Portraits of Thinking: The Manual and Mental in General Surgery

I’m reading Matthew Crawford’s Shop Class as Soulcraft, which has been getting a wide reception. These last few months have also seen the release in paperback of Richard Sennett’s The Craftsman. And, by the luck of publication schedules, an essay of mine drawn from The Mind at Work, came out two weeks ago in The American Scholar. These have different orientations and goals, but share an affirmation of work of the hand, an examination of the intellectual and ethical possibilities of work that involves a tangible engagement with the physical world.

I hope, then, that these ideas are in the air, and that we as a society might be predisposed—even be just a little bit ready—to rethink our received ideas about thinking, about what it means to be intelligent. One more book to mention: social psychologist Richard Nisbett’s new Intelligence and How to Get It: Why Schools and Cultures Count dismantles outdated notions about hereditary, mental measurement, and intelligence.

In the entry that follows, which is condensed from The Mind at Work, I continue my portraits of cognition in action with a discussion of some of the thinking involved in performing surgery—and, along the way, some of the cognitive processes involved in physical therapy. I like this passage, for it allows me to further explore themes that run throughout The Mind at Work (and some of the entries on this blog), particularly the limitations of our traditional separation of the manual and the mental and the problematic conceptualization of cognition, intelligence, and ability that issue from that separation. 

We as a society have developed a popular vocabulary of work that leads us to make easy but substantial distinctions between work of body and brain, of white collar and blue—these days expressed as the new knowledge work versus old-style industry and service work.

While these distinctions surely have meaning in terms of status and income, they may be less definitive than we think and may blind us to commonalities in the way different kinds of work actually get done at the level of immediate, day-to-day practice. We gain, I believe, a richer appreciation of competent performance, a broader sense of it, by observing, for example, the sequencing and pacing of tasks in a range of both blue-collar and white occupational contexts, or the strategic combining of the senses in service of both the tradesperson's and the surgeon's diagnosis. With that, let me introduce Ronald Tompkins, M.D.

* * *

Ron Tompkins has been a surgeon for thirty-nine years, was Chief of General Surgery at UCLA. He and I are watching an instructional CD of a laparoscopic gallbladder operation. Dr. Tompkins is explaining what unfolds on the screen.

The surgeon's instrument is moving onto some small vascular structures. "See these little vessels right here," Tompkins says. "They're coming out of the liver directly into the gall bladder." His finger guides me. "They're tiny, but they bleed like hell if you don't cauterize them. That's what he's doing now." And a tiny puff of smoke comes off the vessel.

I ask Tompkins about the anatomy here. A first-year resident I played the CD for could recognize basic structures, but was still learning about detail and variation. The resident spoke as well about the difference between learning the anatomy from a textbook or even from a cadaver—which is inert, bloodless, without pulsation—and elaborating and refining one's knowledge through the living human body. "Ducts in the biliary system," Tompkins agrees, "have a wide variation. And, yes, a textbook may have a chart of twenty variations, but then you'll go in and find a misplaced artery." He continues, explaining the importance of hands-on experience, guided by more senior surgeons—"no, don't feel down there, feel up here" – integrating textbook and laboratory knowledge with this knowledge of how things actually feel and look. 

Tompkins pauses the CD and talks a bit about the importance of visualizing the anatomy, speaking almost geographically about the interior of the body, in terms of landmarks and signposts and planes of tissue. (One of Tompkins' colleagues speculated with me that surgeons "think graphically…have a lot of images stored.") Vision is also crucial in assessing pathology. One of the residents I interviewed described his first encounter with abdominal surgery, where the supervising surgeon said "Oh, this looks great…", but to the resident " it looks like this nasty, open wound." Over time, however, the resident noted, "you develop an eye for what looks good and what doesn't….You get to the point where you feel comfortable looking at something and evaluating it." As happens with immersion in other kinds of work, the young surgeon's perception is becoming more disciplined. 

This visual and topographical orientation interacts with touch, and, turning attention back to the gallbladder procedure progressing now on the screen, Tompkins notes the physical limitations in current laparoscopic technique. "You lose that tactile sense that a lot of us have grown up with. You might be looking at something on the anterior surface, but you need to know what's behind it, so you get your fingers behind there and you feel: does it feel like a tumor, or a lymph node, or does it feel like a blood vesse—you know, you can feel the pulsation." I'm reminded here of the expert plumber "seeing" with his fingers as he feels structures hidden from sight behind a wall. If the surgeon who speculated about a storehouse of images is right, I suspect that there is, in a surgeon's knowledge, a storehouse of the feel of things as well. In a sense, the geographical language Tompkins and his colleagues use is not metaphorical. The surgeon's knowledge of anatomy has to be physical. He or she will be working in tissue, moving it, tugging on it, cutting into it. Knowing is visual, tactile, practical. 

This fact complicates easy distinctions between abstract and concrete knowledge, what is seen and felt is freighted with meaning, and abstractions about physiology or pathology are useless unless embodied. One thinks one's way through an operation by feel and image as much as by proposition.

I want to dwell a bit longer on this blending of the ideational and the tactile, for, in educational and occupational discourse, the conceptual is so often separated from the physical—and given more status. About a year before my time in the Medical Center, I observed the training of physical therapists, a different field of health care that also requires manual skill, but in a way that integrates, no, fuses touch and concept. Take, for example, the key notion of resistance.

Put simply, resistance refers to the stiffness of a musculoskeletal structure—the degree of flexibility or fluidity of movement of a knee or vertebrae—and a physical therapist tests resistance by manipulating the structure by hand through its potential range of motion. Resistance is a concept of key diagnostic importance, for it provides a way to understand and convey how severely a patient's mobility is restricted and provides information, tactile data, that contributes to diagnosis and treatment. 

Physical therapy students first learn about resistance in coursework and textbooks, but then must blend book knowledge with clinical experience for resistance to become more than an inert concept, to be truly known and to be of use. The effective assessment of resistance requires that the physical therapist's manual technique—the positioning and motion of hands and body—be skillful and adroit, otherwise the inefficiencies in the therapist's own movements will contaminate the information sought about the patient's range of motion. The therapist's body, then, not only provides the means of treatment, but also becomes the instrument that receives information from the patient's body. The therapist's hands are both tool and gauge.

As therapists train, their tactile sense of resistance becomes more discriminating. And one of the things that makes the development of this discrimination difficult is the number of musculoskeletal structures involved, each with its own range of motion—from the limited movement of spinal vertebra to the wide swing of the shoulder. A therapist must also gain a sense of the range of normal variation, person by person. As one experienced therapist explained it: "You need to get a feel for all the feels. Then you'll form an idea….you need to get a sense in your hand." Resistance, truly known, is an average of feels, a tactile abstraction, a kinesthetic concept. It's quite hard, here—as it was in a number of the occupations I observed—to separate hand from idea.

Let us now return to Dr. Tompkins' narration. At various stages of the gallbladder surgery, Tompkins has been talking about the importance of technique—in laparoscopic or open procedure—and the interplay of technique and the body. The importance of "being gentle on the tissue…knowing what tissue will take and what it won't take." And though direct touch is critical, the surgeon, with experience, develops the ability to feel, as one writer puts it, "with the instrument as if by…fingertips." As I saw with many tradespersons, the skillful use of the tool provides feedback to the hand. I think of carpenter Jeff Taylor’s observation in Tools of the Trade: “At a certain point, upon a day, you almost become the work, a moving and cognitive part of the tool in your own hand.” 

Beyond technique, or more precisely, developing from it, is the ability to manage the steps in a process. Not only getting each technical move right, but arranging the moves properly and fluidly. I had the opportunity to observe more experienced, fourth-year residents operating on a series of plastic models—removing an embolism, resecting a colon—and, to a person, each commented on the challenge, at their stage, of knowing what to do next, and next—each necessary step anticipated and followed in order—and what decisions to make when there is no supervising surgeon present to guide them.

And there is a further consideration here. Though surgical procedures involve predictable sequences of steps, one must continually respond to variations in the patient's anatomy, the residue of trauma or prior surgeries, the surgeon's own mistakes—a nick, a clumsy move—and the unexpected responses of the patient's body. As with the other kinds of work I observed, effective decision-making requires not only a repertoire of skillful routines but also a developed sense of how to modify routines in order to gain a desired effect, a technical suppleness. 

The surgeon on the screen is bringing things to a close. I ask Dr. Tompkins what might have happened if, say, the gall bladder had been in an odd position or if the surgeon had run into scar tissue from a previous surgery. "You've got to be prepared for these things," he says, "and you've got to be able to judge when its not safe to continue this laparoscopic procedure and convert to open surgery.

Dr. Tompkins continues to talk about judgment. It is a topic that other senior surgeons I met focus on as well—perhaps the most pressing issue as they attempt to train young surgeons.

Good surgical judgment, they tell me, involves the information one has about the patient. And it involves what one knows about the procedure in question – what's been published about it, what techniques detailed, what probabilities of good outcome. This book knowledge is augmented, revised, made incarnate through experience.

Surgical judgment emerges from a physical knowledge of anatomy, from technical finesse, from procedural skill. And, as with so many of the kinds of work I observed, important craft values are woven through this competence: persistence, self-monitoring, knowing limits. 

"You know," Tompkins reflects, leaning back from the computer and turning directly to me, "you can talk about judgment and describe it more than you can define it. You can describe situations where it comes into play, and by describing those situations, then you can, kind of, put flesh on the thing." Drawing on a complex mix of knowledge, skill, and character, surgical judgment is, if I understand it, contextual and in-the-moment. And though it involves abstractions (for example, probabilities of outcomes or generalizations about disease processes), it is also profoundly immediate and physical.

There is a powerful tendency in Twentieth Century intellectual life to create mathematical or logical models to represent reasoning and decision-making. I think it would be pretty difficult to model surgical judgment. Surgical judgment provides yet another example of the way dichotomies such as technique versus reflection and concrete versus abstract break down in practice. The surgeon's judgment is simultaneously technical and deliberative, and that mix is the source of its power.

Portraits of Thinking: Two Primary-Grade Teachers

Here is another story about cognition in action, an account of two primary-grade teachers. In this portrait (and one to follow in a few weeks), I want to call attention to the thought involved in good teaching. In our current policy environment, “qualified teachers” are rightly championed, but there is little discussion of teaching itself. The teacher becomes the mediating mechanism between student and test score—important, but faceless. In the following vignette I try to highlight some of the teacherly knowledge and skill at play in a primary classroom: The complex blend of planning, coordinating of tasks, on-the-spot decision making, knowledge of cognitive development, and pedagogical sensibility.

For those of you who missed the previous entries where I discuss the purpose of these portraits of thinking, I’ll repeat two introductory paragraphs now. If you did read the earlier entries, you can skip right to the story of Anne Brown and Abby Cowan, which is drawn from Possible Lives.

As I’ve been arguing during the year of this blog’s existence—and for some time before—we tend to think too narrowly about intelligence, and that narrow thinking has affected the way we judge each other, organize work, and define ability and achievement in school. We miss so much.

I hope that the portraits I offer over the next few months illustrate the majesty and surprise of intelligence, its varied manifestations, its subtlety and nuance. The play of mind around us. I hope that collectively the portraits help us think in a richer way about teaching, learning, achievement, and the purpose of education—a richer way than that found in our current national policy and political discourse about school.

***

It was the hundredth day of school in Brown Cow’s classroom, which was actually two classrooms and three primary grades combined—the door between them permanently open—kindergarten, first, and second grades brought together and team-taught by Anne Brown and Abby Cowan, who, in the three years of this partnership, had become Brown Cow. The children, together for their three primary years, said that they were in Brown Cow class, that they, themselves, were Brown Cows.

One Hundred Days. A milestone in primary school, so there would be all kinds of activities involving the number 100. The mother of one of the children brought in a piece of fabric printed with a hundred brown cows, fairly realistic cows, but for the red-and-white life jackets each wore. Mrs. Brown had all sixty-one children around her, leading them as they counted off: fif-teen, six-teen, seven-teen. Ms. Cowan was quickly laying out the materials for the next lesson, hustling through the two rooms.

Along the south wall were rows of mimeographed sheets done in anticipation of this hundredth day of school, blanks in sentences which the children filled in. “I can eat 100 grapes,” Yuki’s claimed. “I can hold 100 coins. I can play games 100 times.” Joey’s made different claims. He could blink 100 times, but could not eat 100 beans. Matthew could flush the toilet (he’d whispered this to Mrs. Brown before writing it) 100 times, but certainly not eat 100 Brussels sprouts. Who could? And Chris, he couldn’t no way, hold 100 worms.

Eighty-five…eighty-six…eighty-seven. Mrs. Brown was approaching the last row, touching each cow in turn, but remaining silent, the chorus of high voices rising even higher in anticipation. Crescendo. The century mark. “Wow,” said one boy in front, “it really is a hundred.” “Not all the children can count to a hundred on their own,” Abby said to me, whizzing by, “but those who can’t are guided along by those who can.”

The idea of “mixed age” or “undergraded” primary classrooms gained some national popularity in the late 1950s and sixties, then faded; it is once again being discussed as part of school reform. The pleasant, productive chaos of Rooms 13 and 14 at Franklin Elementary belied the boldness of Anne and Abby’s experiment, for what they were doing challenged one of the most widespread practices in elementary education: setting cognitive and linguistic benchmarks for children’s development.

“Children just don’t learn to read or write or count or compute at the same time,” Abby said in exasperation. “There’s all kinds of normal variation. Some kids don’t really start reading until the second grade, and they go on to become fluent readers.” Yet the anxiety that can be generated when a child doesn’t hit one of these arbitrary benchmarks—especially among some affluent parents who attach great significance to such measures—is considerable and can lead to a range of remedial interventions, some more harmful than helpful. The Brown Cow classroom was attempting a revision of that way of thinking about children’s growth.

By the time the children had finished their cow inventory and had their say about it, Abby had finished setting up the room for the next math lesson. The students would break into two groups. Those who were more advanced mathematically went with Mrs. Brown, and the rest went with Ms. Cowan. This was to be a lesson in counting and grouping by tens. The children had white mats (and the mats Ms. Cowan used had grids on them, clearly marking ten spaces for an added visual clue) and sacks of small objects they had brought in the day before, from pennies to dog biscuits. The children were to count out ten piles of ten.

They got at it, counting, sorting, piling—lots of chatter, to themselves and to others. I sat down and watched Abby. She was all over the floor, on her haunches, kneeling, turning quickly on her knees, stretching backward, extending her line of sight. “Count those out, Joey.” “Good, Melissa.” “Watch, Sebastian, what happens when I do this.” “Mantas, show Brittany what you just did.”

It is remarkable, this ability that good primary teachers have: to take in a room in a glance, to assess in a heartbeat, to, with a word or two, provide feedback, make a connection, pull a child into a task. While the majority of Brown Cow’s children were native speakers of English, there were also Eddie and Mantas, making the transition from their native Lithuanian, Yuki (and her sister Yuko), whose English was limited when they entered the class, and a fair number of students whose first language was Farsi or Spanish. So Abby and Anne made a conscious effort to get native-born children to help Mantas and others—and to get Mantas and company to use their new language to explain things to whomever was close by.

In Anne’s half of the shared classroom, children were making their piles of tens with little trouble, but there would be more for them to do. One of the benefits of the ungraded primary is that students who were excelling in a subject could be encouraged to go beyond kindergarten or first-grade guidelines. Mrs. Brown had written eight problems on the board, to be solved with the help of the students’ “manipulatives,” their pennies and stamps and leaves.

1) 20             2) 60               3) How many 5s in 200?

  +30               +90 

And so on. “How can we do two hundred when we only have one hundred?” Jeremy asked. “Good question,” said Mrs. Brown. “What do you think?”

All the Brown Cow children took districtwide achievement tests, so standard measures of learning—and accountability—were in place. But Anne and Abby have also been trying to develop a different kind of report card, one that reflects the way their class worked. “What does it really mean to say that a kid is doing math at first- or second-grade level?” Anne asked rhetorically. “That’s awfully vague…and not very helpful. What we want to do is provide a description of each child’s strengths and weaknesses. And since we get to know the kids so well over three years, we should be able to do that with precision.”

When the bell finally rang for physical education—a twenty-five minute break when the children would be out in the yard—Anne and Abby started setting up for yet another lesson involving the number 100, this one to combine arithmetic and language arts.

The teachers distributed old newspapers on the tables in two rooms, then scissors, glue, and large pieces of art paper: yellow, blue, green, magenta. As they did this, they reviewed the morning. How did the lessons work out? Who was doing well? Who needed help? How might Anne better integrate the math problems with the use of the manipulatives? How can Abby do more with her children? They also talked about a boy who might be ready to move into the more proficient math group, such movement being central to this mixed-age grouping.

The bell rang, and soon there was the flap and chatter of the children’s return. Ms. Cowan and Mrs. Brown gathered them around and began explaining the lesson with the newspapers. The children would work in assigned groups of eight—the Yellow Group, Green Group, Magenta Group. These were mixed age and ability groups so that the younger children would learn from the older. (Earlier, I had seen Abby pair a second-grader with a kindergartener to read a book; there were lots of possibilities for such peer tutorials in this room.) The students were to find a hundred words that at least one person in their group could read. “One hundred words you know, and cut them out, and paste them.” Then the teachers would put the final products on display.

Mrs. Brown explained the assignment one more time, and off they went, the girl in the flowered pants, the boy in the Raiders jacket, the girl with the oversized sweatshirt. Anne and Abby moved from table to table, organizing, demonstrating, cajoling. “Ms. Cowan,” Lisa said, touching Abby’s arm, “I can’t read yet.” “You know what, sweetheart?” Abby replied, kneeling down. “You’re starting to; you can read some. Look.” And she pointed to some words on the page of advertisements, and Lisa read them: and, the, to, Muppet. Then Lisa wiggled her fingers awkwardly into a pair of scissors and started cutting, Muppet first, then and, then to.

A focused pandemonium spread over the room; kids wrangling for pages with big print, singing the words out as they cut them, pounding them onto art paper, reading loudly, and more loudly, the words they knew, discovering them amid a growing jumble of newsprint. You, book,tax, four, down, Clinton, dream, deal, warranty, house, Von’s, blowout, celebration, doctor,banker, slashing, champagne. (“Hey, I found the word champagne”), Cocoa Puffs, matinee,guarantee.

Cut and crumpled paper piled up on the floor, the children kicking through it as they moved around the tables for yet more words: silk, tennis, Vietnam (Abby: “Do you know why that word is important?” The little girl in flowered pants: “There was a war there”), sale, love,dress, book, need. A girl came up to Anne with the word squash stuck to the top of her finger. A boy thumped his new word onto green paper. Abby helped a child read need. Neeeed. And all around the room, words not known, words cut away, fluttered to the floor.