3 PM at the VA, change of shift. Everything is a bit slower. The nurses pair off, share clinical concerns things to do, their personal tales and plans. The patients, in VA, issued ‘pajamas’ meander about, returning from therapy, or the commissary or seating in the ward’s TV room in wheelchairs or government issued couches and chairs. An errant medical student is going to ‘admit’ the new patient, the interns finishing up scut. This is a slower time, time to finish up your tasks and get ready to leave the rest for another day. But not Tuesdays, never Tuesdays. Because like clockwork, as the minute hand moves beyond the twelve, my boss, the Chief of Vascular Surgery arrives for clinical bedside rounds - our weekly clinical recital. My role, as the vascular fellow, was presenting all 25 to 30 patients on the service, their history, pertinent physical findings, their hospital course – a baseline melody – so that my boss could then do his solo, his clinical riffs, a bit of surgical history, a discussion of why one therapy over another. And let me add, my boss was classically trained; this was a guy who could explain why blood flow was turbulent at bifurcations beginning with force = mass times acceIeration. He had a way of finding the things you had missed or ignored; he made you better, but there was no free ride - you grew in relationship to your engagement. Playing the supporting notes, to his clinical solo, was disciplined work.
It was not easy to keep all the baseline notes – diabetes, hypertension, pack-years of smoking, prior surgery straight for those 30 patients. So I cheated and left discrete notes around the bedside, reminders. You know, the 30-pack year smoker with diabetes and hypertension became "30DH" written on a piece of tape, placed to obscure, by the bedside room number. It was a wonderful time, and I learned so much about vascular surgery, my boss and myself. I retell this story because I ran across this sentence the other day while reading Matthew Crawford’s new book (at least to me) The World Beyond your Head; and it has bounced around in my head ever since.
“A jig is a device or procedure that guides a repeated action by constraining the environment in such a way as to make the action go smoothly, the same each time, without his [the carpenter] having to think about it.”
What apparently was bounding around in my head was the realization that those discrete notes, my mental reminders were in fact, jigs. Jigs were something I learned about and used in high school woodshop and making furniture before surgical residency took up so much time and hand energy. Crawford makes clear that jigs are everywhere in what we do, although we use different names, like To-do list or habits or Kanban, the visual reminders used in continuous improvement – the Toyota Way. Kanban shows you and your team where you are in a process and the next steps – how to proceed. Jigs help us shape the information within our environment. Crawford goes on to quote David Kirsch, a Canadian cognitive scientist at the University of California, San Diego
“Kirsch finds that experts ‘constantly re-arrange items to make it easy to 1. Track the task; 2. Figure out, remember, or notice the properties signaling what to do next; 3. Predict the effect of actions.’”
And while the layout of that ward at the VA made it easy to track my task, it was those little notes, hidden in plain sight, that signaled for me, what to do or say next. I was taught a specific, ordered way to prepare an operative field – to get from the skin incision to the point at which the target vessel is exposed, ready to clamp, open and fix. It became a habit, and it is an example of a jig that predicted the effect of my actions. When you think about it, my bedside performance at clinical rounds with it jigs of discrete reminders was just a jig for my boss, who used the melody that my jig created as a jig for his clinical solo, those riffs that informed, challenged and open new doors.
It’s interesting how those moments of learning, now thirty-some years past, return in unexpected moments providing new realizations. While jigs can make our life easier and better, they also serve to support the work and concerns of those around us. All we need to do is to get jiggy.