requires effective and often unspoken communication between its members.
Members of a surgical team stand in extremely close proximity, their upper bodies often in contact while performing. Often there is little eye contact, as participants' attention is fixed upon a directly viewed organ or a screen. Faces may be concealed by masks and unnecessary speech is curtailed. Specialized abbreviated terminology such as the names of instruments or anatomical structures is widely used and the language of the operating theater is adapted for its purpose Kneebone, This is a subtle process, of which many participants are unaware.
Much is conveyed by barely perceptible movements, tiny gestures take on a heightened significance, and sequences of movements are closely coordinated. For example, as a surgeon is tying a knot in a length of suture, other team members collectively but unconsciously anticipate the next move. The scrub nurse passes scissors to an assistant who reaches out to cut the excess thread, then hands the scissors back while the surgeon continues tying the next suture before the cycle repeats Bezemer et al. Puppetry constitutes a performance domain where objects hold particular significance and offers illuminating parallels Wilson and Milne, ; Francis, Puppeteers have an intense relationship with material objects, which they manipulate with a dexterity and precision which echoes the movements of the surgeon.
Unlike the solo performance of a close-up magician, puppeteers are part of a theatrical ensemble which shares many of the constraints of the operating theater. Puppeteers perform in close physical proximity, especially when collaboratively working a single puppet. Puppeteers cannot talk to one another during performance, and their collective focus is upon their puppets, not upon one another or the audience.
Puppeteers deliberately foster a sensitivity to the physical signals they receive from one another while performing. As described above, Bunraku puppetry requires coordinated teamwork similar to an operating team, where the roles of surgeon, first assistant and scrub nurse are distinct, complementary and interdependent and every member is indispensable.
In surgery, the collective focus of the team is on the patient, much as the puppeteers' focus is the puppet. In surgery and in puppetry, fine motor skills acquired individually but applied collectively are displayed in a choreographed performance which is jointly constituted. The diversity of puppet performance offers parallels with open, laparoscopic and other types of surgery.
Marionettes require puppeteers to handle long threads without getting them tangled up—a process well known to vascular surgeons when performing anastomosis joining together of small arteries and veins. Rod puppetry, like keyhole laparoscopic surgery, uses long rigid instruments to manipulate structures at a distance and requires similar levels of spatial awareness and precise control.
For puppeteers, an intense focus on dexterity centers on the intersection between hands, instruments and materials and the ability to respond to subtle physical signals. Surgery requires intense and prolonged practice over many years, leading eventually to unconscious mastery.
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Yet though dexterity and precision lie at the heart of operating, the aims of surgery removing this tumor, repairing that injury, replacing this joint overshadow the means by which this is achieved the complex coordination of hands and fingers between members of an expert team. For many surgeons, their hands are a means of manipulating the instruments which effect the procedure rather than a focus of attention in their own right. Though gaining such mastery is a satisfying experience in its own right, there are dangers than an unduly technicist focus will overshadow the social skills of live performance.
This resonates with anxieties in the surgical world, where students and trainees may over-focus on technical challenges and lose sight of the wider clinical context. In surgery, physical dexterity takes place within a team setting where surgeon, assistant s and scrub nurse work together as coordinated unit. In the past, stable teams of surgeons, nurses and others worked together for years or decades, developing shared vocabularies of embodied practice.