This essay has uses examples of being-in-the world over time. How something was learned. How are these types of findings used and how can they be integrated into our life and work? The examples are: 1. Shock and Awe 2. A summer spent in a tipi with a high school teacher 3. A class on how to close your mind. 4. An investigation of nursing service administration 5. On being a subject of social science investigation 6. Sudden automatic reactions 7. A Loss of Innocence 8. Joe 6 Pack at Death’s Door 9. A Dance to the Music of Time CHILDHOOD Spring Shock and Awe Looking back many years to my six year old self there is this memory of briefly being on the edge of something important and some action of mine having more of an impact than I expected. Recalling this event growing up as a child in WWII with an impressive but mostly absent father the memory was comforting. I was on the side of the good guys. My Dad and I were on the small Chris-Craft my grandfather and Uncle Chan, a “conch,” native Floridian, used to fish out of Miami. We were following the cruiser Tuscaloosa out of Biscayne Bay. In those innocent days, before terrorism days we could follow closely along side. A line of sailors in Navy white tropical uniforms was lined up along the rail. As we passed the flag at the stern I saluted the flag and the officer of the deck called the sailors to attention and returned the salute. I was tremendously excited. This great war machine had actually responded to something I did. Excited but probably scared as well. Unintended consequences. Be careful what you wish for. Etc. SUMMER. YOUNG ADULTHOOD A Summer Spent in a Tipi The summer of 1952 I was 17 I lived in a tipi at the Henderson’s camps on Lopez Island as an assistant counselor to Bill Holm. Bill was then a high school art teacher at Lincoln High in Seattle. Bill was working on a Master’s Degree in Fine Arts at the University of Washington. He had been a forward artillery observer perhaps the closest thing in modern times to an Indian scout. During the day we managed, taught and controlled when possible, a “tribe” of 11 year old boys. At night all were in tipis and Bill and I were in his tipi. Unlike the others it was built to his specifications. I learned Bill had a very special, serious, relationship with Native Americans (just Indians back then). He had lived in Hardin, Montana just off the Crow, Northern Cheyenne reservation. His family moved to Seattle when he was 12 and his early interest continued. He had learned Indian crafts and Plains Indian dances. In Seattle he found the Burke Museum and met anthropologist Erna Gunther and had opportunities to learn of NW Indian culture, inland and coastal. His career combined eventually scholarship, highly skilled craftsmanship, art and teaching. These artificial distinctions are a limiting problem of our hyper-specialization and labeling, in Bill it was just one authentic, integrated person. Like the eleven year old campers I was impressed with his abilities but not until many years later did I appreciate how much I had learned, without knowing it, by simply being there and watching. Over that summer I watched him make a song flute out of cedar, a headdress out of horse hair, and three bows out of yew wood. The completion of these projects was very slow and patient. First efforts had to be revised, changes made. Bill seemed to be working from a mental model but it was not apparent to me what it was. Somehow Bill had established a relationship with a Northwest Indian Tribe and invited representatives to visit the camp for a summer celebration, a Potlatch. There were many dances and a salmon bake, authentically over an open fire. In later years Bill carved Indian canoes out of cedar logs. One year my brother at that time waterfront director at the camp cruised around the San Juan Islands with Bill in one of the canoes. His replication of art, craft, and dance gave an entry into other cultures that was respectful, non-intrusive, and avoided over-eager interpretation of cultural meaning on the basis of dominant culture experience. For a slightly later development of a similar approach see the Introdcution in The Headman and I: Ambiguity and Ambivalence in Fieldworking Experience.CITE DOES NOT WORK HERE ? BETA ? Jump forward in time to 1970, I had completed training as a psychiatrist and psychoanalyst and been a consultant at the University of Washington Adolescent Clinic. One of the pediatrics graduates was now director of a hospital in Montana and need a psychiatric consultant. I jumped at the chance but before heading for Montana tried to find Bill. He was now ethnology curator at the University’s Burke Museum. A talk with him was very helpful and renewed my identification with his methods of learning about tribal customs. My consultation developed into 12 years of part time work with Plains and other Indian tribes and HeadStart. I found in simply watching Bill work and casual conversation I had found a mentor for appreciating the crafts and interests of different cultures. Almost all of this was outside my conscious awareness. I find in old age an increased appreciation of this as I reflect on my life. YOUNG ADULTHOOD A Class on How to Close Your Mind My undergraduate major was psychology. I chose that major as a pre-med student because it had no language requirement and that allowed me courses in history, philosophy (Logic, Philosophy of Mind), cultural anthropology, andcriminology other than more chemistry and physics of which I had enough. (Enough already as they say these days.) To progress to upper division courses there was a boring, tedious course taught by “Saint Thomas” that was referred to by all students as the “catechism class.” Here we were to pledge our lives to behaviorism and associated cognitive theories and deny all other biologic, social science, child development, or (God forbid) psychodynamic (Freud, Jung, Piaget, Janet) knowledge. Anything deviating from behaviorism, especially B.F.Skinner, was the object of ridicule and carried the threat of ex-communication or even worse having to repeat the course. Even over the years the terminal boredom and suppressed anger stands out above all the competition. It taught me how Not to teach. “What is being done is what is being learned.” (Edwin Guthrie) In this example learning to suppress thinking and learning how to be angry and bored and passively accept horse manure. An Investigation of Nursing Service Administration Would I be accepted to medical school?(1954) There was some doubt, it was quite competitive. If not what would I do. I decided with a friend to take a course on Human Relations in Business taught by some new faculty, from Harvard, in the Business School We did well as psych majors and were invited to be very junior investigators that summer in a study of a large city hospital of “Human Relations in Nursing Service Administration” a large grant from the Kellogg Foundation. All the administration would be shadowed by observers. My friend and I were to follow the night shift nursing supervisors, be quiet, use non-directive interviewing and dictate our notes at the end of the night. Within a couple of weeks we knew all about the supervisors, their families, the wards, the hospitals, and all that one sees in exaggerated form on “Grey’s Anatomy” or other medical soap operas. Eight file drawers of dictated notes were transcribed. In trying to follow up what happened to the study I was informed it was unpublishable. Senior authors went on to other things. The method turned out to be too powerful for the data. Unexpected results. On Being a Subject of Social Science Investigation Criminology class taught me that at least on adjective check list questions “the inmates of the Texas State Reformatory and the freshmen males at Washington State University reported equal incidence of crimes committed.” The difference being the Reformatory inmates were caught. During college as a psych major a few times I was a subject in various experiments of faculties in the social sciences Sometimes a willing almost paid participant, sometimes a passively-aggressive compelled subject. Guess what? Often the subjects are at least as smart sometimes smarter than the investigators and enjoy producing false, misleading, deliberately deceptive, or exaggerated answers to what are considered dumb, insulting questions or the whole study is considered stupid or evil. (In the same way "native’ informants of anthropologists have been known to tell tall stories, play jokes, or cleverly mislead the investigators.) Medical students and psychiatry residents were subjected to more intense study, sometimes quite intrusive, and often without “informed consent.” Some biologic experiments may have been dangerous. Some of my classmates took radioactive labelled compounds for a hefty fee to study hemoglobin metabolism. I was offered 25 dollars to take LSD. I turned it down as I had observed the effects on rats and cats. When social scientists “shadowed” us on the wards and wrote us up in their social science, experience distant language, generally to prove a pre-conceived notion of their own we found it disturbing. We felt they did not understand the systems, the stresses in our lives, or even what we were doing. The shoe was on the other foot. Or to quote Native Americans “before you criticize us walk a mile in our mocccassins.” ADULTHOOD. AUTUMN A Loss of Innocence When I was starting our in medical practice I interviewed for a part-time position as a director of a clinical center. I was one of several applicants and the best qualified by education and experience. The interview was conducted by the acting director and he questioned me closely about what I would do if I took over as director. I had some fairly detailed and ambitious ideas about what could be done with the resources then available. The job went to someone I considered less-qualified and at the time I felt somewhat hurt. A few years later the director was ousted, my interviewer took over and the plans I had described were put in action. Belatedly I realized this had been the idea all along. Despite having book learning about organizations, having seen the “dark side” of several organizations, when it came to my own welfare I was naive and did not notice hints nor remind myself that decisions were not always fair or made on merits. In the long run this was a very valuable experience. I had no part-time work to “fall back on” and had to make my own practice successful with no safety net. Joe 6 Pack at Death’s Door A few years ago I was admitted to a critical care ward in septic shock. Some evil little germs had invaded my system and used their toxins to make me critically ill. It turned out they came from a quarter inch cut on the top of my foot and now my whole right leg looked like a rotten ham. Both arms had iv drips of anti-biotic, the right leg was elevated and the left had a pump that contracted and expanded to exercise the leg and prevent blood clots from forming. I was not going anywhere. I acquired a roommate here called Joe 6 Pack. A exhausted looking fellow, salt of the earth type, with a big family and devoted wife who visited daily. When they were not there we would visit a little. He was there for a cardiac workup but it was delayed as his blood tests revealed serious kidney problems, added on to his heart, lung, diabetes and sleep apnea problems. He lived over a hundred miles from a regional hospital and about fifty miles from the nearest physician. Joe’s family doctor had retired the year before and he then became discouraged and sicker and was shuffled from specialist to specialist with no one then really being “his” doctor. I heard the family and Joe discuss this several times: how good Dr. X had been, how he told the family what to do, how Joe trusted him, how they could talk on the telephone. When the residents and hospitalist made rounds they barely talked to Joe. “He is waiting for test results” the resident would say. “How are you feeling, Joe?” the hospitalist would say. Joe would slowly drag out “OK, I guess” and they would move on to me, a more “interesting” patient. Joe sounded tired, depressed and full of woe. At night I listened to his sporadic snoring and gasping, typical of sleep apnea. I asked him about it. It had be diagnosed but he did not follow thru on recommendations and the doctors “didn’t seem to think it was what caused everything.” True enough but certainly it was making everything worse. A particular useless communication took place each day when the cardiologist made his rounds. I wonder how much he charged. He spoke in technical terms with an strong accent, he described the test they were going to do but could not do until kidney work up., He spoke so hurriedly, so technically, I could barely make it out. All this took thirty seconds. “Any questions?” and out the door. Clearly Joe did not understand; he could not explain to his family who seemed to be holding a premature wake. The bill was growing, nothing seemed to be happening except Joe’s despair and apathy getting worse. Being there, as a passive and fairly sick observer was discouraging. Had medical care really fallen to this level. In his discouragement Joe was on the way to being a difficult patient where once he had been active in his medical care. To the doctors in this hospital he was just a case not a person. It was not much better in the town near his home where he went from specialist to another, a test to another. He was much loved by his family but they clearly had no picture of how to help him and were prematurely measuring him for a coffin. The current economics of medicine reward procedures and hospitalization but not close follow up.Little attention goes toexplaining things until the patient understands and works actively to cooperate, and engaging family members, when available. Patients this ill forget what they ARE told. These sorts of medical behavior are deplorable,for a patient like Joe it probably fatal. Incidently he is still INSURED, he has only LOST HIS DOCTOR. The day after these observations I had a bad day. To combat my septic shock I had been given lots of fluids. Too much it turned out. My iv’s infiltrated and I had to be stuck a lot which was exhausting. As the night wore on I became very tired but noticed my lungs were very wet and tried to get nursing attention. I noticed I was becoming indifferent, What is the use? My wife came by early took one look and got everyone’s attention. Drugs to pump out the fluid were prescribed and an accidental drowning prevented. I had a new appreciation from my own experience how ridiculous the modern mantra of the patient being a partner in their health care can be when people are really sick. They need a responsible doctor and nurse who care enough to follow them closely. Medical accidents often happen at the gaps in medical care. THEORY AND PRACTICE “It is a false premise ”what is true in theory is true in practice." Colin Turbayne, my college Logic teacher. “In theory there is no difference between theory and practice. In practice there is.” Yogi Berra “If Theory and Facts disagree, so much the worse for Facts.” Allegedly attributed to Hegel. “What is being done is what is being learned.” Edwin Guthrie A PRACTICAL PATH TO EXPERT PERFORMANCE Our emotional life gives value and meaning to what we do. Errors of all kinds reflected upon, give rise to experience. Keeping experience in mind leads to a personal knowledge base. Careful observation and reflective thinking allow us to develop a Personal Knowledge Base. Participant Observation is one component of making sense of our world. For those interested there is extensive information available. Explore using Participant Observation as a search topic. THICK DESCRIPTION This brief report has introduced Participant Observation, one type or one component of learning about complex situations. The term “thick description” was introduced by Gilbert Ryle a British Philosopher. Clifford Geertz used the concept in anthropologic field work and Edwin Hutchins in his anthropologically enriched study of Cognitive Science. I have found the concept quite useful in reflecting upon the causes and cures of medical error. We are often inclined to bias our observations based on our own experience and culture rather than let the events speak to us in a variety of ways until something that both feels truthful rather than expedient and has some practical relation to reality emerges. This may require reflective thinking, participant observation, searching for communication problems and even unknown unknowns. LINKS TO SOME OF THE IDEAS INCLUDED IN THIS ARTICLE. END NOTES SHOCK AND AWE The USS Tuscaloosa https:// en.wikipedia.org/ wiki/ USS_Tuscaloosa_%28CA–37%29 The ship was lucky in WWII serving both in Atlantic and Pacific. The departure from Miami was probably 3 December 1940. Grandfather Roy and Uncle Chan’s ChrisCraft http://www.chris-craft.org/archive/browse_doc.php?f=jp%2FqrNve2oH%2FP5GGrs%2BQUNKECIBTx2RoChd2yy6KrjXlHR7WmvzmCZkZKzMl7gAnnkk2V84uva%2Fr1HwB2FlL1N3UDuMJMe3XhV10PWnbKfCTMrFI%2FnIC93whw1gypckYOuVmJih1pIA%3D A SUMMER SPENT IN A TIPI Camp Norwester was established by Frank (Tyee) and Lucille (Rabbit) Henderson in the 1930’s. I worked there two summers 1952 and 1953. My brother Howard was waterfront director later and cruised with Bill and Marty Holm and others some years later in the 26 foot cedar sealing canoe. The canoe was carved by Bill out of a cedar log http://norwester.org If you drill down in the pictures of building the Long House at the new camp you will see Bill Holm working on a large pole. There are also pictures of the camper’s tipis. Bill’s tipi was a slightly smaller model with a full liner to direct air over the occupant’s heads and out the top (summer) and modify the smoke direction up thru the smoke flaps. A complete biographical essay covering Bill’s life and his major contributions to understanding Northwest Indian Art and culture as well.It is worth noting that Bill accomplished this during a period of considerable hostility and resentment of anthropologists, such as throwing stones at them. http://www.washington.edu/burkemuseum/bhc/ManFromRoundup.pdf A CLASS ON HOW TO CLOSE YOUR MIND A distinction is made in education between knowing What and Knowing How or theory and practice. Two teachers stand out in my memory of undergraduate years for the practical use of what they taught and how they encouraged learning, reading and scholarship. Edwin Guthrie and Colin Turbayne. Edwin Guthrie, then a senior Full Professor in the Department began his career in a Philosophy Department before Psychology Departments existed. He was influenced by the idea that _mind is an observable object_ and did a classic experiment on cats in a puzzle box where it appeared cats used an escape method where they repeated acts _associated_ with their escape from the box. This differed from B.F. Skinner’s current behaviorist dogma. Guthrie also applied his ideas to classroom learning and famously taught when the class was bored, they were learning to BE bored rather than the content being taught.That is the single most important thing I have learned about teaching classes and has been invaluable in my teaching activities. I always try to observe the classes reaction and make appropriate interventions. Colin Turbayne taught Philosophy of Mind and Logic classes
Introduction Preliminary efforts and literature review led to the creation of Narrative Descriptions. The user was asked to describe an event, and associated emotions. Then a discussion was added with three points of view, personal, interpersonal-communicative, and organizational. Originally these were for discussion within our group. Later we suggested a written narrative focus be added with consideration of probable uses: editing and re-reading, a naive reader, a teaching file, a categorization or an ontology. These could be characterized as goals or _WorkPoints._ Our beginning trials with the Narrative Discussions revealed a complexity requiring a more complete examination of events. We discovered John Flanagan’s early work on the Critical Incident Technique (CIT) , His goal was to develop a scientific basis for identifying critical factors to account for WWII student pilots who failed in training. Previously reasons given by examiners were often cliches or lacked depth. This large careful study with well defined goals led to many other applications both in aviation and later in manufacturing, business, management and nursing . (PubMed alone has 2543 articles and 231 review articles on CIT in Nursing.) Early attempts to cope with medical error tended to focus on a model of Blame and Train however, safety studies from other fields suggested there was greater complexity. To a psychiatrist it appeared there was little attempt to search for problems outside of awareness, due to unconscious, denied or unobserved detail. We combined the approach of examining specific events (CIT) with pushing the user to consider emotional reactions and states in our Complex Context Critical Incident Report (CCCIR). In this new approach the user applies multiple points of view to include feelings and emotions, the nature of communication, or lack thereof, and systemic/organizational factors. We asked users of our reflection tools to include any possible relevant associations: what comes to mind, even if it was a tune, a book, a movie, a distant memory of an event. Keywords are added for future categorization or teaching. _WorkPoints_ could indicate ideas to be explored, related concepts, or plans of action or solution. The rather complicated template embraces and clarifies complex situations The final tool was called a Complex Context Critical Incident Report (CCCIR). While with some support even naive users can rapidly learn to use such a template a simplified unit was needed for self-training in close observation and participant observation. Repetitive use also increases recall, associations, and resolves minor impasse. We have some optimism that a future system could be developed utilizing more productively the world wide web, social media and hypertext elements. While computers speed up these tools, all that is necessary is pencil and paper. We hope these tools may be useful in worlds as different as academic medical centers and pre-literate tribal societies. _Literacy Bridge_ a clever and effective program produces changes in maternal and child health and agriculture by supporting communication with spoken word devices. Complexity Complex systems have multiple parts. Human use the technical parts and interact with other humans, introducing communication. All this is in constant change over time. I stumbled upon this example on the internet. We could consider the magnets as non-human parts of the system, marbles as humans, and sticks and pieces of wood as designed control factors to keep the components in a safe range. We can see there are many ways things can go wrong and how hard it is to modify one part without unexpected results elsewhere. Note there could be a cascading series of minor defects in the system that could result in a complete breakdown. We will return to that idea. Also note that while the marbles are almost passive once they are set in motion, humans can observe and react in complex processes in which they find themselves. Richard Cook in the next section feels this is how expert participants can pick up errors in progress and intervene to change the course of events. To perform in that way they must have learned thru mistakes. That is how knowledge is acquired and generalized to new situations. Investigating and Defining Complex Systems Failure This area has been investigated extensively and from many points of view. A summary of important considerations concerning health care is found at the Cognitve Technologies Lab in a handout by Richard I. Cook: _How Complex Systems Fail_ accessible as full text through Research Gate. One of the problems of research in this area is the view from the top down is strongly influenced by the language and habits of the different disciplines, they are looking for a particular canary in the coal mine, one from the areas with which they are familiar and were they can develop testable hypotheses. From the ground, the bottom up, the case report, the life story, the perspective is somewhat different. We do not want to miss something just because it is new, or rare or unfamiliar to us. One of the most troubling problems in medicine is the patient who presents with something unexpected or unknown to us. They are frequently blamed for not having the right picture to fit our expectations. They are blamed for imagining something or come to feel they are hypochondriacs. One of my OB/Gyn professors drummed into our minds the “first symptom of carcinoma of the cervix is no symptoms.” Extending an Investigation While we began with specific incidents we found in order to have an adequate context we needed both a wider and a deeper look. In the literature this is called _thick description_ an idea introduced by Gilbert Ryle, a philosopher of Mind ,and popularized by Clifford Geertz, an anthropologist, who applied the idea in field work in Bali. . In our reflection tools the deeper look is expressed in the Narrative Report, the wider look is the result of the Complex Context Critcal Incident Report. The SwampNote is the basic description of one view of an incident and the author’s view including their feeling state. In repeated use observation and description are sharpened. Several notes may contribute to a Narrative Report and/or a CCCIR. We provide samples of the tools in Section 4 and clarify how they relate to each other and how they can and should be adapted to local, on the ground conditions. The next sections explain what situations and questions led us to develop this way of looking at important life incidents.