Sharing sound: teaching, learning, and researching sonic skills

Abstract

Articulating how to enact a sensory skill is a challenging prospect, as illustrated through the teaching and learning of novices. This article examines strategies employed to overcome the challenges of sharing sensory experience by exploring how medical professionals learn and teach skills of listening to sound: that is, of teaching medical students, and of medical students learning, sonic skills. The article draws on ethnographic research conducted in medical schools and hospitals in Australia and the Netherlands and on historical research conducted in medical archives and libraries in France, the United Kingdom and the United States, from the 1950s until the present. The first part of the paper focuses on the key, often creative, solutions our participants constructed for sharing their knowledge of body sounds, and techniques for its analysis. These didactic solutions are organized in three sections: demonstration; mimicry and repetition; and rhythm and improvisation. We argue that no one strategy leads to the enskillment of novices in listening, but rather, that through the coordination of practices of learning and teaching there is an attempt to obtain ‘sonic alignment’. The second part of the article extends our study of sharing sounds by examining how researchers learn about sonic skills from research participants. Looking at the proposed methodological solutions to the conundrum of how to share audible experience, we reflect on our own ethnographic and historical techniques to attempt sonic alignment with those we study. By integrating into our analysis how we, as researchers, enacted our research material, we understand more about how life we study is enacted too.

Keywords:

• History
• ethnography
• listening skills
• medicine
• enskillment

Introduction

Articulating how to enact a sensory skill is a challenging prospect, as highlighted by the teaching of novices. The difficulty of educating the senses lies in finding ways to describe and tell about practice and sensory experience. Conversely, the difficulty of learning skills and ‘tuning’ the senses involves embedding this instruction into one’s own practice.¹ A plethora of instances from everyday life illustrate these challenges. Take for example what is involved in the instruction and learning of how to make a loaf of bread. Nowadays, if an amateur cook wants to learn to make bread ‘from scratch’, he or she might turn to one of many cookbooks dedicated to instructing the at-home baker. Such recipes are filled with written descriptions that attempt to create sensory awareness of the bread-making process: instructions abound for recognizing the sweet/sour smell of yeasty mixtures, the glutinous feel of kneaded dough, and the requisite ‘hollow knock’ on the bottom of the loaf at the end of baking.

While such recipes assist the amateur baker, much goes unsaid between each described step. The skill of bread-making is developed over time, ‘with practice’. Learning to understand what ‘hollow’ sounds like takes a great number of knocks, layered onto bodily memory of previous knocks (and burnt knuckles). Going to a master class, baking with a more experienced cook, or watching a YouTube video are additional forms of instruction that the novice can weave into their own practices, as they develop personal techniques. There are thus many ways to learn and to teach sensory skills. This article will examine these strategies by exploring how medical professionals learn and teach skills related to sound, to novices. We focus specifically on processes of what we will refer to as ‘sharing sound’, that is of teaching medical students, and of medical students learning, sonic skills. Sonic skills are defined within the larger Sonic Skills research project at Maastricht University to which this research contributes,² as listening skills and other skills (including technical and musical skills) needed to employ the tools for listening – a definition necessitating reflection on various uses of the body and the other senses in listening.

For some time, literature on enskillment has drawn predominantly from examples of manual skills, such as learning how to ride a bicycle,³ to play the cello,⁴ or tennis.⁵ Much of this literature highlights the implicit nature of skilled development, citing philosopher Michael Polanyi’s⁶ work on tacit knowledge and sociologist Pierre Bourdieu’s⁷ work on habitus. In the last decade, scholarly interest in other sensory skills besides a predominant focus on manual skills have resulted in studies of skilled vision,⁸ skilled smelling,⁹ and skilled tasting.¹⁰ In this growing literature on sensory education, listening skills are largely overlooked. Important exceptions, such as anthropologist Tom Rice’s¹¹ study of listening in medicine, will be referenced throughout this paper. The opening bread-making example illustrates how sound and listening are important aspects of many bodily skills, equally emphasizing the conundrum that arises when learning how to listen: how does a novice baker know what ‘hollow’ sounds like? How can one differentiate between the sounds of the loaf as it bakes? Similarly, how does a novice doctor learn what a heart murmur sounds like? What are the tools, resources, and strategies that help novices and experts share sounds and learn these sonic skills? This is a ‘vexing subject’,¹² not only in relation to vision, smell, and taste, as the authors above have indicated, but also in relation to listening.

In medicine, as in other professions, sharing sounds helps to enact community.¹³ Belonging is brought about through practices, such as learning auscultation. Through this pedagogical process, sharing and creating sounds is a more collective activity than in everyday application by professionals,¹⁴ such as when a doctor uses a stethoscope to listen to their patient’s interior. While Jean Lave and Etienne Wenger¹⁵ underline that apprenticeships in communities of practice involve a wide array of actors, this article focuses specifically on the expert–novice relationship. As with the other senses, the issue of intersubjectivity¹⁶ is at stake when it comes to sharing bodily sounds.¹⁷ In addition, sound’s ephemerality makes learning sonic skills particularly difficult. Such difficulties render themselves particularly open to creative and innovative solutions of sharing.

The plurality of approaches used to address the problem of sharing body sounds in medicine provides rich material for ethnographic and historical analysis. This article draws from our own research conducted during fieldwork and in the archives. Anna Harris spent five months conducting participant observation in Australian and Dutch medical schools and hospitals, studying the listening practices of medical students, teachers, doctors, and other hospital staff. She also conducted interviews, recorded sounds, and made drawings. Melissa Van Drie explored British, American, and French medical archives and libraries to study how a variety of written and audiovisual resources (1950–2010) described sonic skills and chronicled teaching strategies and learning practices. How sounds are taught in medicine is a common starting point for our research, and we intersperse observations of contemporary and historical practice throughout the article. We focus principally on sounds and listening, even though sonic skills cannot be isolated from other sensory skills in practice, nor would we want to. Further, we recognize along with many of the aforementioned authors that skills are not properties of individual bodies, but part of an ecological arrangement that includes materials, places, and talk.

Divided into two main parts, the article first examines key, often creative, solutions our participants found for sonic skills learning and teaching. We organize these solutions for purposes of analysis into three sections: demonstration; mimicry and repetition; rhythm and improvisation. These are not discrete ‘stages’ of a delineated process, but are ways of skills teaching and learning that build upon, and continually refer back to, one another. We argue that no one strategy leads to the enskillment of novices in listening but rather that through the coordination of practices of learning and teaching there is an attempt for ‘sonic alignment’.

The term sonic alignment was introduced by anthropologists Vannini and colleagues to underline a performative process of harmonization within a particular environment through sound. They define this as an ordering of one’s meaning of sound with others to achieve a ‘sonic order’.¹⁸ We adapt and develop this term, using our own historical and ethnographic research. For us, what is important is the attempted coordination of sensory experience enacted through practices for sharing body sounds. These are solutions and strategies towards obtaining intersubjective congruence. While Vannini et al. consider sonic alignment as a means of achieving sonic order, we take our cues from philosopher Annemarie Mol,¹⁹ who uses the term coordination not to evoke a single overarching coherent order, but rather the continuing effort that goes into making things hang together. Looking at the suggestions and the solutions that go into the attempt to share sounds between novice and expert, we explore coordination through the practices of demonstration, mimicry, repetition, and improvisation. Examples discussed will include vocalizations, rhythm production, learning bodily dispositions, making drawings, and listening to recordings.

While the sensory studies work mentioned above certainly inspires our analysis, this article will draw, more generally, from the work of anthropologist Tim Ingold.²⁰ Ingold has developed a substantial body of work that explores skill as fundamental to human existence. Rather than being passed on through processes of transmission and acquisition, Ingold argues that skills are developed through practice, through the practitioner’s active engagement with their surroundings. He differentiates his work, as do we, from Polanyi’s notion of tacit knowledge, which is commonly used in discussions of skilled learning. Ingold suggests that Polanyi’s (1966) dictum underlying the theory of tacit knowledge, ‘we can know more than we can tell’, adopts a narrow definition of telling, limited to words. If personal knowledge can be shared through gesture and other bodily means, Ingold posits it may not be so ‘tacit’ after all. Telling is possible, but articulating is hard. In this article we pursue how telling can happen through action and practice: through the use of fingers, hands, and bodies, and through engaging written texts and audiovisual materials. While in this article certain differentiations will be developed in regard to Ingold’s work, we find his ideas particularly useful as ‘food for thought’ for our own reflection on sonic enskillment: not only for this broader conceptualization of telling that highlights ways of sharing we encountered in our archival and fieldwork material, but also for his consideration (more detailed than many other theorists on tacit knowledge) of the process of skills learning from a perspective of both researcher and novice.

In the second part of the article we consider how researchers learn about sonic skills from research participants. This follows Ingold in contemplating the researcher as a novice learning in the ‘workshop’ of the field, and, we propose, in the archive. We deepen our investigation of the proposed methodological solutions to the conundrum of sharing auditory experience by reflecting on our own ethnographic and historical techniques. As anthropologist of medicine and historian of auditory culture, we too were novices, diving into new acoustic worlds and adopting unfamiliar postures to learn about the listening practices of our participants, and how they come to know these practices. Like the novices we study, we also drew upon a range of techniques to understand more about sonic skills, and attempted to coordinate these. We discuss how we lived with artifacts and spent time learning in practice, in medical schools and hospitals. The main premise underlying this second part of the article is that by integrating into our analysis how we, as researchers, enacted our research material, we can understand more about how life we study is enacted too.²¹

Teaching novices/learning novices

Demonstration

In the process of teaching new skills and training bodily technique, demonstration is an invaluable first step. In fields such as science and technology studies and the history of science, demonstration is generally taken to mean the empirical demonstration of scientific fact.²² Here, however, we adopt the definition used by our participants in medical contexts: demonstration as the showing of clinical techniques to novices. While in many ways demonstrations are about proving that there is something to hear, in the case of medical education, demonstration also involves setting up or highlighting situations, enabling the novice to get ‘a feel’ for the skill itself. Through this form of showing, Ingold argues that the skilled practitioner can point out features of the environment, including sounds, which the novice might otherwise fail to notice. Showing something to someone is about making it become present for direct apprehension.

Medical auscultation is perhaps one of the most well-known professional listening techniques specifically demonstrated to novices. While the practice’s place in medicine is continuously shifting, due in part to the growing number of diagnostic devices available, the emphasis on learning this sonic skill in medicine remains relatively constant. For medical novices, the first introduction to auscultation may occur in a lecture hall, where professors find ways of sharing knowledge of sounds and expressing their own techniques for hearing them. In the 1960s, cardiologist Dr W. Proctor Harvey²³ writes about how he used recordings of symphony orchestras to introduce students to the principles and techniques of aural identification and sound classification. Students were guided through repeated listening of the recording, much like a Schaferian ‘ear cleaning’ exercise, to learn to isolate a particular instrument from the more general orchestral background, before turning to similar analysis and descriptions of heart sounds.²⁴ It is one ‘creative’ approach drawing on musical practice and familiar cultural reference to create an entry point into learning auscultation.

This example of demonstration in the lecture hall illustrates how ‘aural thinking’ – which historian Susan Schmidt-Horning defines as the capacity to ‘detect sounds embedded within a dense matrix, a knowledge of what to listen for, what to tune out, and the ability to know when your ears need a rest’ – is addressed when teaching sonic skills.²⁵ The premise is that before one can even begin to distinguish between ‘normal’ and ‘abnormal’ sounds one needs to be attentive to the sounds in that situation. When the novice first listens through a stethoscope the amplification properties of the instrument reveal the polyphony of the body’s sounds. The task of learning is to identify and analyze how specific sounds standout. As a student continues to learn the technique, they begin to recognize the qualities of a particular sound: the notion of ‘deep listening’ could equally be evoked, defined by Sound Studies scholars Michael Bull and Les Back as ‘agile listening’, involving ‘tuning our ears to listen again to the multiple layers of meaning potentially embedded in the same sound’.²⁶

One of the defining aspects of auscultation is becoming familiar with listening alone through the stethoscope’s closed aural pathway to the patient’s body. Dr Harvey’s collective listening to a symphony or heart sounds through loudspeakers is limited because it does not reproduce the particular feeling of listening through an instrument. Collective teaching stethoscopes with multiple earpieces attached to one bell (from the 1880s), collective electronic stethoscopes (from the 1920s), and specially equipped conference halls allowing doctors to individually plug into a lecturer’s stethoscope (also from the 1920s) offer teaching solutions: the student maintains an individual listening posture, while the professor demonstrates and guides listening to particular sounds (see Figure 1).²⁷

Figure 1. Medical students or doctors listening collectively to their own bodies using an electrical stethoscope. Photograph attributed to Central News, 1920s. Wellcome Library, London, Ref. L0029039.

Lectures continue to have an important role in medical education. However, most medical schools have now moved towards smaller group learning in the form of tutorials. These may take place in tutorial classrooms but are more traditionally conducted at the bedside. In teaching sounds, tutors must be creative and resourceful,²⁸ using their own skills and drawing on their own clinical experiences to show students how to listen and to tell about sounds. In tutorial rooms, Harris observed how it was never too long before the teacher would start mimicking the sounds of the lung or the heart: moving their mouths in animation, gesticulating with their hands to enhance the sounds they made with their mouths, moving to embody the murmur or lung pathology. Like scientists who gesture their scientific findings,²⁹ the teachers Harris studied brought their own bodies into their demonstrations of bodily sound. Similar to an orchestra conductor’s hand position, the teachers’ fingers often sketch the breath cycle: inspiration in an upward point and expiration in a diminuendo gesture, with a pregnant pause represented in the space between the two hands.

When hands failed to show what was intended, the teachers might pick up a whiteboard marker to make drawings of respiratory rhythms and heart murmurs, a technique we explore later on. In tutorials, analogies are also part of a teacher’s repertoire of teaching techniques where a medical sound is compared to all sorts of familiar, everyday sounds. Inspiratory stridor was likened to the sound of someone being strangled on CSI Miami, the TV crime show. In the Netherlands, pleuritic rubs were described as sounding like feet crunching in snow – students in the Dutch classes nodded their heads silently in acknowledgement, while the analogy was understandably absent in Australia. Analogies were not only culturally, but also time-specific. Professor Smith,³⁰ one professor whom Harris followed and learned from, was an experienced and renowned respiratory physician in Australia, having taught for over 50 years. He commented on the ways analogies for lung sounds had changed over time. For example, he no longer referred to pleural rub as sounding like squeaking leather, as Melbourne trams no longer used leather in their suspension, and thus students did not recognize the sound; however, he was still reluctant to use the more recent likeness of coarse crackles to Velcro. Long present in learning auscultation, analogies of this nature – like drawings and hand gestures – are ways that teachers attempt to bring novices closer to, or make them more conscious of, the sounds they need to learn. We argue that these are attempts towards sonic alignment, a coordination of perception and definition of terms. These creative techniques are used in lectures and classrooms, but what happens when teaching moves to real patients on the wards?

In the hospitals, bedside teaching is still a privileged teaching method. Every Tuesday morning, Professor Smith would meet his students on Ward 5 South West in a Melbourne hospital to teach them clinical examination skills. Professor Smith was a doctor renowned for his bedside skills, who had what the students called an ‘old-school’ style. He met them dressed in a long white lab-coat and used index cards to note details of patients and make his drawings. Like Dr Coltart in Rice’s study of medical listening in a London hospital, this elegant Professor also demonstrated listening points on patients’ bodies, helping students to correctly apply the stethoscope on skin and listen for ‘land-mark’ sounds.³¹ Like his English compatriot, Professor Smith also used the cheapest, simplest stethoscope model he could find, indicating that it was not the technology that mattered, but rather the knowledge and experience of the sounds that produced effective diagnosis.³²

Professor Smith’s teaching attested to the power not only of demonstrating, but of guiding the novice in the activity they are learning.³³ Ingold, alongside many theorists of tacit knowledge, argues that this is the only way to learn skills: in practice. These authors argue that it is difficult to codify or document skills: that they resist explication or formulae.³⁴ While we found that learning in practice is an important aspect of sonic skills learning, we disagree with these scholars’ dismissal of words, photographs, and other documented representations as ways to teach and learn sounds. We suggest that these resources have an important role not only in demonstrating sonic skills, but in creating additional opportunities for the student to practise new techniques.

Since the elaboration of the technique of auscultation, medical textbooks, manuals, audio cassettes, videos, and recent multimedia websites all accompany live teaching situations. Often crafted by skilled practitioners, we also consider these materials as forms of demonstration, which indicate to the novice features of the environment that they might otherwise ignore, giving analogies for remembering a particular sound, or descriptions for recreating stages of a technique. Written by ‘experts’, medical textbooks often document the pedagogic philosophies of particular institutions or courses, preparing or reinforcing learning conducted in the clinical session, lecture or tutorial, or bedside demonstrations. Take for example lung sound auscultation sections of textbooks in which one finds the same sound analogies as those mentioned above, usually inserted after more technical descriptions of pathologies and their sonic nomenclature.³⁵ Practical advice related to performing the technique through the proper application of the stethoscope is also elaborated.³⁶ Listening points and patterns to follow in an examination of a patient’s body are diagrammed, and the point of a pathological sound’s occurrence in the respiration cycle is also charted: for this the professors’ up and down finger gestures find graphic representation (see Figure 2).

Figure 2. Graphic representations of breath sounds are sometimes printed in medical textbooks, especially in late nineteenth/early twentieth-century editions. Source: Crocket, Physical Examination of the Chest, 242, Fig. 55. Wellcome Library, London, Ref. L0073570.

Like us, anthropologist David Howes is a little more lenient than those who consider that practice resists codification in representations, arguing that many learn skills from how-to guides.³⁷ Sociologist Richard Sennett also proposes that one can learn from such remote direction, but that these instructions need to be ‘expressive’, linking technical craft to imagination.³⁸ Expressiveness, however, varies between texts, and the written or recorded artifact is not always useful or available to the novice. Novices need additional ways to learn about listening and the sounds they are meant to hear. In the next section, we focus on how techniques introduced through demonstration are taught using mimicry and are incorporated by the novice through imitation and repetitive practice.

Mimicry and repetition

We have already implied that imitation was a common method used to share sounds with novices. Using breath, teeth, tongue, lips, and throat, the body is the most immediate reproduction instrument at a teacher’s disposal. One cardiologist in Melbourne was renowned for his skills in mimicry. In his heart sound lecture, students raised their hands and asked for him ‘to be aortic regurgitation’. In addition to providing those everyday analogies found in medical demonstrations, medical textbooks also give instructions for physically imitating a sound synonymous with the one heard through the stethoscope. Classic examples include ‘putting the tip of your tongue on the roof of your mouth and breathing in and out through an open mouth’ for bronchial breathing,³⁹ or ‘rolling the hair found at one’s temple between the thumb and forefinger next to the ear’ for fine crackles.⁴⁰

Sound recording technologies have also been conferred a role of mimicking body sounds. Parallels can be drawn to the professor mimicking a particular sound, isolating it from others to aid understanding. Microphones were attached to stethoscopes since the early twentieth century to make recordings. Cabot’s 1930 textbook is one early example, with its companion ‘Gamble–Cabot’ sound recording (produced by Columbia Records).⁴¹ More contemporary CDs, YouTube videos, mp3 files and websites extend the idea of self-practice, personalizing learning situations and incorporating everyday sound media practices.⁴² Certainly these recordings represent different sensorial experiences than those offered at the bedside, but this is not to say that the recordings ignore the use of tools or the professional environment of the skill. Instructions of a 1970s sound recording illustrate the attempt to simulate a more complete bodily experience:

In order to preserve realism this recording has been prepared such that faithful, life-like reproduction will be achieved only if you listen to the cassette with a stethoscope. Thus, the cassette player serves as a substitute chest and a stethoscope is interposed between the listener and the electronic ‘chest’ as it is in real life.⁴³

Yet, the fragility of such a sensorial re-enactment is underlined by the precision needed at the stereo in order to create the proper listening conditions:

Hold the bell [of the stethoscope] 2 to 3 inches from the speaker of your tape recorder. If you place the bell on the speaker, you will hear more noise than breath sounds. If you listen to the sounds without a stethoscope, they will sound unnaturally loud and booming.⁴⁴

These enactments using mimetic machines generate kinesthetically and affectively charged knowledge,⁴⁵ underlining the importance of bodily mimicry in not only mimicking sounds for purposes of recognition, memory, and communication, but in mimicking corporal positions for recollection of the technique. Mimicry of professional dispositions and gestures is an important part of learning sonic skills, entailing an apprenticeship style of learning. Especially during bedside tutorials, but also during ward rounds and other learning events, Harris noticed that medical students in Melbourne would learn by imitating the techniques demonstrated by their teachers. In first-year tutorials observed in Maastricht, students were observed mimicking their teachers’ techniques, copying what they were taught with, and on, their own bodies. This mimicry was encouraged by teachers through continual repetition and practice.

While we have highlighted the corporal aspects of sonic skills learning, an important aspect of sharing sounds is learning new vocabularies, mimicking words used by teachers and textbooks, and connecting them to sounds heard. Atkinson makes a similar point in his study of haematologists, positing that ‘learning to see’ pathological slides is a process of socialization into ways of looking and required vocabularies of description.⁴⁶ Latour points out that before sensory training, pupils are inarticulate: the novice perfumer cannot speak about odors, and different odors elicit the same behavior and descriptions.⁴⁷ Being educated, learning to be affected by these differences entails learning new words, just as learning about wine entails learning wine talk.⁴⁸ The articulation of words is incorporated into the practices the novices are learning.

Each kind of mimicry explored above involves forms of repetition: by making or listening to sounds over again, in learning and using new vocabulary, or through repeated trials at practice. Vocal and gestural mimicry and repetition, as well as novices’ interactions with ‘mimetic’ machines are all proposed solutions aimed at sonic alignment through bodily and material experimentation. There are challenges, however, in learning about sounds through some of these methods of imitation and repetition. Medical students may hold their stethoscope like their mentor, but the difficultly lies in adjusting one’s perception, in tuning in and identifying what their skilled professor heard easily in the patient’s chest. As Sennett argues, the masters’ lesson is often presumed to be observed by osmosis, putting burden on the apprentice, and creating difficulties when they have not figured out ‘what turned the key in the lock’.⁴⁹ The novice needs more than demonstration, imitation, and repetition in order to learn a skill: learning to listen also requires developing a personalized rhythm where the novice ideally integrates their own improvised form of practice. These are improvisations that build not only on what is being taught, but also on mistakes.

Rhythm and improvisation

The various methods and spaces that we have elaborated upon in the previous sections illustrate instances of collective rhythm making, where the beat or measure is established by the expert/teacher. An important aspect of learning also occurs when the novice initiates or generates their own rhythm in practice, which we explore further in this section. In their cultural theory of rhythm, Henriques et al. indicate that there are not one but many ways of working with the concept of rhythm.⁵⁰ Our own understanding of rhythm is defined as how we come to learn to listen with our bodies, how we individualize this, and how we become sensitive to the affective dimensions of the world.

In medicine, as in other professions, exercises are devised to help the student incorporate the ‘feeling’ of sonic skills in order to train the body. In Rice’s work, Dr Coltart asked medical students to nod their head to the beat of the heart or to tap a rhythm with their foot, ‘lending the sounds a kind of kinesthetic amplification’.⁵¹ In Melbourne and Maastricht medical students were encouraged to practise skills not only on patients, but also on their family members, one another, their pets, and themselves. They started to go out into the world, attuning their sensibilities in new places in everyday life. At the same time, the students’ own body was an ever-present source of learning and repetitive practice as they listened to themselves and tapped out organs.⁵² Through these repeated movements on their own bodies, medical students began to generate confidence and an individualized technique. The students were finding their own way, discovering and embodying technique while experimenting with their own sonic spaces. These examples show how the novice’s environment becomes filled with potential learning opportunities, indicating how these skills are part of a larger ecological arrangement including materials (bodies, instruments, air) and places.⁵³ Learning a skill means not only finding the rhythm of a technique, but to accord it to the polyrhythms of a particular space. In learning auscultation for example, the medical student must learn to attune to the respiratory cycle or the heartbeat, while also attending simultaneously to one’s own body sounds and those of the hospital setting.

Sociologist Henri Lefebvre wrote that there is no rhythm without repetition in time and space (of gestures, actions, situations, differences), but that there is always something new that introduces itself into the repetitive.⁵⁴ Hospitals are chaotic settings, filled with all sorts of audible and inaudible (affective) resonances.⁵⁵ A doctor’s work is practised in such spaces where no one patient’s sounds are the same, no day on the ward similar. In the hospitals, students construct a ‘library’ of personalized reference points from which they construct knowledge, which differ from learning in classrooms and through CDs. Enskillment means not only building this library, mastering techniques, but also knowing how to improvise creatively when encountering the new or unknown. Improvising is thus the act of developing one’s own rhythm and ways of manoeuvering professionally in the world. On the hospital wards Harris observed how students would develop their own techniques during informal teaching situations: for example, when they would go and visit patients on their own, improvising their techniques according to the situation.

Ingold’s work on the improvisatory nature of enskillment is useful here. He discusses a ‘continual sensory attunement of the practitioner’s movements to the inherent rhythmicity of those components of the environment with which he or she is engaged,’ where the novice seeks through repeated trials to achieve the kinds of rhythmic adjustments of perception and action at the heart of fluency.⁵⁶ While we find improvisation an important part of skills learning in our research, we differ from Ingold in his statements above in a few ways. First, Ingold tends to focus on the learning rather than teaching of skills. As we have discussed in this first part of the article, teachers offer a range of solutions to the conundrum of how to share knowledge of sonic skills with novices and these strategies are often incredibly improvisatory. Teaching occurs through creative forms of demonstration, mimicry, and repetition, involving ‘haptic creativity’⁵⁷ and other forms of improvisation; these often use materials, which come to hand: a taut curtain or handkerchief to demonstrate a heart murmur, for example. These experts, having mastered the skill, show that improvisation is central to the ongoing performance of sonic skills.

Ingold is also somewhat limited for dealing with unskilled performances, with mistakes, and with those who do not achieve fluency. Some of the medical students we spoke to could not distinguish between different sounds no matter how hard they tried. Not all practitioners developed the kind of fluent performance that Ingold and others write of. We have pointed to instances where the novice is expected to learn by osmosis, or expected to know how to magically turn the key in the lock. Not every student can become a master. As researchers, we know only too well the difficulties of learning these skills, through our own attempts. We turn now to the second part of the article, which examines how researchers, including ourselves, have studied the sharing of sounds, and how they have attempted to align themselves and follow the rhythms of their participants.

Studying sonic skills learning

According to Lefebvre, one can only appreciate rhythms by attending to oneself, one’s own heartbeat or breathing, one’s own day- and night-time rhythms.⁵⁸ Increasing attention has been paid to a reflexive engagement with sensory research practice, and how our ways of knowing are produced. ⁵⁹ The events we study are enacted not only by the individuals and materials studied, but also by the research methods employed to study the phenomena of interest. By reflecting on how anthropologists and historians, including ourselves, learn about sonic skills from participants and artifacts, we are thus able to offer further insight into the sonic skills learning process. In doing so, we consider both participant observation and historical enquiry as ways of enacting an ‘empathetic engagement with the practices and places that are important to the people participating in the research’.⁶⁰ These are methods, each with their own possibilities and limitations, which are bodily ways of seeking routes by which to share or imagine the actions of the people we study.⁶¹ Like Dicks, we acknowledge the difficulties of using the word empathy here to relate to intersubjectivity.⁶² However, we consider that empathetic engagement correlates with our findings of attempts at sonic alignment in the sites we studied.

Participant observation is often considered the main means by which to document and understand skilled practice and ways of sharing sensory knowledge. Anthropologists claim that they have access to other people’s ways of perceiving by joining with them in the same currents of practical activity, and by learning to attend to things – as would any novice practitioner – in terms of what they afford in the contexts of what has to be done.⁶³

Texts on sensory methods also privilege participant observation as a means of learning about sensory practice.⁶⁴ Pink describes an anthropological type of sensory ethnography that is apprentice-like in nature, where the method is about ‘being with’ participants. This entails a route to understanding the experiences and meanings of other people’s lives through different variations of being, and doing things, with them – in many ways a form of alignment between researcher and informant that is similar to the alignment or attempted coordination between expert and novice that was described in the previous section. These methods and forms of learning from participants assume that certain kinds of knowledge cannot be gained through pure observation, and that one must attend to their own body as researcher, in order to learn about the bodily skills of others.

Ethnographers have long been interested in the sonic rhythms of their environment and various functions of sound. The difficulties of accessing other people’s ways of perceiving sound has challenged ethnographers, and they have found various strategies to study these subjective experiences. For example, Steven Feld used the technique of listening and talking about his forest recordings with participants as a way to gain a better ‘sense of how to be an ethnographic listener’.⁶⁵ Tom Rice adopted the apprenticeship model to learn auscultation – his ‘ears on’ approach reflects on his own apprenticeship in stethoscopic listening.⁶⁶ Historians have a different task: to find ways to access how past generations have listened and learned listening techniques. One can never fully know the conditions of how certain historical documents attest or contribute to the emergence or perpetuation of a practice.⁶⁷ The boundaries between the spoken and the non-spoken of a particular historical moment remain ongoing pursuits in the histories of multisensorial experience. Historian of science Peter Heering argues that understanding past practice is enshrouded in certain failure due to the fact that different representations of a perceptual experience cannot capture the original lived one.⁶⁸ We suggest, however, that archival resources can offer rich insights into past practices.

A historian with a background in music, Van Drie was a novice to medical auscultation. Passing the thresholds of medical school libraries and archives signified a moment of initiation for her. Van Drie began learning about the skill of auscultation through consulting multiple kinds of documents and objects (including textbooks, photographs, drawings, sound recordings, videos). Indeed, her own position as novice also contributed to her hypotheses about the role of such documents in learning auscultation; for example, what aspects of the skill seemed fully explained and what seemed missing. Van Drie adopted a historical ‘ears on approach’ to her reflection of these documents. For example, she attended to short anecdotes, notes, and tips within textbooks concerning listening or specific sounds that went beyond standardized descriptions and hinted at aspects of ‘expressive’ instruction (recalling Sennett), doting the skill with personal experience. Such sources reflected live sharing situations and their particular juxtaposition of diverse data – drawings, notation, photographs of the doctor at work, metaphors, tips – can be seen as a way of prompting embodied remembering outside the hospital ward.

We evoked above how medical educators created recordings in the 1970s that made sense only when listened to through stethoscopes, thus forcing the student to simulate a stethoscopic experience outside the ward. Van Drie was curious in experimenting herself with the sorts of bodily postures and aural experiences that such medical educational sound recordings attempted to create for the student. After digging up machines that could actually play old tapes, she found that each audiocassette example (ranging from the 1960s to the 1980s) proposed a particular pedagogical strategy, created a particular soundscape and learning style. These provided interesting counterpoints to textual learning materials and pointed to the fact that teaching tools are sculpted by different didactic methods. Noting slight variations in how this ‘canon’ of instructions was organized and represented over time, through different mediums, allowed for new hypotheses to be formulated concerning changing modalities of learning listening skills and the function of such resources themselves in sensory learning.

In contemporary hospitals Harris tried to understand more about how participants heard and shared sounds by how they drew them. As mentioned earlier, doctors were often drawing sounds. Inspired by this, Harris would ask someone she was interviewing to draw in her notebook, and they would easily fill a page with notations of the sounds they were learning or teaching. These drawings were ways of enacting sounds, through trace and gesture. Gestures of chalk strokes or pen marks are embodied forms of understanding, performing, and sharing knowledge with others; another way of telling. Harris also made many drawings during her fieldwork, such as copying the illustrations that junior doctors made in medical charts, drawing the way a stethoscope was worn, or trying to capture something of a gesture that a teacher was making with their hands. She considered drawings not only as a way in which her participants shared sounds with each other, but also as a way in which she could learn about the sounds from them (see Figures 3 and 4).

Figure 3. Fieldnotes with images of lung sound drawings copied from patient’s notes (Anna Harris’s own fieldnotes and photo).

Figure 4. Whiteboard in a clinical skills tutorial room, with extra drawings of heart murmurs and lung sounds in red made by clinical tutor during interview with Anna (photo: Anna Harris).

Ethnographers often make drawings in their notebooks but, with a few exceptions⁶⁹ they have rarely been considered methodologically,⁷⁰ or as ways of understanding more about the object of study. Just as the practitioners we studied found drawing a way of getting closer to the sounds they were studying, so too is drawing another way in which we, as researchers, can attempt to get closer to the sonic skills we study. Drawing allows an improvisatory form of engagement in the field, which involves the researcher in embodied notation, making interpretations that attend to different rhythms of the environment than may be picked up by written words or sound recordings.⁷¹

Through engaging with archival materials, the historian tries to come closer to the sonic skills they study. Just as the novice reads textbooks or listens to tapes, the historian can also tap into and build upon their own histories of embodied practices through their own methodological experimentation with artifacts, including re-enactments. The ethnographer, like the historian, also attempts to get closer to practice through elicitation techniques, drawing, and other forms of ‘being with’ participants. Researchers in the fields of history and anthropology have also used video,⁷² walking,⁷³ diaries and journals⁷⁴ to study sound and other sensory practices. Different methods enact different aspects of the sensory experience and are different ways of sharing. None of these methods are without their limitations. In anthropology, researchers have acknowledged the challenge of researching the implicit nature of skill.⁷⁵ Like a pianist who starts to pay attention to their fingers whilst playing a difficult piece, gets confused and has to stop,⁷⁶ teasing apart the particulars of practice can be disruptive to the skill itself, and make research difficult. The difficulty of documenting sensory experiences such as listening, and sharing sounds, does not render it obsolete, but rather, on the other hand, as anthropologist Natasha Myers suggests, makes it an ever more crucial topic of study.⁷⁷

Conclusion

Learning to listen, through sharing sounds, is a process of belonging for doctors, a membership into their profession. In this article we have shown that sharing sounds takes continual effort, a choreography of practices involving textbooks and drawings, imitated sounds and teaching stethoscopes. This is a process highlighted in teaching and learning, where there is a concentrated attempt at coordination of experience through creative techniques and strategies. This attempt at sonic alignment is a precarious arrangement, not only due to the intersubjective nature of sharing sounds but also because of the ephemerality of what is being shared. Developing sonic skills does not happen seamlessly and the fluency of performance that Ingold writes about is something which the people we studied rarely discussed attaining. Yet, even those who do not master a skill still develop a new sensory awareness.

Despite these challenges, we have argued in this article that teachers and novices use a range of techniques in an attempt to obtain sonic alignment, through forms of demonstration; mimicry and repetition; rhythm and improvisation. We have focused on sonic skills, however, these techniques involve multisensory modes of learning. The first section of the article highlighted the different ways in which sonic skills are demonstrated, in person, as well as through texts and audiovisual material – sources of learning often dismissed by other scholars of enskillment. Through articulating the different forms of demonstration and different ways of showing information, we have shown the different places, tools, and ways of creating sensory awareness. The second section moved to imitation or bodily mimicry, which entailed the novice following the expert closely in repeated trials. In the third section, we discussed how, in order to incorporate practice, the novice develops their own rhythm and improvises techniques. The final sections of the article reflected upon how we as researchers learned about the sonic skills our participants were learning and teaching. By placing our methods and the practical knowledge encountered in the field and in the archive side-by-side with the empirical material we are able to understand more about how sonic skills are shared between expert and novice. We learned that just as researchers cannot learn about sound and listening through a single method,⁷⁸ so too sonic skills cannot be grasped by novices through one technique alone.

Learning how to listen entails bringing together a range of techniques, layered onto past practice, occurring in learning events which are always emplaced, always material. Throughout the article we have examined ways in which experts try to bring the novice closer to the skill. We have focused on learning skills, to the neglect of retaining skills or forgetting skills, which also deserve further study. We have also deliberately focused on the bodily relationship between expert and novice, to the exclusion of discussion about broader societal factors, which may include the politics of teaching clinical skills,⁷⁹ the socialization of children into stethoscopic listening with toys,⁸⁰ the popular culture of stethoscopic listening (radio, television, theater, comedy sketches of the doctor and his/her stethoscope). Nor have we discussed in detail the kinds of collective tacit knowledge⁸¹ surrounding listening in medical practice, and the importance for the profession in constructing not only shared sounds, but a shared world view.⁸² These are indeed important points, which although we did not have room to discuss in this paper, deserve further consideration.

In this article we have explored how learning occurs across sites and materials as a way to bridge gaps between knowing and unknowing. Learning skills involves reading how-to manuals, recipes, textbooks, and help columns (or online fora); it is about looking at and making photographs, YouTube videos, and drawings; it is about learning directly from the experts, whether in the kitchen or hospital. Novices, whether they are research participants, historical characters, or researchers, are all finding their way through life in a multisensory engagement with their environments. In finding their path, they will continue to learn from, and in the process continue to teach skills, to others around them.

Notes on contributors

Anna Harris is an anthropologist who studies medical practices. Drawing also from a science and technology studies perspective, Anna mainly does fieldwork in hospitals and online, where she explores the sensory and material nature of medical work. Originally trained as a doctor, Anna studied medical anthropology at the University of Melbourne. She has been a visiting researcher at McGill University, the University of Amsterdam and the Royal Melbourne Institute of Technology, and has held postdoctoral positions at Maastricht University and the University of Exeter. This article is based on her ethnographic study of how doctors learn to listen to sounds, part of the Sonic Skills project, led by Karin Bijsterveld, in Maastricht. Anna’s future project concerns the role of technologies in medical education. She blogs about regularly at www.pneumaticpost.blogspot.com, and her website is http://annaroseharris.wordpress.com.

Melissa Van Drie studies cultural histories of listening and sound media. She has a background in music, musicology (NYU) and theatre studies (Université Sorbonne Nouvelle-Paris 3). Her PhD examined the impact of early sound reproduction technologies (théâtrophone, phonograph, telephone) on French theatre, and the resulting articulations of new sensory practices in the late nineteenth century. She is interested in engaging sensory approaches to investigate knowledge production and sharing between the arts and sciences. This article draws on historical research of medical textbooks and sound recordings conducted during a postdoc in the Sonic Skills project, led by Karin Bijsterveld at Maastricht University. Additionally, Melissa has held postdoctoral research positions in the LabEx Création, Arts, Patrimoine Project (Université Paris 1 Panthéon-Sorbonne & Centre Georg Simmel, EHESS), and the French ANR project ECHO (Bibliothèque Nationale de France and THALIM Research Center, CNRS) in Paris.

Funding

We are grateful for the financial support of the Netherlands Organisation for Scientific Research (NWO), who funded the Sonic Skills: Sound and Listening in the Development of Science, Technology, Medicine (1920–now) project, of which our research forms a part, via a Vici Grant to Karin Bijsterveld.

Acknowledgements

We would like to thank the many researchers whose comments have shaped this article, including: the members of the Sonic Skills project and the researchers who were present at the Sonic Skills Expert Day at Maastricht University in January 2013. Additionally, we sincerely thank our participants and the medical institutions, archives and libraries, whose testimony and resources made this article possible.

Notes

1. Sennett, The Craftsman, 50.

2. This Dutch (NWO [Netherlands Organisation for Scientific Research], Vici) funded research project Sonic Skills: Sound and Listening in the Development of Science, Technology, Medicine (1920–now) is led by Karin Bijsterveld. It also includes other subprojects by Joeri Bruyninckx, Stefan Krebs, and Alexandra Supper that empirically investigate the role of sound and listening in knowledge production.

3. Collins, Tacit and Explicit Knowledge.

4. Ingold, The Perception of the Environment; Sennett, The Craftsman.

5. Noble and Watkins, “So, How Did Bourdieu Learn to Play Tennis?”

6. Polanyi, The Tacit Dimension.

7. Bourdieu, Outline of a Theory of Practice.

8. Grasseni, “Skilled Vision”; Ellis, “Jizz and the Joy of Pattern Recognition.”

9. Latour, “How to Talk About the Body?”

10. Shapin, “The Tastes of Wine.”

11. Rice, Hearing and the Hospital.

12. Sennett, The Craftsman.

13. Lave and Wenger, Situated Learning.

14. Ellis, “Jizz and the Joy of Pattern Recognition.”

15. Lave and Wenger, Situated Learning.

16. Shapin, “The Tastes of Wine.”

17. Rice, Hearing and the Hospital.

18. Vannini et al., “Sound Acts.”

19. Mol, The Body Multiple.

20. Ingold, The Perception of the Environment.

21. Hicks, “The Material–Cultural Turn.”

22. For example, Shapin and Schaffer, Leviathan and the Air-Pump.

23. Harvey, “Technique and Art of Auscultation,” 53.

24. Van Drie, “Training the Auscultative Ear,” 166.

25. Schmidt-Horning, “Engineering the Performance,” 714.

26. Bull and Back, The Auditory Culture Reader, 3.

27. Krebs and Van Drie, “The Art of Stethoscope Use,” 104–106.

28. Rice, “Learning to Listen,” S43.

29. Myers, “Dance Your PhD.”

30. This is a pseudonym.

31. Rice, Hearing and the Hospital, 100.

32. Ibid.

33. Ingold, The Perception of the Environment.

34. Collins, Tacit and Explicit Knowledge; Delamont and Atkinson, “Doctoring Uncertainty;” Ingold, The Perception of the Environment.

35. Van Drie, “Training the Auscultative Ear,” 180.

36. For example, Bickley and Szilagyi, Bates’ Guide to Physical Examination.

37. Howes, “Reply to Tim Ingold.”

38. Sennett, The Craftsman, 186.

39. Epstein et al., Clinical Examination, 629.

40. Thomas and Monaghan, Oxford Handbook of Clinical Examination, 217.

41. Cabot, Physical Diagnosis.

42. Sterne, “The MP3 as Cultural Artifact.”

43. Cugell, Introduction to Breath Sounds, 1.

44. Lehrer, “Instruction Script for Audiocassette,” 119.

45. Myers, “Dance Your PhD.”

46. Atkinson, Medical Talk.

47. Latour, "How to Talk About the Body?”

48. Shapin, “The Tastes of Wine.”

49. Sennett, The Craftsman, 181.

50. Henriques et al., “Rhythm Returns.”

51. Rice, “Sounding Bodies,” 309.

52. Harris, “Listening-Touch.”

53. Ingold, The Perception of the Environment.

54. Lefebvre, Rhythmanalysis.

55. Schwartz, Making Noise.

56. Ingold Making, 115.

57. Myers, “Dance Your PhD,” 171.

58. Lefebvre, Rhythmanalysis.

59. Pink, “Engaging the Senses.”

60. Pink, “Multimodality, Multisensoriality and Ethnographic Knowing,” 271.

61. Ibid.

62. Dicks, “Action, Experience, Communication.”

63. Ingold, “Worlds of Sense and Sensing the World,” 314.

64. For example, Pink, Doing Sensory Ethnography.

65. Feld and Bernneis, “Doing Anthropology in Sound,” 465.

66. Rice, Hearing and the Hospital, 16.

67. Corbin, “Charting the Cultural History of the Senses,” 135.

68. Heering, "The Enlightened Microscope,” 352.

69. Afonso and Ramos, “New Graphics for Old Stories”; Taussig, I Swear I Saw This; Myers “Dance Your PhD.”

70. Ingold, “Drawing Together: Materials, Gestures, Lines."

71. Ingold, Making.

72. Sutton, “Cooking is Good to Think.”

73. Pink, “Walking With Video.”

74. Waskul and Vannini, “Smell, Odor, and Somatic work.”.

75. For example, Myers, “Dance Your PhD”; Ellis, “Jizz and theJoy of Pattern Recognition.”

76. Polanyi, The Tacit Dimension.

77. Myers, “Dance Your PhD.”

78. Sterne, “Sonic Imaginations.”

79. Rice, Hearing and the Hospital.

80. On the role of toys in visual training, see Grasseni, “Skilled Vision.”

81. Collins, Tacit and Explicit Knowledge.

82. Grasseni, “Skilled Vision.”