Moments of Rupture: The Importance of Affect in Medical Education and Surgical Training

Perspectives from Professional Learning and Philosophy

A. O. Mahendran

• Publisher: Routledge
• Year: 2019
• Print ISBN: 9781138317574
• eBook ISBN: 9780429847844
• Edition: 1
• Topic: Pedagogía
• Subtopic: Teoría y práctica de la educación

Surgery is a craft specialty: 'doing' in response to what is seen, felt and anticipated.

The potent odours and the raw images of flesh, elicit strong sensations and responses in the here-and-now or 'thisness' (haecceities) of practice. These experiences, trigger a world of affects and senses that can disturb or rupture familiar or established ways of thinking and knowing. This book attempts to articulate these emotional complexities of learning and practice by exploring affective encounters with the uncertainty of medical events. Employing a practice based inquiry, grounded in philosophical notions of affect and related concepts, real stories of actual practice are analysed and theorised to examine how events of clinical practice come to matter or become meaningful to surgeons, potentially disclosing new or modified capacities to see, think, understand and act. The philosophical writings of Alfred North Whitehead, Gilles Deleuze, Gilbert Simondon and Brian Massumi inform the exploration.

The critical discussions of this book are relevant for healthcare professionals, medical educators, practitioners and researchers interested in its main exploration: the affective conditions that emerge from disturbances in practice and their power to shape, construct and transform how professionals understand their practice and function within it.

Part I

Context and Theory

1 Introduction

Encountering the messiness of life, learning and practice

A Stolen Harvest

We change into scrub suits, I glance at the white, hospital clock, 10.52pm. The night has yet to begin. The operating theatre is large, cold with a faint whiff of detergent. Vinny, the senior surgeon, vigorously scrubs his hands creating an impressive pink froth. As I dry my hands I think back to earlier in the evening and a fateful conversation with Mr. Carrick, my senior trainer.

“What are you up to this evening?” The tone was nonchalant, but the fixed look in his eyes conveyed a serious purpose. In turn, I faithfully reproduced the expected response, “Hmmmm, nothing important. How can I help Mr. Carrick?”

“We need an extra pair of hands on the organ retrieval tonight… . you haven’t been on one before, have you …?”

Masked, gloved and gowned in sky blue robes, we perch on stools against the theatre door. I ask Vinny, “how many retrievals have you done?” His eyes betray the years of sleepless nights spent harvesting. An organ procurement or retrieval surgery is an operation in which a person who is dying gives prior consent to have their organs removed on death. These surgeries on the not-dead-yet are usually conducted in the unsocial, godless hours between night and twilight. The organs are then implanted in patients on waiting lists with liver, kidney or heart failure. It gives these human lives a second chance. Retrieval teams can travel far and wide to harvest organs. However, the destination always remains the same, a place between the portals of life and death.

I request that as both kidneys are to be retrieved, could I watch him remove the right kidney and then he supervise me with taking out the left? I reassert that he must let me do the procedure by myself; how else am I to learn? The transplant coordinator darts her head through the theatre door and sharply orders us, “the donor is here, everyone be quiet!” (The donor is the patient who has been diagnosed with brain death, kept alive by a heart and lung machine.) The whir of the patient trolley wheels can be heard in the distance, growing nearer with each microsecond. I can also hear a shuffle of feet – the donor is being brought to the theatre doors accompanied by a few members of the family and the nursing staff. Outside the theatre door lie the remaining vestiges of a human life in all its fading colours. Inside the theatre room lies the ultimate destiny of this human life – an offering of their tissues and organs.

Death cannot be coerced or hurried into a time of our choosing. Neither will it politely oblige or fall in line with our convenience. The living, however, are required to be punctual. A retrieval team must be ready to swing into action as soon as death has been pronounced. Our philosophy is, ‘always early, but never late’. The breathing apparatus is stopped. The sound of the donor’s family softly weeping and their heart wrenching sobs waft through what is supposed to be an impenetrable theatre door – a fierce barrier against the spread of infection and disease, but not, it seems, an impervious screen against the human condition. I feel anxious and uneasy, agitating in my gown. I was not prepared for this?! All that had been discussed was the placement of the incision, “from suprasternal notch to pubis,” and “clamp the aorta, move with speed, quickly dissect those tissues, there’s not much time to get those organs out …” Instead, here I am occupying a limbo land – a place where life has been extinguished but death has not quite taken hold, just yet.

The Hindus believe that after the moment of death has passed, the soul of the deceased floats in the atmosphere, waiting for passage into the afterlife. It’s a bit like occupying a seat in a waiting room, biding one’s time. I’ve often wondered what the lingering spirit of a donor patient would make of my surgical handiwork. Would they peer over my shoulder and remark that my hands could be steadier, my dissection more precise and surely, I could work with more speed?! Would they ‘tut-tut’ resignedly or ‘hmmmm’ in approval? Would the surgery school report read, ‘has real potential but must try harder!’

The doors swing open abruptly and the trolley is whisked in. The team turn their faces away. Too late. I see her face. Pale, puffy, swollen skin turgid from the weeks of medications and futile life-saving treatments. Brown, dishevelled hair, grey-blue eyes, dilated, staring into the blank air. I am rooted to the ground, stunned. Vinny seeing my distress, barks, “cover her face … Arundi, come over here and don’t look …” He knows it is too late to warn me. She will now live in a piece of my brain that frequently wakes me up at night with thoughts and images of things I have seen and done. Another person to haunt my being. Her body is transferred and quickly prepared for surgery.

KW – Organ Donor

Kimberley Walsh – Human Being

32-year-old female non-heart beating donor. Cause of death; large cerebral haemorrhage following an RTA (road traffic accident). Hit by oncoming turning vehicle at 40mph. Past medical history: fit and well, D&C (dilatation and curettage) for a miscarriage two years ago. Non-smoker, social drinker. Cervical smear in November clear. Last urine output 72 mls/hour, creatinine 93 mmol/l, blood pressure 110/72, not required inotropes. Registered organ donor. Family at first refused permission for donation to proceed.

Kim is 32 next Wednesday. Lives in Crouch End opposite the clock tower with flat mates Kerry and Sunil. Mum and Dad still live in Bournemouth, brother Jo has also relocated to London. Kim has been dating Neil, whom she met at a friend’s party three months ago. They were planning a week’s break in Malaga at the end of September. Kim teaches year 12 at Cranford Secondary School. She loves cycling and running marathons, is a fully qualified diver. Knocked off her bike three weeks ago whilst cycling home from work.

There is no time to dwell on those eyes. Brush it away. Bury it. But it remains, simmering beneath a veneer. Get on with the job. You have the living to contemplate now. Vinny grabs the knife from me. I have failed at my first organ procurement. The stealth with which he cuts and dissects the tissues is remarkable. He enters the abdominal cavity where the stash we have come for is being held. I watch, numb and paralysed. I had wanted to do this operation so much, but right now I have neither thoughts nor words that can articulate just how I feel at this moment. Later when we’re finished, Vinny pats me on the back saying stiffly and somewhat awkwardly, “Uhh … don’t worry … there’ll be a next time … you just need to do more, that’s all.”

How do I make sense of this strange harvest? We are errant farmers, appearing in the night to steal and abscond with a harvest that we have neither sown nor cultivated to maturity. We were not present at the time of birth to thrill at the beautifully formed fingers and toes, to take pride when the first few words were uttered, to nurse knees grazed on the school playground or to pack a car full of things to be debunked at a university dorm. Instead, we are robber farmers from a limbo land. Reaping a harvest which is carefully and dutifully implanted in the battered landscape of another human being. This harvest, stolen in the night, can nourish a diseased body and provide hope where there was little to begin with. This is the lived reality of our task. But today, I’m not sure that I have what it takes to be a robber farmer. And I’m not sure that I want to be a robber farmer, anymore.

1.1 What is this book about? Who is it for?

This narrative of a young surgeon ‘cutting her teeth’ in transplant surgery is my story, illustrating how an encounter with the reality of surgical practice deeply affected me. In those early years, I would eagerly grab training opportunities like this one – participating in a procedure that junior trainees considered folklore, a surgery that was steeped in mystery and allure. That night, I had expected to operate and acquire a ‘hands-on’ experience of organ procurement, reinforcing my pre-procedure reading and technical discussions with senior colleagues. However, what I actually experienced at the surgery was profoundly unsettling and wholly unexpected. In addition, my supervisor, Vinny, had not anticipated my reaction either and later attempted to brush off the incident. Even after all these years I struggle to verbalise what it was that I actually felt in those immediate moments of encounter and why I was incapacitated, unable to make a skin incision. Over time, I have experienced other clinical events which in those immediate moments of encounter have disturbed, disrupted or slowed down my practice. All this is rather abstract and a challenge to put into words, but, more to the point, why does it even matter? It is precisely this issue of mattering that concerns me in this book. I suggest that how I immediately respond in this encounter with the deceased patient – what I describe as the speechlessness of experience – relates to my unconscious attempt to grasp the experience, to make sense of it, to begin to process it and create meaning. In those initial moments of encounter, an individual is confronted with the ‘newness’ of the experience, its unfamiliarity and strangeness, evoking non-conscious feelings that reflect how the encounter begins to matter to the person. This book attempts to articulate these emotional dimensions of clinical practice from the insider perspective.

Although the book is informed by research data gathered from the experiences and training practices of surgeons, a community I belong to and am very familiar with, it is written for healthcare professionals, medical/clinical educators as well practitioners and researchers who are interested in its main objective: an exploration of the affective conditions that emerge from disturbances in practice and their power to shape, construct and transform how professionals understand their practice and function within it.

In the narrative, the potent odours, the graphic images of flesh, the strange textures and life-altering events, elicit strong sensations and responses, triggering a world of affects and senses that constitute the reality of the encounter for the individual surgeon. Through these powerful affective experiences, an encounter with practice starts to become meaningful to the practitioner, taking on a significance for that individual and potentially leading to ontological and epistemological growth.

1.2 The theoretical struggle of this project: examining aspects of experience which are obscured

In situations similar to the opening narrative, it is not uncommon to dwell on moments of uncertainty which relate to the intensities of affect: ‘What do I do here? How must I think or act? How do I carry on?’ On occasion, as described in the narrative, these emotional states can overwhelm one. However, a key feature of a clinician’s practice is the ability to perform in uncertain or contingent environments in which events cannot be adequately prepared for in advance. A focus on the practical aspects of a task, such as concentrating on the steps of a procedure, can help a practitioner navigate the turbulence of the unanticipated affective state and avoid incapacitation. However, a singular pursuit of the technical steps to a task can also reduce the emerging affective components of the encounter to the category of ‘inconvenient emotions’. The result is that affective behaviours are perceived as more of a hindrance to decisive action rather than a potential strategic tool in practice. But, as discussed in this book, the affective connections that emerge from unexpected clinical experiences can form important modes of learning and enquiry. These statements do not diminish or minimize the critical importance of learning practical skills, particularly in a craft specialty like Surgery. Instead, I argue for an approach that acknowledges the co-existing value of affective learning while recognizing its potential to extend existing pedagogic strategies in education and training.

To illustrate this argument, I use the example of how my practice as a trainer evolved and developed as a direct result of the narrated incident. I could empathise with and understand the educational difficulties that face trainees: predominantly, attempting to learn in unpredictable clinical situations, rich in affective consequences. I designed inductions and simple simulations to progressively immerse trainees in surgical practice. This included a formal initiation period to operative culture which involved exposing surgical trainees to empty operating theatres after hours, when no other staff were present. I anticipated, given my own experience as a new trainee many years ago, that in this new environment, a novice surgeon might develop affective responses on being introduced to aspects of surgery. The culture of the operating theatre is, amongst other things, fast paced, quick thinking, high stakes, unexpected, sexist, hierarchical, adrenaline dripping, all consuming, often joyous and sometimes devastating. A veritable fabric of affect can envelop and overwhelm a surgeon.

These initial student forays into surgical culture were designed to provide learning spaces for the trainee, so that the affective impact of clinical experiences could be facilitated, supported and unpacked. The latter refers to examining something of interest in detail in order to understand its nature. Such a process is important to make visible how affective responses modulate our ways of seeing, doing and understanding in clinical practice and learning. My aim was to help students recognise and reflect on their affective responses in comfortable, unpressured operative environments that permitted the development of individual awareness and personal strategies that would prove useful when forced to cope and learn with real events of actual surgical practice. What I have described is akin to the objectives of simulation training, a fast-developing area of skills acquisition in surgical education. However, my goal is separate to the objectives of standard simulation training. I seek to cultivate an affective awareness in professional (surgeon) training, which may have implications for both the technical and non-technical aspects of a student’s ability.

How can one investigate the affective dimensions of clinical practice, a nebulous aspect of learning experiences? How can the implications of the affective dimension for learning, teaching and practice be demonstrated or understood? These questions reflect some of the challenges that this project attempts to meet.

No discussion of clinical experience is complete without recognising how professional regulations, systems of assessment and performance measurements impact and control the ways in which clinical practice is enacted. Therefore, the second aim of this book is to explore how these aspects of modern medicine, responsible for organising and regulating clinical learning and practice, control, enable or frustrate a clinician’s ability to respond and react in appropriate ways. If it appears that this book is confirmation that I possess all the answers regarding the emotional character of learning and practice, please be forewarned that I do not! Instead, I attempt to instigate discussion about the affective nature of practice: what are its implications for the development of technical proficiency and clinical skill? How does it impact emerging professional identities? What is its role in shaping behaviours and attitudes in clinical practice? Readers are encouraged to engage critically with the ideas and concepts shared in these pages to compare ...

Table of contents

• Cover
• Half Title
• Series
• Title
• Copyright
• Contents
• Acknowledgements
• List of illustrations
• Part I Context and Theory
• Part II Representations of Clinical Practice: ideologies, complexities and candour
• Part III The Affective Conditions of Pedagogy and Practice
• Part IV Encountering the Reality of Clinical Practice: coping and learning in contingent environments
• Index