Expressive instructions: ethnographic insights into the creativity and improvisation entailed in teaching physical skills to medical students

Anna Harris, Jan-Joost Rethans

Creativity and improvisation are recognized as important aspects of training expertise in domains such as business and the arts, yet rarely discussed in medical education. This article examines how creativity and improvisation play out in the ways teachers give 'expressive instructions' to medical students when teaching physical skills. Ethnographic fieldwork was conducted in a medical school in Maastricht, the Netherlands, with first, second and third year students learning physical examination skills. Over 230 h of fieldwork was conducted in the Skills Lab, including 34 tutorials of 1.5 h duration, with 11 different teachers and over 500 students. Patterns found in the fieldnotes were thematically analyzed using an inductive approach, drawing on sociological theories of craftsmanship. Findings showed that teachers improvise beyond the standardized lesson structure and classroom set-up, giving what we call, drawing on sociological theory, 'expressive instructions'. This was visible in two main ways: 1) by teachers using their own bodies; 2) by teachers using materials that came to hand. This research highlights the important yet underexplored role of creativity and improvisation in teaching physical skills. Creativity and improvisation appear to be particularly important when training expertise in skills that are difficult to articulate and thus require expressive instructions, due for example to their sensory nature. Focusing on how expressive instructions play out in medical education offers insights into the tacit components of expertise development, a process which builds upon a long period of teachers' skilled practice.