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social psychologist Richard Nisbett’s new Intelligence and How to Get It: Why Schools and Cultures Count dismantles outdated notions about hereditary, mental measurement, and intelligence.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.

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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.