In Concepts and Transformation, 1(2/3), pp.239-247, 1996.

RESONANCES FROM WITHIN THE PRACTICE: SOCIAL POETICS IN A MENTORSHIP PROGRAM

Arlene M. Katz

Department of Social Medicine

Harvard Medical School

and

John Shotter

Department of Communication

University of New Hampshire

ABSTRACT: In this, the second of two interlinked articles, we describe an experimental mentoring program conducted in a major medical school in the Northeast of the United States. In it, primary care physicians mentored medical students in the course of conducting their daily practices. All involved were trained in a special reflecting process that led them to focus on, and to discuss, concrete events occurring during the day. We illustrate how, both in pairs and in larger meetings, in discussing events within their practice together that they were 'struck by', student-mentees not only came to a more practical grasp of the medical knowledge of the classroom and textbook, but that all involved in the program came to create between them a resourceful community. At work within this program was a practice that functioned, not only to help the students, but the whole ongoing practice: for within it, besides moments of teaching, where other kinds of shared moments to do with the details of clinical practice, ethical issues, administrative problems, and so on - with all involved helping each other with what we have called, the appreciative evaluation and elaboration of their practices.

In the article above (Shotter and Katz, this issue), we have been concerned with those kind of circumstances in which a group of people involved in the conduct and discussion of a practice together, respond to each other's different activities within it, not in terms of any pre-established meanings, and especially not in terms of a set of disciplinary of professional meanings, but in terms of how they are each 'struck by' certain fleeting moments from within the ongoing conduct of the practice. And furthermore, we have been interested in how these moments 'gesture toward', 'express', or 'manifest' something special within their shared lives together, and with how they suggest new possible connections and relations between aspects of those shared lives previously unnoticed. One of the most unusual features of such dialogical circumstances as these, however, is that initially, the new relational-responsive meanings to which they give rise, instead of occurring in people's heads, are 'out there' in the 'space' of activities occurring between them. So, while such meanings may be codified by the group and internalized later by individuals, it is within the ongoing activities of the group that they first come into existence and have their currency. But once 'out there' in the 'space' between group members, they can function as a resource of already established 'topics' or 'commonplaces' that those engaged 'in' the conversation can all draw upon and refer to in what they say or do - even though they may be far from having any fully explicit articulation or representation.

Below, then, we want to present some such moments that occurred in two video-taped conversations, between primary care physician-mentors and their medical student mentees, that we were a part of an experimental mentoring program designed and co-directed by one of us (AMK)⁽¹⁾ in a major medical school in the Northeast of the United States. But first, let us mention some of the details of the program, some of the 'instruments' and 'methods' used: Each time the mentors met their mentees, they were asked to enter into a dialogue with them: 1) To first ask them, what do you want to focus on today? 2) Next, to conduct the doing of it. And then 3) to have the student reflect with their mentor on what had happened during the day. In this way, over time, what can be called a reflecting practice emerged within the ongoing primary care practice. Or, in other words, a way of doing mentoring emerged that was dialogical, iterative or elaborative, and formative. It was iterative or elaborative in the sense that, as each new 'topic' of discussion was created between them in the dialogue, it was added to those already existing in the 'space' between them, thus to enrich it. And it was formative in the sense that, in articulating the noticed features of their practice together, it rendering these features visible, as it were, so that they could be explicitly made use of and referred to in both their subsequent mentoring and in their clinical activities. Further 'tools' were used throughout the year in the institution of the reflecting practice: Each time the mentors gathered, they were asked to write of moments in the mentoring process that had struck them, e.g., teachable moments, clinical moments, researchable moments, along with a plan for how they might make use of such moments in practice - as mentors with their mentees, or, as one of the mentors put it, with their mentee as "a dialog partner." Given these 'tools', over time, the reflections encouraged at the different phases of the program, became a general part of how to 'go on' for everyone involved in the program: choose what to focus on, do it, and reflect upon what 'struck' you in it. In such a way, a practice began to be was articulated from within the practice which led to the original practice becoming self-elaborating, self-modifying, and also, as we shall see in turning to events occurring within the larger gatherings, self-appraising and appreciative.

Before saying anything about these conversational gatherings in detail, overall we must comment on the degree of engagement exhibited by all those involved in them. Not only did they both overrun their allotted time, but, as is apparent from the video-tapes, everyone displays an intense engagement in the conversation. Furthermore, all the comments made were all listened to with rapt attention, and received as making sense and as valued comments. Also, rather than critical comments of a negative kind, the comments were all appreciative, in the sense of offering what they thought would be useful to each other in 'going on' in practice, in the overall program. We must mention too, the fact of our own rapt involvement - AMK's deep involvement in overseeing the whole program, and JS's involvement in viewing the video-tapes. Like the other participants, we also worked in terms of picking out things we were 'struck by'. In the first of these gatherings, the participants⁽²⁾, both mentors and mentees were asked to discuss what they felt that they had got from the program; whilst in the second gathering (a year later), after having watched a selected portion of the video-tape of the first meeting, they were asked specifically for what they had been 'struck by' in their experience of the program. We will begin with a quote from a student in the first group:

".. And we walked in and it was a boy who had run into a fence and cut his chin and the gland was all swollen. And my mentor looked and he said, 'What is the lymph node drainage superficial left side? And I answered. And he said, 'Where is the swelling going to be if it's infected?' And all of a sudden, ...all of the hours you put in and all of the associated facts that are supposed to be attached, all of a sudden... it's a person, so it really matters; it means something. And you finally understood why you're doing this, why it matters. And why it's important to know these things. And it's an eye opener just as much as anything we do in medical school in the traditional curriculum is an eye opener."

The comment illustrates how the 'relational landscape' upon which students can 'place' their technical knowledge and orient themselves toward its application in patient's lives, is beginning to open up for them. And the student is expressing some profound awareness at the fact, that it was only in the mentorship program that he realized that the interrelating of their classroom learnt medical knowledge with everyday relational issues, is an important issue for them. Indeed, a student in the second group begins his comments by saying that he was initially disappointed by his mentorship experience: "But after the third or fourth time, I realized that each patient is different, each infection was different... The doctor handled each patient differently. I would have missed how the disease was affecting their lives. I would only have seen the disease." A number of others commented along similar lines that they had not realized how many things there were going on in people's lives that doctors were involved it. Or: "You never know what's going to be a teacher..."

The role of dialogue in first creating, and then in further elaborating, a communal 'space of resources' between all those involved, is crucial. Indeed, it is the interweaving of official medical knowledge with the particular details of a patient's illness displayed as relational knowledge (by mentors and patients themselves), that made the official knowledge more memorable and also articulated its relation to practice. As one mentee stated: "Just knowing that... there's a finding here and this is, you know, what it means and this is how the patient reacts to this information... And when you finally hear low pitched ronchi or the consolidated lung or whatever it is your patient has, you remember because Dr. X [my mentor] showed me this and the boy had asthma... Then you remember it from that." On hearing this, another student added that the continuity of the program made it possible for him to begin learning things that could be completed at a later time: "Its like I know its 'out there'... and when the time comes, I'll be able to make sense of it then."

Thus, by displaying the indefinite number of roles and contexts in which the different events occurring within the mentorship program might appear in their daily lives as practicing physicians, mentees were given the opportunity to explore the immense number of ways in which classroom medical knowledge could be applied and made sense of. But it was their own intense involvement in the whole ongoing flow of activity constituting the different phases of the mentorship program that, we suggest, was crucial. It was because of their mutual involvement in 'finding their way about' in such a 'relational landscape', that all t he partcipants in the mentorship program found the subtle and fleeting moments they encountered in their involvement in it 'striking', and expressed them as such. And, it was as a result of them reflectively 'going over' them, that they worked them into, as Wittgenstein (1980a, p.26 - see epigraph) put it, into "a proper synopsis," "a synopsis of trivialities."

Indeed, participants were not at all unaware of the subtle, detailed nature of what is involved in the whole process of the clinical practice of pediatric medicine, as well as of the involvement of the clinical process within the mentorship program overall. As one mentor doctor comments: "Everything we do reflects the wonderful subtlety of it... there is no right way... its all very personal..." While a student commented: "... subtle things can be picked up... one feels ready to take the next step... This is the advantage of a long-term program like this... how to put things together..." Indeed, in this respect, one of mentor-doctors, a participant in the second meeting, made it clear that he was aware, not only of the importance of the subtle details in the process, but also of the fact that doctors don't usually "reflect about these things ourselves," and that doing so gives students the chance, not only "to help us" but "to surpass us."

For us, all these comments resonate back and forth with Wittgenstein's (1953) claim, that: "We talk, we utter words, and only later," says Wittgenstein (p.209), do we "get a picture of their life," and resonance from within the actual practice with his methods - what elsewhere we have called a 'social poetics' (Katz and Shotter, 1996) - in gaining that picture of their life. As we sense one in the light of the other, we begin to see what each means more fully: we begin to see the connections and relations the participants have in mind, implicitly, as they make their comments - they come to exist as 'topics', as implicit 'resources' between us, something that all of us involved in this project can begin to articulate more fully and explicitly between us. Indeed, there is a realization that the kind of conversations that everyone has in this program are important to them. A doctor, this time from the first group, also comments on this:

"...for me the most fun part of all this is, it gave me an excuse to think out loud, ... It can be kind of a solitary job, you're constantly, relating to patients, ...on a professional level.... but ...it's rare to have someone by you... right there in front of the patient, but if not ... the minute you walk out of the room. Every patient is still a learning issue for me. And I think that,... as long as that stays the case, you'll stay a good doctor... A good doctor knows what they don't know, and they know when to ask for help. ... If we've taught you this, ... this early in your training through this program, then I think the program has accomplished more than it even hoped to at the outset."

The unending, unfinalizable nature of the practice of a practice, is apparent to this doctor. Also apparent, again, is the importance of dialogue, of having someone to talk to, to be able to get issues 'out there' on a 'relational landscape, in a 'dialogical space of possibilities', thus to be able to explore their relational nature further. In other words, a special dynamic emerged in the course of this program, in the mentor-mentee relationship, and within the whole group of the mentor-mentee pairs. Not only does the mentee learn to interweave the different knowledges - technical and relational - that go to make up the daily practice of community-based general medicine, but mentors realize that they also gain from participating in what becomes a living, resourceful community.

Finally, we must add a comment about 'criticism', for it seems to be absent from the process. Indeed, as one of the researcher physicians remarked on seeing his doctor colleagues talking on the tapes: "We don't usually talk like this." Rather than the more usual 'academic' critiques, rather than competitive and contested fragments, the conversations manifested the building of an articulated fund of knowledge. The opportunity to reflect on their practices, that had been built into the process of them learning to be mentors, seemed to have a profound effect in their increased awareness of their own and each other's clinical practices. Thus alternative proposals were offered as a complement to their colleague's claims, not as a 'better' alternative. So, what has happened to the expected 'academic' kind of criticism here? What we might call an appreciative evaluation and elaboration has taken its place. As the shared landscape of possibilities opens up between them, there was an appreciation of ways to 'place' all the different ways of doing things in relation to each other. To repeat the comment of the doctor quoted above: "Everything we do reflects the wonderful subtlety of it... there is no right way... its all very personal..."

Conclusions

We began this pair of articles with references to Gustavsen's work: to his emphasis on collaborative inquiry, to such inquiry being an everyday part of ongoing practices, to the inseparable nature of 'theory' and experience, and to the idea of a 'process carrying structure' (Gustavsen, 1992, 1993, 1996, in press). We feel in tune, so to speak, with all the same issues. What we have added, however, is a focus on fleeting events, on subtleties, on the unique, novel, only 'once occurrent' events that 'strike' us, to which we cannot not respond. It is this emphasis that moves us away from what in the past has been called theory, toward what (to be distinctive) we have called the methods of a 'social poetics'. Introduced by one of us (AMK) into a practice (see Katz and Shotter, this issue, below) these methods worked within the practice to 'move' those involved in it, to pay attention to aspects or details of it that might otherwise pass them by unnoticed. Under the impetus of AMK as a consultant-researcher, this distinctive 'marking out' of experiential events, served to create a shared knowledge of these details, to get them 'out there' into a public space. "Here," says Taylor (1985), "we have an expressive use of signs, which is unconnected with a characterizing or representative use... Thanks to this expression, there is now something entre nous" (p.264). That is, those involved in such a space have something distinctive before them, a set of 'topics' or 'commonplaces' that they can return again and again, to discuss them and to further elaborate them in detail. Thus, even if not everything is known about such commonplaces, they can serve as 'orientation marks', as 'signposts', indicating places to go, as well as their relation to other places, on a whole landscape of resources shared by those in the community of the practice.

This shared field of creativity within which both researchers and practitioners alike are engaged, emerges in the collaborative activity between them. In their responsive conversations together - with some being just between the doctor and mentee, others being between the doctors and researchers, and yet others being when the whole group comes together - they shift between moments in which details of clinical practice are articulated, moments of teaching, and research moments, with each informing and specifying the other. As the details of the different moments are spelt out, the non-separable character of the different aspects of their nature becomes apparent: the doing, the commentary, the sharing, the elaborating, the critiquing, the teaching, the researching, the relating of medicine to the other crafts and practices surrounding it, to economics, to its administration, and, especially, to people's everyday lives, etc., are all intermingled in together. Indeed, in this process, practitioners become co-researchers, and researchers become co-practitioners, as each articulates what they have been 'struck by' in the unfolding process. As a result, clinical activity, teaching, and research are all enfolded with each other, as one in-forms and creates the other in a evolving, generative fashion.

Notes:

1. The mentorship program was co-directed by Drs. A.M. Katz and B. Siegel with the supoport of the Generalist Initiative of the Robert Wood Johnson Foundation, and the Primary Care Center and Department of Pediatrics Boston University School of Medicine, in collaboration with the Massachusetts Chapter of the American Academy of Pediatrics.

2. At least, all those able to come to the meeting.

References:

Gustavsen, B. (1992) Dialogue and Development. Van Assen, Netherlands: Gorcum.

Gustavsen, B. (1993) Creating productive structures: the role of research and development.. In F. Naschold et al. (Eds.) Constructing the New Industrial Society. Van Assen, Netherlands: Van Gorcom.

Gustavsen, B. (1996) Action research, democratic dialogue, and the issue of 'critical mass' in change. Qualitative Inquiry, 2. pp.90-103.

Gustavsen, B. Development and social change. In S. Toulmin and B. Gustavsen (Eds.) Beyond Theory: Changing Organizations Through Participation. Amsterdam/Philadelphia: John Benjamins. in press.

Katz, A.M. and Martin, M. (1994) The patient as teacher: multiple perspectives on the interview process. Instructional video-tape, Harvard Medical School.

Katz, A.M., O'Rourke, E., and Young, G. (1995) Teaching with Patients and their Parents: A Hands on Practicum," Harvard Medical School Pediatric Faculty Development Handbook, Harvard Medical School.

Katz, A. and Shotter, J. (1996) Hearing the patient's voice: toward a 'social poetics' in diagnostic interviews. Social Science and Medicine, 46, pp.919-931.

Shotter and Katz (this issue) Articulating a practive from within the practice itself: establishing formative dialogues by the use of a 'social poetics'. Concepts and Transformations.

Biographical notes:

John Shotter is a professor of interpersonal relations in the Department of Communication, University of New Hampshire. He is the author of Cultural Politics of Everyday Life: Social Constructionism, Rhetoric, and Knowing of the Third Kind (Open University, 1993), and Conversational Realities: the Construction of Life through Language (Sage, 1993). Currently, he is Senior Faculty Fellow in the Center for the Humanities, University of New Hampshire.

Arlene Katz is an instructor in the Department of Social Medicine at Harvard Medical School and is a psychologist with a specialty in family therapy and consultation. She has created two video productions: The Patient as Teacher: Multiple perspectives on the Interview Processes (Harvard Medical School, 1994), the other honoring Harry Goolishian (1992). Her research interests include cultural responses to illness and a dialogical approach to the patient-doctor relationship.