Tinkering and innovation in medicine: Ethnographic experiments for studying repair and maintenance

The following text was written by Anna Harris, Associate Professor at Maastricht University, and reflects her presentation at our Closing Conference, “Repairing Technology – Fixing Society?” from 13-14 October 2022 in Luxemburg.

Every summer at a medical school in Maastricht, in the Netherlands, several secretaries at a place called a Skills Laboratory gather in one room. In this room, they collect all the teaching models used to teach medical students clinical skills they can find in the storage cupboards and lay them out on tutorial tables in the empty classrooms. They inspect them carefully, searching for those in need of repair or discarding that year. I was not fortunate enough to witness this summer survey, but I saw traces of their work in the tutorial room cupboards and in clinical skills classes that I followed during my years of ethnographic fieldwork at this medical school, trying to learn more about the materiality of learning diagnostic skills in medicine.

Opening the pencil sharpeners by the sinks in each room, for example, might reveal shavings from dermatograph pencils (or eyeliner pencils as they are known outside the medical school), which secretaries prepare for the respiratory examination lesson to help students with the embodied skill of marking out the lung sounds they hear with stethoscopes. Objects in cupboards, side drawers and other storage places are neatly stacked and labelled, again by the secretaries. Microscopes are cleaned, in this case by the teachers who take these classes, their various lenses inspected and slides prepared. The little toes of pediatric dolls are re-stitched and missing parts glued back on.

Although there was a sense of salvage and upcycling of materials at the Skills Laboratory in Maastricht, there was also plenty of time to make these repairs. The staff working at the medical school in Ghana where my colleague on the same multi-site ethnographic-historical project (Making Clinical Sense), Andrea, did fieldwork did not have the same extra hours on hand to do this in their working time. The same could be seen at the University of Accra, where the curator of the pathology museum spoke to another team member, John, both observing the numerous jars with evaporating formaldehyde that the curator lacked the time and funds to maintain as he would have liked. The curator had years of experience doing this work, having trained at several workshops to learn about keeping specimens. He had developed his own storage and repair techniques and while he could maintain the museum up to a point, he was lacking the time and materials which would allow him to care for these items as he would have liked.

For the STS-orientated philosopher Maria Puig de la Bellacasa (2017), care “stands for necessary yet mostly dismissed labors of everyday maintenance of life, an ethico-political commitment to neglected things, and the affective remaking of relationships with our objects. All these dimensions of caring can integrate the everyday doings of knowledge in and about technoscience.” She reminds us that it is often because of the devalued significance of care that feminist research on care practices is often oriented towards neglected things, practices and experiences made invisible or marginalized. Bellacasa connects her work to the growing literature on repair and maintenance, which has captured the attention of a growing body of anthropologists. Despite this interest, the repair of materials in educational contexts has eluded attention to date, though one could easily think of examples from everyday learning, such as a Montessori approach to caring for materials as part of the learning environment and pedagogical approach. Similarly, little has been written about repair in medical education research, despite medical practice being considered as care work.

Although there is literature on medical equipment maintenance, we are still in the dark about much of the backstage care and repair that I believe has an important role to play in medical knowledge reproduction. What gets repaired? How and by whom? In the Skills Laboratory the objects that did not make it to repair were those for which it was considered that another material or medium, often digital, could replace the learning that it was involved in. Here we see curriculum designers involved in the curation of medical teaching objects, negotiating and navigating their preferences with the secretaries. Skills Lab teachers would also “save” their favorite objects from being discarded – a beloved knitted uterus in Maastricht was an example of this. These were objects that taught a sensory lesson in a particular way that digital alternatives could not. Some of these objects, such as the woolly uterus and also dolls for pediatric examination techniques, were handmade by teachers.

This work was not always valued at the time – the teacher who made a pediatric doll to teach hip examination, for example, describes how the male pediatricians in the hospital were highly skeptical of her handmade creations. The doll is simple in its design, without distracting features. It is used solely for teaching hip examination, not for any other aspect of the exam. The flexibility of the doll’s hip means that the flexion and movement can be exaggerated. Such objects are therefore particularly useful for the sensory details that are most important for the lessons – the flexible hips of the doll in this example, or the ribbed cuff of the woolly uterus for cervical dilation –, allowing the skill to be ingrained through an embodied and material lesson that is felt and remembered by students.

Such tinkering and making in medical education happens in the shadows, to be occasionally “unearthed” by anthropologists and entrepreneurs (see Maker Health (Young 2021)). Craftwork has had an important role in scientific knowledge production in other domains, such as dolls houses in forensic science (Goldfarb 2020) and crochet in mathematics (Wertheim, Henderson, Taimina 2004-2005). While many of the female technicians working in mid-20th-century London laboratories who historians Hartley and Tansey (2015) spoke to reported being hired because of skills in sewing, for example, female scientists using craft methods such as dollhouse miniatures and crochet have also been celebrated (often decades after initial skeptical responses) for revolutionizing their fields (Criado-Perez 2019:310). Those who make their own learning tools may be a rarity in medicine, along with the few scientists who make their own instruments (Mody 2005), but it may also be that such practices are more common than medical education ethnographies and research lead us to believe.

And so will begin my presentation at the Repairing Technology conference, with tales from the field of an ethnographic project. From these insights from the Making Clinical Sense project concerning the importance of handmade, local, improvised materials in medical teaching and their role in crafting the clinical imaginations of medical students, I will turn to practices of repair, care and maintenance in medicine. I will introduce a more speculative discussion about a new project that ties into the long tradition of tinkering and frugal innovation in medicine/science more generally, and the current explosion of upcycling and makeshift innovative practices in healthcare due to the pandemic in particular (e.g. cargo container ship hospitals, handmade masks, scuba diving respirators). This new project aims to critically explore the practices, rhetoric and possibilities of thrifty medicine as a site of innovation in healthcare. I would like to explore the kinds of methodologies which may be relevant for probing new research ideas – methodologies which have developed from the Making Clinical Sense project and other collaborations, including learnings from the REPAIR project around re-enactment. Possible methods to be explored include analysis of medical tinkerer obituaries and, if possible, diaries; a citizen science project with a known archive of diaries of explorer doctors; ethnographic studies of sites of medical innovation in constrained material circumstances and hospital makerspaces; material analysis of innovative/tinkered technologies and objects in medical museum collections; filmed oral histories with medical innovators; and finally, data reuse. These will be discussed in relation to how they may elucidate everyday practices of repair and tinkering in fields such as medicine and other related areas, with a focus on the kind of repair, maintenance and improvisation that takes place in constrained material conditions.