River Water and Observation

Cate Kennedy has a new collection of poems.

I heard Cate talk with Ramona Koval about The Taste of River Water.

She read two of her poems during the interview on The Book Show.

Both seemed to me to be wonderful guides for those who observe and analyse performance.

The first was Thinking the room empty and the second was 8 x 10 colour enlargements S16.50.

I read Cate’s poems after finishing Stanley Fish’s How to Write A Sentence And How To Read One and delighted in Cate’s craft.

I liked too the introductory quote she used from Kristin Henry:

Here, there is no edge for cutting, and no garde for avanting, there is only the same old story, fresh as resurrection.

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Morning Mist

In a Dark Wood and Out Again: Freedom

I have missed listening to Radio National’s Book Show of late. I seem to have been in the wrong place at the wrong time for over a month.

If today’s program is a guide then I have missed an enormous amount of good stuff!

Jonathan Franzen was the guest and in a repeat of an interview from November 2010 he discussed his work, including his new novel Freedom, with Ramona Koval. My attention was grabbed in his first response when asked about his championing of Paula Fox‘s work:

You know, you enter a dark wood at a certain point in your life and things start falling apart; your life is not what you expected it to be. And if you encounter a book that really speaks to where you are at that moment, it’s a life-changing encounter, and that happened to me with Desperate Characters. I just thought, ‘Why have I not heard of this book?’ I have not read a better novel written by an American since 1945. It was an incredible book, and it was out of print, so I started vacuuming up all these sort of second-hand copies, and wrote about my experience. And people paid attention to that and now of course she’s back in print; she has a new book coming out this fall.

Amongst other gems in the interview was a passing mention to Jonathan’s Ten Rules for Writing shared with The Guardian:

  1. The reader is a friend, not an adversary, not a spectator.
  2. Fiction that isn’t an author’s personal adventure into the frightening or the unknown isn’t worth writing for anything but money.
  3. Never use the word “then” as a ­conjunction – we have “and” for this purpose. Substituting “then” is the lazy or tone-deaf writer’s non-solution to the problem of too many “ands” on the page.
  4. Write in the third person unless a ­really distinctive first-person voice ­offers itself irresistibly.
  5. When information becomes free and universally accessible, voluminous research for a novel is devalued along with it.
  6. The most purely autobiographical ­fiction requires pure invention. Nobody ever wrote a more auto­biographical story than “The Meta­morphosis”.
  7. You see more sitting still than chasing after.
  8. It’s doubtful that anyone with an internet connection at his workplace is writing good fiction.
  9. Interesting verbs are seldom very interesting.
  10. You have to love before you can be relentless.

I was very interested in his discussion of observation too:

I’m not one of those writers who walks around with a little notebook and is kind of sitting in cafes studying people and taking detailed notes. I chastise myself for being too much of an amateur to do that, or not having the discipline. I did notice, I got a new glasses’ prescription a couple of weeks ago and I got these progressives, which are very good for reading and also seeing for distance, but one thing they don’t have—it’s a very narrow little part of the lens that you actually use, so much of the lens is just blurry. And I’ve noticed that I just, I can’t stand walking down a sidewalk anymore. Because I realise that all the time my eyes are kind of looking sideways at people, and I can’t do that because now they’re all blurry and you can’t… What the optician tells you is, ‘Oh you just have to turn your head and look at them,’ and I say, ‘Precisely not! I want to see them without their seeing that I’m looking at them and that requires these kind of sidelong glances.’ And I realised as soon as I put these glasses on, I must be doing that constantly when I’m walking down the sidewalk.

It was a wonderful way to spend thirty-five minutes on a road journey. Fortunately in the light of Number 8 on Jonathan’s ten writing tips I am writing a report of his interview rather than a fictional account.

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Visual Representation of a Reading List



In November this year I wrote about Paul Barach‘s work in developing team work in health care. I have been thinking about his insights since my encounter with his work.

I have found this paper (Barach et al, 2008) subsequently and note from its conclusion that:

Pediatric cardiac surgery is an ideal model to study the coordinated efforts of team members in a complex organizational structure. Adverse events occurred routinely during pediatric cardiac surgery and were mostly compensated. Case complexity was a significant predictor of major adverse events. The number of major adverse events per patient correlated with clinical outcomes.

A more recent paper (Schraagen et al, 2010) provides details about observation protocols for recording intraoperative non-routine events (NREs). The paper has some interesting points to make about inter-observer agreement and the training required:

The authors trained human factors observers to observe and code the NRE’s and teamwork from time of arrival of the patient into the operating room (OR) to the patient handover in the intensive care unit. The observers underwent immersive training in which each observer attended 10 operations, learnt in detail about the technical procedures and clinical tasks and received practice in coding teamwork. Two observers were used interchangeably to observe OR teamwork. The authors instigated a rigorous training and assessment protocol, with independent assessment of their performance by both senior medical and human factors experts using video-based assessment. Real-time teamwork observations were supplemented with process mapping, questionnaires on safety culture, level of preparedness by the team, difficulty of the operation and outcome measures.

I have have been thinking a great deal about error, harm and care in the last month and have shared Paul’s insights with a number of people working in team contexts. My original contact with his work was through his interview with Norman Swan (link to podcast) on Radio National’s Health Report.

More Examples of Care

Yesterday (20 December) I learned of the release of the ANZASM 2009 Annual Report by the Australian and New Zealand Audit of Surgical Mortality (ANZASM). This report is based on the activities and outcomes during 2009. The announcement of the report’s availability notes that:

The primary objective of the audit is peer review of all deaths associated with surgical care. The audit process is designed to highlight system and process errors and trends associated with surgical mortality.

I learned yesterday too about the work of Anna Tharyan (Professor of Psychiatry, Christian Medical College,
Vellore, Southern India) and Prathap Tharyan (Professor of Psychiatry, Christian Medical College, Vellore,
Southern India). I found out about Cochrane Collaborations and in passing the work of Clive Adams (Professor of Mental Health Services Research,University of Nottingham, UK). What fascinated me about their work was their sense of caring and the use of a collaborative approach to care. A transcript of the Health Report program about their work can be found here.

In the program Anna starts the interview with this observation:

After 26 years of working within the confines of a large teaching department of psychiatry I was invited by a man who had organised a not for profit organisation to just, as he said, do rounds on the street. He says doctor, you’re going round and round your hospital wards, would you care to come with me down the street and see how many of your patients sit by the roadside? And this man who hasn’t completed a school education opened my eyes to the vast section of the people who need professional psychiatric help who were not existing as far as we were concerned.

Prathap discusses evidence-based medicine in his interview and shares his insights into low cost, clinic-based research design involving real life patients and the kind of working conditions found:

This was a real world trial and we didn’t exclude large numbers of people because most trials tend to exclude somebody with this condition or that condition. But a clinician doesn’t have that luxury, you’ve got to treat everybody who comes so a lot of that evidence isn’t applicable to us. So we decided to create our own evidence using our own patients using our usual clinical practice.

With Clive Adams he has been investigating effective medication for violent patients. Their work exemplified for me the possibilities created by collaborative caring.

Collaborating to Care

I was fascinated to learn about Cochrane Centres in the Health Report and was attracted immediately to the democratic potential of such collaboration.  I have discovered that the Cochrane Collaborative is made up of contributors and entities based all around the world. The majority of the Collaborative’s work is conducted online.

Each entity is a ‘mini-organisation’ in itself, with its own funding, website and workload. Contributors affiliate themselves to an entity, or in some cases several entities, based on their interests, expertise and/or geographical location.

The Collaborative produces Cochrane Reviews which are systematic reviews of primary research in human health care and health policy:

They investigate the effects of interventions (literally meaning to intervene to modify an outcome) for prevention, treatment and rehabilitation. They also assess the accuracy of a diagnostic test for a given condition in a specific patient group and setting. (For information about the structure of these reviews see here.)

I was interested to read about the impact these Reviews have on practice in the UK National Health Service.


Paul Barach’s work has taken me on a journey of discovery. I was attracted intuitively to his approach to systematic observation and how teams might use observation to enhance performance and promote trust. The link between Paul, Anna, Prathap and Clive was made for me by Norman Swan. The Cochrane Collaborative is a real bonus in this wayfinding.

I am hopeful that by exploring a range of contexts for caring that my understanding and practice of care is developed. I am looking forward to exploring inter-professional learning in much more depth in 2011.

Photo Credits

Baby in Hand

PS Asleep on a Bench