The craft of intensive care medicine

Abstract

The practice of medicine is often represented as a dualism: is medicine a 'science' or an 'art'? This dualism has been long-lasting, with evident appeal for the medical profession. It also appears to have been rhetorically powerful, for example in enabling clinicians to resist the encroachment of 'scientific' evidencebased medicine into core areas of medical work such as individual clinical judgement. In this article I want to make the case for a more valid conceptualisation of medical practice: that it is a 'craft' activity. The case I make is founded on a theoretical synthesis of the concept of craft, combined with an analysis of ethnographic observations of routine medical practice in intensive care. For this context the craft aspects of medical work can be seen in how biomedical and other types of knowledge are used in practice, the embodied skills and practical judgement of practitioners and the technological and material environment. These aspects are brought together in two conceptual dimensions for 'craft': first, the application of knowledge; second, interaction with the material world. Some practical and political implications of a 'craft' metaphor for medical practice are noted.

What Farmers Know: Experiential Knowledge and Care in Vine Growing

“…Intuition in this context is to be understood not as guesswork or supernatural inspiration, but as what other writers on skill have described as maximum grip (Ponty ), flow (Csikszentmihalyi ), or being in harmony in the world of action (O'Connor ), in other words the capacity to respond quickly and accurately to the contingencies of the situation ‘without the conscious analytical division of situations into parts and evaluation according to context‐independent rules’ (Flyvbjerg , p. 22). It is important to note that the positive role of intuition in decision‐making has been observed in other contexts such as engineering (Wetmore ), agronomy (Richardson‐Ngwenya ), medical practice (Carmel ), and indigenous hunting (Anderson ; Ingold ; Peloquin and Berkes ). Intuitive action can than be understood as a form of intelligent behaviour, but one which goes beyond cognitivist understandings of humans as rational and calculating decision‐makers (Flyvbjerg , p. 14), an understanding which typically underlies regulatory action.…”

ED healthcare professionals and their notions of productivity

“…Specifically the issues relating to: the dominance of quantification and clock time,18 the pervasive surveillance and the perceived threat to healthcare ‘craft work’19 20 acted as barriers to HCPs reconciliation work. Colley et al 21 have previously described how the privileging of clock time at an organisational or policy level can shift practice along a continuum whereby caring and meeting the clinical and emotional needs of the clients are consumed by surveillance and control.…”

Exchanging implements: the micro‐materialities of multidisciplinary work in the operating theatre

“…How the scrub nurse arranges, grasps, handles, manipulates and passes implements within the operating theatre is a highly specialised activity, an activity that is dependent upon an extraordinary sensitivity to the contingent production of medical procedures and the occasioned requirements of each and every exchange. It relies on and reproduces, par excellence , the interdependence of technical and craft knowledge (Carmel , Pope ), critical to the collaborative accomplishment of surgical procedures.…”

“…There has been there has been a growing interest in re‐conceptualising health and illness in terms of practice, treating practice as the ‘primary unit of enquiry’ (see for example Mol , Mol and Law , and more recently Carmel , Cohn , and Twine ). Notwithstanding the important, but very different contributions of Giddens and Bourdieu to our understanding of practice, these initiatives have been largely informed by the contributions of Latour (, ) and others within science and technology studies, and the commitment to taking the non‐human, the material, and its agency seriously; to consider the interdependencies and interconnectedness of the human and non‐human in action (see for example Maller ).…”

“…The bodily actions through which implements and materials are grasped, manipulated and exchanged have received less attention and yet the interaction that arises in and through the bodily conduct of personnel within the operating theatre is critical to the successful accomplishment of the operation. More generally, notwithstanding the burgeoning interest in body work and material practice in health care (including Carmel , Cohn , McDowell , Twigg, , Twine ), the ways in which bodily conduct as embodied action features in the collaborative production of medical work remains relatively unexplored.…”