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On Getting Better
I am a knitting blog lurker. When I should be sleeping, or writing this column, I visit some of the dozens – hundreds? thousands? – of blogs maintained by alarmingly efficient women, and a few men, who knit, design, write about knitting and design, and also hold down jobs, raise families, and go places other than the LYS (local yarn shop). I have been known to ogle some bloggers’ FOs (finished objects) on Flickr, the photo-sharing website. I tell myself that this is Research.
I learned the basics of knitting as a child; I’ve picked up techniques from patterns, books, LYS owners, and other knitters. But if I want to find out how lots of knitters are tackling the same problems, improving the same set of techniques, and sharing what they’ve learned, I head for the blogs. Take the legendary Clapotis: a challenging pattern for a gorgeous scarf. Knitters have written poems about this pattern. It’s perpetually on my project list. If I go to my LYS, I may not meet anyone who has tackled the Clapotis, or I may get depressed talking to someone whose pile of UFOs (unfinished objects) includes this one. I can stare at the pattern on my own, and lose my nerve. Or I can type “Clapotis” into Google, and connect with a worldwide continuous quality improvement project dedicated to one scarf, in which dozens of knitters are teaching the rest of us exactly how it’s done and how to do it better. This collective enterprise pushes everyone’s skills upward, even for those of us who are still lurking, learning, getting up our nerve, and praying we won’t screw up when it’s time to cast on.
A fellow knitter talks about learning “on my hands”: when her hands know what to do, she’s confident that she’s mastered the technique she’s set out to learn. Surgeons are like knitters in this respect. They work with their hands and learn on their hands; they are obsessed with technique, with getting better at their craft, with developing new techniques to solve old problems. (While certain surgical applications, such as devices to support weakened cardiac muscles and arteries, rely on stretchy, strong knitted textiles, I have yet to come across any surgeons-who-knit blogs. However, mathematicians love to knit and to blog about the math of knitting.)
“Surgical innovation” is an ethically challenging topic. Surgeons may have to innovate on the spot during a procedure, when they encounter an anatomical anomaly. Following standard practice could harm this patient, so they come up with an alternative that seems to work in this case. If they encounter the same anomaly again, they’re likely to use the same problem-solving technique. Residents who observe the new technique, and other surgeons who hear about it, may start using it themselves, in cases that do not involve rare anomalies, and their patients may do well, too. Is this innovation to improve quality of care – or uncontrolled experimentation without consent? What began as a conscious departure from a standard of care in response to field conditions in one case shifted into what quality improvement experts call “practical drift,” a movement away from standard practice toward something believed – but not demonstrated – to be as good as or better than the standard. Once practical drift begins, it can pick up speed, as practitioners start following one another in what looks like the right direction. And then, someone may get hurt.
So surgeons can’t just do their own thing. They can solve problems as they arise – we rely on them to do this. And they can talk with their peers about how they solved a problem – we rely on them to do this, too. But, as a matter of ethics, they can’t call a case-specific solution an improvement, or a best practice. Without comparative data on outcomes from standard and alternative methods, they don’t yet know if something that works under particular circumstances is “best,” better, or even good practice for all.
Knitters can do their own thing – the stakes are a lot lower. So in a very important way, surgeons are not anything like knitters. But both of these groups that learn on their hands expect to make, and learn from, mistakes. Elizabeth Zimmerman, the legendary demystifier of knitting, wrote that knitting improvements tend to originate in mistakes – inadvertent departures from the standard, the pattern – and the careful analysis of these mistakes. Atul Gawande, writing about surgeons like himself, tells us that mistakes are how surgeons learn: unnerving as this insight may be for prospective patients, there may be no other way for surgeons to learn how not to do something than to do it, or nearly do it, once. And both surgeons and knitters, once they believe they’ve learned something on their own – how not to make that mistake, how to master that technique – tend to bring that solution to their peers, to see if the stitches will hold, or if they’ve got to unravel them and start over.
So, what can chaplains learn from surgeons and knitters on how to get better at what they do? If I were writing a pattern, here’s what it would look like:
Step 1: Pick a practice that addresses an important need in your field, and that is
teachable. As we say in ethics, “ought” implies “can” – if this is something
only a uniquely gifted person can do, it can’t be a standard for others.
Step 2: Put the practice up for discussion. Don’t call it a “best practice” yet: you don’t
yet know if it’s good, better, best, or not good enough. It just seems to do the job. “Promising practice” may be a more helpful term, a reminder to look critically.
Step 3: Have a candid discussion of the practice’s usefulness and its problems. Flush out
and analyze any data that may have been collected concerning this practice.
Propose ways to improve it, bearing in mind that while improvement requires
change, all change is not improvement. Identify and justify acceptable variations, if any. Health care professions aim to limit practice variation, and even knitters accept that sometimes you’ve got to follow the pattern exactly to get the desired results.
Step 4: If the practice doesn’t hold up under scrutiny, say so, and retire it. In every
field, it is difficult to stop believing in things that don’t work. Making a habit of
critical thinking, and of research, can counteract this human tendency.
Step 5: If the practice is found to be good, say why. Describe how to get the desired
results consistently. Publish and promote what you’ve learned. Keep looking for
ways to collect and analyze more data on the practice, so the discussion can
continue.
Step 6: Repeat from Step 1. The practice of getting better never ends.
For further enrichment and enjoyment:
Atul Gawande, Better: A Surgeon’s Notes on Performance (2007)
www.knitty.com/ISSUEfall04/PATTclapotis.html
www.shawlministry.com/
www.toroidalsnark.net/mathknit.htm
Nancy Berlinger is Deputy Director and Research Associate at The Hastings Center. Her research interests focus on clinical ethics and include end of life care; ethics in health care chaplaincy; conscientious objection and moral distress in health care; and patient safety and the resolution of medical harm. Her broader interests include bioethics issues in cancer care, narrative ethics, and medical humanities.
As Deputy Director, she manages the Center’s organizational capacity-building initiative, Bioethics and the Public Interest, which has received major support from the Ford Foundation.
Berlinger is the author of After Harm: Medical Error and the Ethics of Forgiveness
(Johns Hopkins, 2005), which will be released in paperback in fall 2007. She serves on the ethics research group of the Joint Commission, the ethics faculty of the American Society of Healthcare Risk Managers (ASHRM), the bioethics committees at Montefiore Medical Center, Bronx, New York and at Richmond of New York, and the editorial board of Medical Ethics Advisor
. She is a frequent presenter at grand rounds and other ethics education programs for health care professionals. She volunteers on the Chaplaincy Service at Memorial Sloan-Kettering Cancer Center in New York City.
She is a graduate of Smith College and holds the Ph.D. in English Literature from the University of Glasgow and the M.Div. in Christian Ethics from Union Theological Seminary.
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