Crafting Health
Of Workmanship and Medicine
Notes from a Family Meeting is a newsletter where I hope to join the curious conversations that hang about the intersections of health and the human condition. Poems and medical journals alike will join us in our explorations. If you want to come along with me, subscribe and every new edition of the newsletter goes directly to your inbox.
For those of you just joining, consider starting here to trace how I’ve been thinking about medicine and technology, a conversation I’ve been returning to time and again.
During my training, in the refining fire of the ICU, I learned how to place specialized intravenous catheters called “central lines” in one of three major veins (the femoral, the subclavian, or, now favored, the internal jugular vein). Patients were often unconscious or semiconscious, hypotensive, and likely to die without intervention. Still, I needed to be meticulous about each step to ensure proper, safe placement of the catheter. Gather supplies, prep the patient, find the vein, insert the needle, pass the wire, pass the catheter… Each milestone traversed afforded its own surge of accomplishment until finally it was all done. The patient was still sick, but I had moored them to some of the technology that would keep them alive.
Placing central lines, like so many other procedures, is a form of workmanship. David Pye, professor of furniture design at the Royal College of London, wrote that workmanship depends on “judgment, dexterity, and care.” If I’m cutting a board for a table, I need to make decisions about the length and width of the board, how that board will join to the others, how I make my measurements, what to use to cut the board, and so on. Even before that, I’ve made decisions about what kind of wood to use and what kind of furniture I should make. When it comes time to make the cut, my hands feel the wood and the saw. I sight my line. I know where I intend to cut. Throughout the whole process, I take care to bring my work as closely into alignment with the design as possible. There’s also a deeper care, in that I want to produce a good piece of furniture for its purpose - not only functional, but beautiful. I care about the environment and people it will serve.
I learned how to make tables long after I learned how to place central lines, but that same mix of judgment, dexterity, and care is in the work of the clinician just as in the woodworker. Pye would say both the making of a table and the placing of a central line are examples of the “workmanship of risk.” The quality of the result is not predetermined. “The result is continually at risk during the process of making.” Contrast this with the “workmanship of certainty,” which in furniture-making takes the form of factory production. There’s nothing like it (yet) in the placement of central lines.
Nor is there in my present line of work. I’m a palliative medicine clinician now. I haven’t placed a central line in years. Instead, I spend my days helping people with symptoms that bother them (e.g., pain, nausea, anxiety), and I also help them and their inner circle deal with their health (e.g., making big decisions, exploring services and supports). One of the major venues of my work is the serious illness conversation, where a patient, their inner circle, and clinicians come together to discuss this patient’s health in the context of a major problem like cancer or organ failure.
Here, my words are my tools. Like placing a central line or making a table, these conversations require judgment. I need to choose my words and behaviors carefully. When should I have this conversation? Who else should be there? Do I sit or stand? Do I speak in this tone or that? Do I lighten my affect or not? Which questions do I ask and when? This requires judgment beforehand about an overall strategy for the conversation, and moment-to-moment judgments over the course of the encounter. Judgment requires that I have myself in view (these are, after all, decisions about what I will or won’t do), but at the same time judgment requires me to get beyond myself as I serve something else (e.g., the health of another person).
Likewise, I can’t dispense with dexterity. I need to attend well. I need to place this conversation in the context of all the other information I have about this persons’ health. I need to be responsive and attuned to the behavior and emotions of others. I need to feel the emotional temperature of the room and appreciate the tolerance others have before any given word I speak.
makes the case in Shop Class as Soulcraft that there are truths that exist apart from our perception (e.g., something real has led to the malfunctioning of someone’s motorcycle). The mechanic’s dexterity must respond to this truth:“…finding this truth requires a certain disposition in the individual: attentiveness, enlivened by a sense of responsibility to the motorcycle. He has to internalize the well working of the motorcycle as an object of passionate concern. The truth does not reveal itself to idle spectators.”
So these conversations require care. In one sense, I need to care about my patient as who they are, not as an object of intellectual curiosity. Anatole Broyard, reflecting on his experience of prostate cancer, suggests:
“To the typical physician, my illness is a routine incident in his rounds, while for me it’s the crisis of my life. I would feel better if I had doctor who at least perceived this incongruity. … I see no reason or need for my doctor to love me - nor would I expect him to suffer with me. I wouldn’t demand a lot of my doctor’s time: I just wish he would brood on my situation for perhaps five minutes, that he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way.”
To the extent you believe you can get by in medicine without this first sense of care, to that same extent you’ll ignore your patient as the person they are.
In another sense, I need to be careful. This is what guides judgment and dexterity. Through care, I check my work against a standard (in this case, it would be whether the conversation is serving the patient’s health by guiding the patient toward a good decision). Am I actually helping this person? It’s remarkably easy to stop being careful when chasing after numbers that have been layered over what’s most important.
Crawford doesn’t reference the word “care,” but weaves the idea throughout his reflections on his work as a motorcycle mechanic. He uses the word agency instead. To combine the ideas, you might say that we are most able to care when our agency is best supported within the limits of our activity:
“It is activity directed toward some end that is affirmed as good by the actor, but this affirmation is not something arbitrary and private. Rather, it flows from an apprehension of real features of the world. … There is a progressive revelation of why one ought to aim at just this, as well as how one can achieve it. As you learn your trade this particular end takes its place in a larger picture that is emerging, a picture of what it means to be a good plumber or a good mechanic. Usually there is a real flesh-and-blood person who embodies this ideal, whom you emulate … The progressive character of revelation energizes your efforts to become competent - something about the world is coming into clearer view, and it is exciting. The sense that your judgments are becoming truer is part of the experience of being fully engaged in what you are doing; it is a feeling of joining a world that is independent of yourself, with the help of another who is further along.”
Caring is embodied in community with others. Caring invigorates work. Caring about how the work measures up to the standard provides feedback to hone the craft and increase competence.
If you read either Pye or Crawford and surmise that judgment, dexterity, and care devolve to mere ingenuity in service to personal whims (“the customer is always right”), Crawford has some push-back for you:
“My point, finally, isn’t to recommend motorcycling in particular, nor to idealize the life of a mechanic. It is rather to suggest that if we follow the traces of our own actions to their source, they intimate some understanding of the good life. This understanding may be hard to articulate; bringing it more fully into view is the task of moral inquiry. Such inquiry may be helped along by practical activities in company with others, a sort of conversation in deed. In this conversation lies the potential of work to bring some measure of coherence to our lives.”
Our work flows from our beliefs, however inchoate, about the good life. Our work also shapes what we take to be the good life. It shapes our life anyway. We might not see it right away, but that’s why Crawford invites us into a closer reading of our lives and work. What are we saying about the good life when, say, all medicine becomes technique in service to the preferences of individuals, rather than something in pursuit of an objective standard of health? Or when corporations mine the clinical encounter for money? What are saying about “lives worth living” in the way we deploy certain technologies? What are we saying about what makes for a good life?
Given the stakes, wouldn’t it be nice if we could increase certainty and reduce risk? We’ve got some little devices that do just that. We call them jigs.
Jigging Health Care
Sometimes I use a device called a jig to guide a tool. If I want to reliably cut a piece of wood to the same length over and over, I can use a fence and a stop block. A jig reduces the amount of dexterity I need and therefore results in a safer, more reproducible cut. Jigs also reduce the amount of judgment any given action requires, although they do this by requiring an up-front investment of judgment in the creation of the jig. All this increases certainty.
Medicine is full of jigs. Consider again the placement of a central line. Once I’ve inserted a needle into the vein, I pass a wire down that needle. I thread the catheter over the wire to guide it into the vein and then remove the wire. I suppose I could skip the wire and try to place the catheter without it, but not only would that be more difficult, it’d be less safe and result in the loss of more blood. The guide wire is a jig to make central line placement easier, safer, and cleaner.
What’s the difference between a tool and a jig? A tool accomplishes an action on the work itself, whereas a jig guides or modifies the tool. In the case of placing central lines, the needle is a tool, whereas the guide wire is a jig. Reference materials for looking up diagnostic algorithms and treatment strategies are tools, but an EMR alert is a jig. The algorithms themselves are jigs, refining and guiding diagnosis and treatment.
Clinicians sometimes try to jig serious illness conversations. Conversation maps are jigs. They reduce the amount of dexterity and judgment required by attempting to create a more reproducible action: when this happens, say or do this. This is different from serious illness communication training, in which the clinician learns to better use their words by honing judgment and dexterity.
Reaching for absolute certainty, it’s possible to over-jig a project. You might spend so much time thinking about jigs, making them, sorting through them, and admiring them that the project suffers. You lose sight of the design. I’ve never had the resources or the time to go too far down this path with woodworking, but I did it early in my medical training. Reference materials weighed down my white coat pockets as I woozily juggled scholarly papers sent to me by my teachers. I honed my note templates to make documentation as efficient as possible. I refined my rounding techniques. I stumbled through conversation maps in the middle of conversations. I needed to learn all that content and figure out a useful workflow, but jigs wouldn’t help me learn judgment, dexterity, and care.
Clinicians and administrators who lust after technical fixes - e.g., EMR alerts, order sets, note templates - place too much faith in jigs. Crawford warns against hobbling the cultivation of judgment leading to a loss of excellence:
“…we see fewer occasions for the exercise of judgment, such as the old-timers needed in riding their bikes. The necessity of such judgment calls forth human excellence. In the first place, the intellectual virtue of judging things rightly must be cultivated, and this is typically not the product of detached contemplation. It seems to require that the user of a machine have something at stake, an interest of the sort that arises through bodily immersion in some hard reality, the kind that kicks back. Corollary to such immersion is the development of what we might call a sub-ethical virtue: the user holds himself responsible to external reality, and opens himself to being schooled by it. His will is educated—both chastened and focused—so it no longer resembles that of a raging baby who knows only that he wants. Both as workers and as consumers, technical education seems to contribute to moral education.”
Medical training is so arduous in part because there’s newfound risk and responsibility with only nascent competence. But how else can you learn judgment and therefore pursue excellence in the craft? We may be tempted to jig medical education, smooth out its difficulty, and improve standardization, reproducibility, and certainty. The risk in reducing those risks is clinicians won’t then cultivate the necessary judgment to do excellent work, to know and pursue good things through their craft. This is, of course, in service to the burgeoning medical bureaucracy that presumably serves the whims of customers (I mean, patients), as Farr Curlin and Jacob Blythe observe:
“When componentiality is carried over into the practice of medicine, physicians and patients themselves become components, and each patient is conceptualized as a collection of increasingly minute components to be tinkered with at will. At each level of organization, these components are expected to serve the ends of the mechanisticity, predictability, reproducibility, and measurability. As such, each component’s function must be identical to that of its corresponding components. Unique entities are inimical to the componential mindset, as they threaten the aforementioned goods of mechanisticity, predictability, reproducibility, and measurability.”
In such a bureaucracy, with the primary aim of efficiency, the point of medical education (whether in school or throughout a career) isn’t to cultivate judgment. In fact, judgment is antithetical to the purposes of bureaucracy. Artificial intelligence (AI) is compelling to medical bureaucracies not first and foremost for improved clinical outcomes. It promises to provide those outcomes without the mediating fuzziness and fallibility of the human clinician. Of course, of course we’ll keep humans “in the loop.” We need someone who bears responsibility for errors, after all. But those humans will have had their judgment so atrophied by the use of machines and jigs that in time they will be only scapegoats.
Reaching for a jig isn’t a bad thing. But scrabbling after more and more jigs may be. Over-jigging may be a sign of value collapse: chasing after some metric of efficiency becomes the locus of attention, rather than serving the purpose of the practice. More jigs may not necessarily mean progress. Leo Marx offered a warning for those who would put too much faith in their tools. For the tradesman, they should also ask whether any given jig actually affords progress to their work:
“Does improved technology mean progress? Yes, it certainly could mean just that. But only if we are willing and able to answer the next question: progress toward what? What is it that we want our new technologies to accomplish? What do we want beyond such immediate, limited goals as achieving efficiencies, decreasing financial costs, and eliminating the troubling human element from our workplaces? In the absence of answers to these questions, technological improvements may very well turn out to be incompatible with genuine, that is to say social, progress.”
There is no health care without tools. But jigging health care, in an attempt to relieve the excellent tools of the fallible technicians, is not a viable path forward. We’ve always needed ways of cultivating and sustaining judgment, dexterity, and care. We need those ways even more now that our tools are more powerful.
"Judgment, dexterity, and care"-- that really does sum it up.