Master’s Thesis: Gazing in the operating room

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Master’s Thesis: Gazing in the operating room

Abstract

This study aims to provide insights on the function of gazing in the operating room. In our everyday interactions we tend to gaze at one another frequently. Our gazing behavior is not only considered as a social act, it is also helping us in creating a mutual understanding of what is being said or done. This study shows that the gazing behavior of surgeons is very different from the gazing behavior in other interactional settings. Surgeons hardly gaze at each other while performing surgery, they remain focused on the patient’s body. Only in a few occasions do they gaze at each other. Five hip replacement surgeries were recorded with GoPro cameras worn by the surgeons, and one GoPro camera was mounted in front of the operating table to get a clear overview. While analyzing the recordings a categorization of gazing sequences was made to make it observable when gazing occurred most frequent. A prototypical example from each of the sequences that occurred most frequent was then analyzed with the usage of Elan. In all examples accountability plays an important role in reaching a mutual understanding. Intersubjectivity is needed to understand what the other surgeon is saying or doing. Intersubjectivity is also needed to make the joint activity of performing surgery a success. The function of gazing in the operating room is the same as in any other setting. Gazing aids in reaching a mutual understanding. However, the way surgeons reach intersubjectivity is worth mentioning. In some occasions intersubjectivity needs to be recalibrated. Gazing aids in recalibrating the intersubjectivity. In other occasions, intersubjectivity is reached by interacting verbally. On these occasions gazing also aids in reaching a mutual understanding, but mutual understanding is mainly created by talking to another.

Name: Michiel Willems

Student number: S1780956

Email: m.a.willems.1@student.rug.nl Education: Communication science Thesis supervisor: Dr. Mike Huiskes

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Preface

Two years ago I made a radical decision. I was already working in the field of Communication after graduating with a Bachelor’s degree from the Hanze University for applied sciences. However, I never felt being in the right place. When applying for the coolest jobs they always seemed to be out of reach because I didn’t earn a Master’s degree. So I chose to go back to University and get that Master’s degree. I cruised through the Premaster (first year) earning fairly good grades, just like my time at Hanze University. I really enjoyed my first year, especially the way we are being taught and how we are researching communication as a phenomenon. I decided to raise the bar and pursue the highest grades possible and earning that Cum Laude title for my Master’s degree. One year of hard work would make me benefit from it for a lifetime, right? Well, what a year it has been. I started the year overexcited. I attended discussion groups, mostly made up of professors and PhD students, just because I loved research that much. In late September my father suffered a brain stroke while being on a flight back to Amsterdam from Cape Town. An emergency landing was made in Antalya, Turkey. For two days I didn’t know if my father was still alive. After three weeks of laying a coma he woke up and he could slowly start with his recovery in order to get back home. Luckily, I can say that my father is doing rather well. I will never forget the stress that came with his brain stroke and I am thankful for all the professors who accepted me walking out of class again to take another phone call from a doctor. Special thanks to the professors who took the extra time out of their agendas to give me some private classes on the lessons I had missed. And, although I gave it my all, one grade killed off my dreams of earning the Cum Laude title. However, I remained optimistic and really enjoyed the courses that followed. I began to develop an interested in gazing behavior while following a course on communication skills in medical interaction. Within the course, our data consisted of five operations where surgeons replaced a hip. Our task was to analyze the recruitments and assessments being made to improve the communication skills of the surgeons while performing surgery. I, however, noticed that gazing to one another was very different from when having a normal conversation. I wrote a paper on gazing and decided I wanted to dedicate my thesis to the same subject. My professor Mike Huiskes challenged me to go even further into detail regarding the gazing behavior. Little did I know that the challenge would become even bigger than I imagined. When my father finally came home after a couple of months of recovery in Turkey, my mom was taking him to the hospital multiple times a week. Not long after bad luck struck again. My mom managed to break her back, leaving them both in need assistance. Now, I might sound like one of those families that always seem to have something going on but, my parents have had no medical history like this prior to these incidents. Being one of two sons this meant taking my parents to the hospital multiple times a week. My focus shifted from studying to taking care of my parents and time for this thesis became scarce. I want to thank my supervisor Mike Huiskes for his flexibility during these challenging times. I also want to thank him for his ever optimistic stance on the work I handed in. I do believe Mike is one of the best in the business when it comes to giving feedback. He does not only gives feedback on what has to change, but he explains clearly why it has to change, while retaining a positive tone. Mike, thank you for managing me through my thesis.

And now I am here, both parents doing well and I am about to finish my thesis and earning that master’s degree. No Cum Laude title but averaging a seven, which to me feels like Cum Laude given circumstances.

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Introduction

Humans are prone to use multiple forms of nonverbal interaction when communicating with one another. This embodied interaction, as we call it consists of the usage of the feet, legs, hips, waist, upper body, arms, hands, neck, cheek, mouth, face and the eyes (Dinger, 2011). Some researchers even claim that when we interact with one another we use more nonverbal than verbal features to communicate. According to Matsumoto et al. (2010, p. 299): “When two people communicate, words compose only 35% of their exchange. That is, 65% of human communication takes place through nonverbal communication, such as affect, gestures, speech pace, and other behavior.” While operating, some of these nonverbal features are hard to use or remain hidden. A surgeon cannot use his arms and hands while he is working on the patient’s body. And to ensure hygiene is at its best, the surgeons wear a surgical suit to protect the patient’s health. With the suit comes a protective mask and hat, which covers up most of the surgeon’s face. This leaves out the eyes of the surgeon. Gazing has an important role in our nonverbal interaction, this study will focus on the gazing behavior of surgeons when they gaze at one another. For us to discuss gazing behavior I will start by describing how our eyes work.

We assume that the eye did not primarily evolve to make us communicate better. They evolved to make us perceive the world around us. Because of our eyes we could move easier through rough terrains and spot prey from a distance. Later, evolution led to the whitening of our sclera. This gave us the possibility to use our eyes for other purposes than just seeing the world. We are the only primate species with a white sclera. Studies have shown that the white sclera provides us with a different function, called “gaze signaling” (Kobayashi, 1997, 2001; Kobayashi & Hashiya, 2011) whereas the dark sclera of other primates contributes to “gaze camouflaging”. With “gaze signaling” we give other humans the possibility to see where we are directing our gaze to. With “gaze

camouflaging” the direction of the gaze is much harder to notice since the sclera is dark. Tomasello et al. (2007) came to similar conclusions when conducting an experiment. He noticed that human infants relied on the eyes of the experimenter when following a human experimenter, while primates relied mostly on the direction of the head. It is scientifically proven that humans can judge the direction of the gaze of another person to within only a few degrees of arc (Gibson & Pick, 1963). This is very useful when interacting with another person. Being able to identify where someone else is gazing at improves the understanding of what others are thinking or are intending to do (Frith & Frith, 2001). Gazing at another person’s face is usually more interactionally relevant than looking elsewhere, at least in Western cultures (Goodwin, 1981; Kendon, 1967). Rossano (2009) showed us that in other cultures gazing behavior is treated very different. He states that members of a Mayan community living in Mexico and speaking Tzeltal tend to look away from the speaker when spoken to. They tend to look at nothing in particular, when they look at something in particular it is considered a sign of losing interest in the conversation. Their default is not looking at the speaker whereas in Western cultures the default is looking at the speaker when spoken to, at least for a considerable amount of time.

In the late 1960’s researchers began to develop an interest in embodied interaction. The works of Albert Mehrabian (1967) introduced the commonly known phrase “communication is more than 90% body language”. Although this phrase received a tremendous amount of criticism from the scientific world, we do know that embodied interaction plays an important part when we

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Kendon (1967) described the functions of gazing as follows:

1. Monitoring—‘to gather information about how [an interactant] is behaving’ (p. 53) (i.e. to seek feedback or a ‘response’ from a listener.

2. Regulatory—to signal one’s intentions with respect to ‘floor apportionment’ (i.e. switching speaking turns).

3. Expressive—to reveal feelings and attitudes (e.g. gaze avoidance at points of ‘high emotion’). And, according to Rossano (2012) the function of gazing is: “gaze, indeed, is used to perceive the world, to control the accuracy of our own body moments and those of others, as well as to display attentiveness and engagement, but it can be used for structural purposes as well.”

Over the years, researching gazing behavior proved to be challenging. Eye gazing is a very subtle phenomenon, and it is hard to notice. Therefore, it has not been researched a lot in comparison to embodied interaction, let alone conversation analysis. Goodwin (1981) described these challenges as follows: “Because multiple participants were included on the screen, it was frequently impossible to distinguish individuals’ eyeballs.” Goodwin describes that although the term “direction of the head toward the other” would be more suited, the term gaze is used instead. This is due to the fact that the first would make analyses hard to follow. In addition, Scheflen (1974) and Exline (1974) noted that the gaze towards another person does not directly focus at the eyes of another person, but rather in the region of the face, meaning that the term gaze can also be used when a person gazes in the direction of another person’s face. Modern times have changed this perception. Thanks to new technologies such as POV cameras and eye-tracker devices it has become easier to research the direction of the eye.

Goodwin’s (1981) findings showed that recipients usually gaze to speakers at the beginning and ends of a multiunit extended telling. He demonstrated that certain rules apply on having a conversation. The first rule is that a speaker should obtain the gaze of his recipient during the course of a turn at talk. “the turn at talk provides a slot for the hearer to gaze at the speaker.[..]The

presence of such a slot would establish the relevance of the hearer’s gaze at a particular place, while yet providing other places in the turn where the hearer could gaze elsewhere than at the speaker without producing a situation where gaze is to be treated as absent” Goodwin (1980, p. 287). The second rule states that a recipient should be gazing at the speaker when the speaker is gazing at the hearer. “While a hearer may and should gaze frequently at the speaker if the rule is to be satisfied, the speaker is under no such obligation; the speaker’s gaze toward the hearer can in fact be intermittent” Goodwin (1980, p. 288).

However, not all researchers believe these are the functions of gazing. Rossano (2012) for instance, showed us in his dissertation that he has found evidence against the ideas proposed by Goodwin and Kendon. Although he did find supporting evidence for the patterns of Kendon in his data, Rossano believes that gazing occurs at different moments. He points out that gazing is

organized by reference to sequences and the specific actions performed by the person who looks at the other are key roles in the occurrence of gazing. He states:

“By sustaining gaze toward the speaker a recipient displays an understanding of what the course of action will be and the potential willingness to act as a recipient where it would otherwise be possible to take the floor and become the speaker. [..] With a possible intrinsic understanding of what the things we do or say are “about”, [..] one takes a more “action”

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oriented perspective and sees recipient’s gaze as an active cue for the speaker, rather than a mere display of attentiveness. It shows action recognition and shared intentionality.” (Rossano 2012, p. 125)

Meaning: “I can see what you are trying to do and I am going to align with it to make it possible”. Goodwin did change his stance on gazing behavior in later years. In “The body in action” (2003, p. 30-31) Goodwin discusses an image of two girls sitting on the ground. The left girl points towards a certain area on the ground, both girls gaze upon the area that is pointed out.

“Ann gazes toward her gesturing hand and the soil it is tied to. The gesture is visibly and publicly what she is attending to, and thus something that others should take into account if they want to co-participate in action with her, or understand what she is saying and doing. At the same time Ann’s gesture is also organised with reference to the visible orientation of her addressee’s body. The gesturing hand is placed right in Sue’s line of sight. It is designed not only to express what the speaker is saying, but quite literally to how Sue something, and moreover to insist that Sue look at it by intruding into her visual focus on the soil she is working with.”

This description of when gazing occurs is more in line with the ideas of Rossano. Goodwin states that the gesture of Ann (pointing at something) and her gaze towards the specific area make others gaze at the same area if they want to co-participate in action, meaning that her gesture and her gaze are not so much organized by turn at talk but rather by reference to sequences and the specific actions Ann is performing. The abovementioned researchers do agree on the fact that gazing is not merely used as a way of understanding speech better, but it is also used as a social act.

In all cases, gazing occurs in a joint activity. One can gaze at anything in particular, it will need another person to interpret that gaze and reflect on what he or she is thinking or doing (Clark, 1996). A joint activity can be anything from a job interview to a basketball game. Within the joint activity we are not just participants, we have certain activity roles. For instance, when I talk to my professor about gazing behavior and he explains something, I am not just a listener, I am also a student trying to learn something (hopefully) from my professor. Another important thing is the goal of the joint activity. In the example I mentioned before, the goal for me would be to gain knowledge. My professor his goal would be to make me understand new theories brought up in that particular conversation. One can have multiple goals within the same joint activity. Next to gaining knowledge, I may also have interpersonal goals like being polite or maintaining self-respect.

A joint activity is made up out of joint actions. Joint actions come in many forms, shapes and sizes. When we speak face to face, we consider that a joint action. But also writing a letter to another person is considered a joint action. Joint actions require coordination of individual actions to make it work. A joint action consists of multiple layers of action. If we go back to the example where I am the student talking to my professor, communication is the base layer of the joint action. One vocalizes something, the other person listens. We’re also forming a joint action on gaining knowledge as my professor is explaining new theories to me.

Another joint activity could be that of surgeons performing surgery. Within this joint activity various joint actions will be taking place. One such joint action could be drilling into the femur bone. Another joint action could be stitching the skin back together when the surgery is almost completed. The goal of the joint activity would be replacing the hip without any problems. Other interpersonal goals may be present but this paper is not about researching those interpersonal goals. For this

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paper I am particularly interested in the gazing behavior of surgeons. While analyzing hip

replacement surgeries, I noticed that the gazing behavior of surgeons differs from that of any other form of social interaction. As Goodwin (1981) and Kendon (1967) explained, we tend to gaze upon each other when we interact, yet in the operating room surgeons tend to gaze at the operating area, even when interacting with the other surgeon. To get a better understanding of how surgeons work I will describe the process that surgeons use for hip replacement surgeries.

At the University Medical Center Groningen, a hip replacement operation is performed by a surgeon, an assistant and someone to hand over the tools necessary to either the surgeon or the assistant. Other people, such as the anesthesiologist and his or her assistants are also present in the room. However, while performing surgery, there is hardly any communication between the

anesthesiologist and/or his or her assistants and the surgical team. Therefore, this paper focuses solely on the gazing behavior of the surgical team. Surgeons performing a hip replacement surgery work following a four-stage-cycle. It can be depicted as follows:

This cycle consist of four stages. When a new environment is presented, the surgeons will need to make a judgement regarding how to treat that new environment, this may involve creating a common ground regarding the new environment. When intersubjectivity has been reached a decision is made. What follows next is the motor action of the decision, the actual performance. With each motor action, new environments are created, leading to a new moment of judgement, decisions and motor actions. The surgeons are mainly focused on the hip area and continue to gaze upon the patient’s hip for most of the time. While performing the surgical procedure surgeons can sometimes operate and talk for more than ten minutes while they do not gaze at one another. Only on a few occasions do they gaze, sometimes ending up in a mutual gaze.

Performing surgery is not a form of interaction. It is a joint activity with a clear task, which is to successfully replace a hip. Within the joint activity of performing surgery, surgeons need their eyes for their primary task, which is to observe what they are doing while treating the patient’s body. The surgeons must be focused on the operating area since a short loss of focus could lead to devastating consequences for the patient’s health. To my knowledge, no one has ever researched the gazing behavior of surgeons before. Since interacting with the other surgeon is crucial in order to make the surgery a success, it is interesting to get an insight on the gazing behavior of surgeons and the function of those gazes when they gaze at one another.

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Method

For this research paper conversation analytic research methods have been used. Conversation analysis (CA) was developed by Harvey Sacks. CA is a research method that focuses on all forms of verbal and non-verbal interactions. With the usage of CA we can describe how the surgeons behave in the setting of performing a medical operation. The video recordings show us what the surgeons utter, and how they non-verbally (re)act. CA does not intend to make statements on what is going on in the heads of the surgeons and how they interpreted the actions of their colleagues.

The data consists of six surgical procedures of a hip replacement performed by surgeons at the University Medical Center Groningen. In the six medical operations, different surgeons are performing the procedure. The expertise of the surgeons varies, this is why in some cases there is a supervisor, assistant or a co-assistant present. The operations are recorded with multiple GoPro cameras. One GoPro camera is positioned above the head of the patient. This camera provides an overview on what is happening. A second camera is attached to a headband worn by the leading surgeon. A third GoPro camera is worn on the head by the second surgeon (assistant). The videos have been edited so that all three point of views are viewable on one screen. One video had the three camera standpoints running at a different timing. With the camera standpoints not running synchronized it was impossible to see if a mutual gaze had taken place. Therefore, I chose to analyze five surgeries. From the five videos of the surgeries, one video was missing the overview camera standpoint. This did not prove to be a problem while analyzing the video.

The surgeons are wearing GoPro cameras on their heads giving us a clear view on where the surgeons are gazing towards, except for the moments when the surgeons are looking down. Since I am only interested in the occurrence of gazing, this is not considered being a problem. The duration of the operation varies from 1 hour up to 1 hour and 45 minutes.

Before I discuss the results I will go into detail regarding the setting. In most occasions, the leading surgeon is standing on the left side of the operating table. He or she is recognizable by the rainbow colored headband he or she is wearing. We call him or her O. The second surgeon is standing in most occasions on the right side of the operating table, he or she (differs per setting) works as the assistant or the supervisor (also depending on the setting) of O, and is recognizable by the black headband he or she is wearing. We call him or her A/S. Next to A there is a man or woman standing that hands over all the tools necessary to perform the surgery. He or she stands almost the entire time on the right side of the table, he or she is recognizable by being fully suited up, but not wearing any headband. We call him or her Z.

When analyzing the videos of the surgeries I described every gazing moment in a table. A gazing moment could best be described as the very moment in which either one or both surgeons are gazing at one another. Gazing at each other was always triggered by either an utterance or the unexpected movement by one of the surgeons. Therefore, I made a classification/category based on the type of utterance, the time of when the gazing occurred in the video, who was gazing at who, what was being said, and I made of short description on what was going on. I made a table for every surgery. A table would look like this:

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Classification Time Direction Utterances Description Count STAP 1

Question 2.45 S->O S: Of vind je dat

vervelend? S asks if O would not approve of some Music during the operation 1 Movement 5.14 S->O 2 Negotiation 6.11 S->O 3 Social 8.19 S->O 4 STAP 5

Suggestion 32.50 S->O S: Ik zou eerst.. 5

Online commentary 38.59 S->O O: O says

something (inaudible) about the importance of the size of the tool they are using

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This gave me the possibility to collect fragments of the gazing behavior, making this research paper a collection study. Needless to say, a collection study consists of multiple fragments in which one specific aspect of interaction is being analyzed. The tables gave a clear overview on how often gazing occurred and how often the same classification/category of the gazing behavior occurred. After re-watching the surgeries I highlighted prototypical examples of the categories. I analyzed these examples with the usage of Elan. Elan is a computer program designed by the Max Planck Institute for Psycholinguistics. It is a professional tool for the creation of complex annotations on video and audio resources. Elan gave me the possibility to analyze the gazing behavior, frame by frame, making it easier to analyze who gazes at who (first) and if someone would start gazing at the other person before uttering something or whether someone would first start uttering something. I added every gaze and utterance on the timeline in Elan to get a better understanding of what exactly happened during a gazing moment. This would then give me the possibility to describe the gazing moments by using theories on social behavior. In the following chapter I will describe the results I have found while analyzing the surgeries.

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Results

I divided the gazing moments into different categories based on the utterances of the surgeons. For example, if a surgeon would make a suggestion to the other surgeon and would gaze at the other surgeon then this would become a new category called “Suggestion”. Another example would be: if a surgeon would give an explanation and would start to gaze at the other surgeon, or the surgeon giving the explanation would make the other surgeon gaze by giving an explanation, then this gazing moment would fit in the category “Explanation”. When a gaze occurred, I described what was being said and done by the surgeons. This led to 16 different categories, as depicted in table 1.

Table 1 total gazing moments by function

Table 1 shows a total amount 169 of gazing moments. A gazing moment starts when one of the surgeons starts uttering something in which a gaze follows. A gazing moment can also start when a surgeon starts gazing and an utterance follows. In a few occasions a gaze is triggered by unusual movement of one surgeon, in such occasions the gazing moment starts with the surgeon moving. A gazing moment ends when the other surgeon reacted (if applicable) to what the first surgeon said. It is possible that the supervisor would gaze at the surgeon, would look away and would gaze again at the surgeon while asking a question or making a suggestion, making it possible that there are more than one gazes at the other within one gazing moment, but this occurred only in a few occasions. A gaze ending up in a mutual gaze occurred more frequent.

The categories in which gazing occurred most frequent are: Ascertaining, Suggestion,

Decision, Movement, Explanation, Question and Social. Interestingly, recruitments aren’t as common as assessments. This could be explained by the fact that the procedures are very structured. The person who is handing over the tools knows which tool will be needed next. Therefore, recruitments in the form of report of need are not very common. Also the “embodied display of trouble” only occurs three times. At the top of the table we can see three main categories, the first one being assessments.

Within the joint activity the surgeons rely on each other and, in order to make the surgery a success, they use each other’s knowledge by communicating verbally and non-verbally. A lot of the task-driven communication consists of ascertaining, making suggestions and decisions. Although they are different from each other, they are all assessments. And since they are such a big part of our interaction the assessments have a category of their own. The second main category is Recruitments. Recruitments are a big part of our interaction when it comes to cooperation and collaboration. Just think of the simple things like holding the door for someone else. Or how often have you been asked if you have a lighter so that someone can smoke. Recruitment is a necessity in order to arrange social interaction, this is why it is the second main category. The third and last main category is

Miscellaneous. This category contains social talks, sudden movement and other means that trigger gazing.

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surgeon. This can be explained by the role that the assistant has. The assistant is helping the leading surgeon, therefore the assistant is performing the fairly easier tasks, such as cleaning the wound by sucking away the blood. This task doesn’t demand full attention. It is therefore much easier for the assistant to disengage from the task at hand and gaze at the surgeon. Because of this the assistant and the supervisor are both more prone to comment on the task at hand, and those comments often lead to a moment in where the assistant or supervisor will gaze at the leading surgeon. In total there were 184 gazes, from those 184 only 25 were mutual gazes. The number of gazing moments varied per surgery. The tables below show the categories of gazing moments by function and how often the gazing moments occurred for every surgery. There are only 15 categories visible. That is because in only one surgery the category “Remark” was used. In the other tables you will see

“Acknowledgement” instead of “Remark”. Table 2 Gazing moments by function in surgery T1

Surgery T1 has a total of 33 gazing moments. The surgery took 1 hour and 10 minutes to be completed. The surgery was performed by two experienced male surgeons.

Table 3 Gazing moments by function in surgery T2

Surgery T2 has of total of 28 gazing moments. The surgery took 1 hours and 35 minutes to complete. The surgery was performed by a novice male surgeon and an experienced female supervisor. There was also student of medicine assisting.

Table 4 Gazing moments by function in surgery L1

Surgery L1 has a total 60 gazing moments. This is by far the highest count of gazing moments. The duration of the surgery was also the longest. The surgery 1.45 hours. The surgery was performed by a male surgeon and an experienced female supervisor.

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Surgery L2 has a total of 26 gazing moments. The surgery took 1 hour and 2 minutes to complete. The surgery was performed by a novice male surgeon and an experienced male supervisor. There was also a surgeon from Japan present, he only assisted the other surgeons occasionally.

Table 6 Gazing moments by function in surgery L3

Surgery L3 has a total of 23 gazing moments. The surgery took 1 hour and 7 minutes. The surgery was performed by two male surgeons. From the categories that occurred most frequent I will describe one prototypical example and give an analysis of what the function of the gaze is.

Recruitment sequence

Although gazing did not occur very frequent when a recruitment was being made, I do think it is important to look at one of these gazing moments. I chose for an example of an embodied display of trouble instead of an example of a report of need because it shows the beauty of our nonverbal interaction. The leading surgeon will show an embodied display of trouble as he is trying to

disentangle the tubes. He seems to have some trouble with it, therefore he starts to hold the tubes higher and higher, within the eyesight of the assistant. He is also holding the tubes further away from himself and closer towards his assistant. By doing so he attracts a gaze from the assistant, which leads to the assistant helping him in disentangling the tubes.

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10 Example 1.1

In Example 1.1 O is trying to disentangle the tubes. He starts disentangling the tubes all by himself. After 05.54 minutes he is starting to hold the tubes above the patient’s body, further away from himself, performing a classic embodied display of trouble. O is having a hard time disentangling the tubes by himself.

Example 1.2

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11 Example 1.3

In Example 1.3 we can see that A noticed the embodied display of trouble of O and starts to help O with disentangling the tubes.

From a theoretical standpoint this example could be best described as a recruitment for a new activity. Clark states in his book Using Language (1996) that: “Most activities don’t come scripted like a marriage ceremony. They emerge in time as two or more people try

extemporaneously to accomplish certain ends.” (p. 31). Within this joint activity both surgeons are understood to be taking part. Within the joint activity of performing surgery another joint activity can be embedded, for instance the aiding of A in disentangling the tubes. Within the joint activity the participants have certain roles. Within this joint activity O his role is that of being the leading surgeon, A is his assistant. These roles help to shape the setting of the joint activity. The norm for what people do is partly defined by the roles they have.

In this example O has a goal. He initiates a joint activity by creating an embodied display of trouble. He wants A to join in on the activity of disentangling the tubes. By holding the tubes further away from his body he attracts the gaze of A. She sees that O is having difficulties with disentangling the tubes. O his movement visibly exposes a trouble, making it publicly available, and thereby provides an occasion for A to assist him. The actions by O recruit A, even though in the first instance they are accountable as an action taken by O to resolve the trouble himself. Shortly thereafter A starts to assist O and thereby resolves his trouble.

For A to understand what O wants or needs with his embodied display of trouble A gazes at O. With the gaze she is trying to get a better understanding of the situation. A is holding O

accountable for his actions. According to Garfinkel’s enthomethodology studies of 1967

accountability could best be described as: “the activities whereby members produce and manage settings of organized everyday affairs are identical with members’ procedures for making those settings ‘account-able’” (p. 1). He went further by stating how people rely on and/or use to make “settings of organized everyday affairs” “definite and sensible” (p. 3). And by “definite and sensible,” Garfinkel meant recognizable and understandable (p. 9). So in the words of Garfinkel A gazes at O to

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make the situation recognizable and understandable. She understands that O is in need of help and starts to assist him.

Movement sequence

Although all the gazing moments that occur during unexpected movement differ from each other a lot, they are all bound by accountability. In all these cases the unexpected movement from one of the surgeons leads to being held accountant for their unexpected behavior by the other surgeon. Movement triggers our attention and, although in some cases it triggers a verbal response, it triggers a gaze first. When something unexpected happens outside of the operating area what cannot be explained while being focused on the operating and needs to be explained, the quickest way to get that answers seems to be by gazing upon the other surgeon.

With the accountability of our movements, we need to construct our behavior in such a way so that it is recognizable by others, it requires a design that others are able to discern in them what we intend with our actions (Wootten, 1989). If someone moves suddenly in a way someone else would not expect, that person who is moving is being held accountable for his or her actions. Those unexpected moves also occur while operating on a patient. In one situation both GoPro cameras collided when A and O were trying to take a look at the femur bone. After the second collision within 3 seconds from the first collision A gazed upon Z and made a remark about wearing a GoPro camera, saying it is like they (A and O) have antlers. In another situation, O suddenly looks up to the lamp that is shining on the area where they are operating. The sudden movement of O makes A start to gaze at O.

The example that I have analyzed can be explained by the theories of accountability. Throughout the surgery both surgeons perform their own tasks within the joint activity. When a difficult situation comes up they will talk to each other to create a mutual understanding of how to continue with the surgery. But, they do not touch each other. In this example A chooses to put her hand on the hand of O. We can describe this behavior as marked behavior (Heritage, 1984). According to Heritage, such marked conduct “is a positive signal for us to initiate a search for an explanation that is appropriate to the circumstances”. The behavior of A is marked, it is somewhat inappropriate to the setting in which the action of A unfolds.

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13 Example 2.1

A and O are working on a cemented cup for the femur bone. O is using a hammer and a spatula to create space for the cup. A is sucking away the blood. O stops hammering to get a good view of the femur bone. In that moment A places her hand on the hand of O which is holding the spatula to create extra stability (44.55 minutes), this is clearly shown in Example 2.2.

Example 2.2

After a second she lets go. 0.6 Seconds later O gazes at A. O is holding A accountable for her marked behavior and is trying to understand the action of A by gazing upon A. Afterwards he giggles. This might be due to the fact that the action of A is quite unusual to the setting.

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Explanation sequence

During the surgery it often happens that O is explaining something to A or that S is explaining something to O. Less often we see A explaining something to O, or O to S. Not all explanation sequences led to gazing at each other. However, on 19 different occasions an explanation led to a gaze. It was interesting to see that from those 19 gazing moments 8 led to a mutual gaze. This is more frequent than the mutual gazing within the other categories. This can partly be explained by the timing of the explanation. Explanation are almost always given when the surgeons are

disengaged from performing surgery on the hip. If they are engaged in surgery, they disengage to give the explanation. This gives the listener also the opportunity to disengage from the surgery and transferring their focus from the hip to the other surgeon, which in these examples includes a gaze.

I have found that explanation sequences come in various forms. In some occasions

explanations are given in retrospect. A surgeon will explain something about an event or procedure that happened in the past. In other occasions explanations are given on how to approach the task at hand. The function of the gaze remains the same in all the explanation sequences. I wanted to describe two different explanation sequences but the availability of the data was limited which led to the analysis of just one explanation sequence.

In this example, it is immediately visible that the default setting within the operating room as described before is not present. It seems to have become a conversation one could have during a meeting, or a lunch. Since the surgeons are not engaged in performing surgery, a small social setting is being created. We can argue that the joint action that is being created within the joint activity of performing the surgery is that of having a “social chat” while being disengaged from the surgery. The accountability of the surgeons also shifts from being a member of the surgical team, to being a member of a social chat. While this is happening it is observable that the gazes, and especially mutual gazing, is considerably longer than when the surgeons are gazing at each other while being engaged in the surgery, as shown in the previous examples. Setting like the one described in this example only occur when the surgeons have to wait for something, or when the operation is almost completed and the patient’s hip doesn’t need the surgeon’s full attention anymore. However, we are not interested in the functions of gazing during a social chat since gazing in a social environment is already researched by many researchers. I am interested in the function of gazing during an

explanation. And, although the sequence ends up in a small social chat, it starts with an explanation given by O with the possibility to continue the last bit of the surgery after the explanation. The example shows that A and O decided to use a cemented cup in the hip. At first O looks at A, he then looks down at the hip. He then starts to tell about his experiences regarding hip replacements in the hospital of Deventer. A starts to gaze at O. He continues by telling that they did not use cemented cups in Deventer and it always worked out just fine. While the surgeons have this conversation both surgeons are not engaged in the performing surgery. It is almost as if the surgeons take a short break from the surgery. In retrospect, O shares his experiences from the hospital of Deventer regarding hip replacement surgeries (see Example 3.1).

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15 Example 3.1

Assessment sequences

Assessments are very common in this corpus. An assessment can be formulated in various ways. To get a better understanding of the function of gazing I have divided this category into three

subcategories: Ascertaining sequence, Suggestion sequence and Decision sequence. In an ascertaining sequence a surgeon ascertains something about the surgery. The function of

ascertaining is to get a better understanding of what the other is doing, it also helps in making the other aware of a particular part of the surgery. For example, the surgeon ascertains that drilling into the femur bone needs to continue to reach the correct depth. In a suggestion sequence the

supervisor or assistant will make a suggestion on how to approach the task at hand. The leading surgeon will then accept or dismiss the suggestion, in some occasions he or she will ask the supervisor or assistant to elaborate on the matter. In a decision sequence the leading surgeon will have to come up with a decision on how to approach the task at hand. Both surgeons give their assessment on the area they are working on. After sharing their assessment a decision will follow on how to approach the task at hand. I will start by describing an example of an ascertaining sequence.

Ascertaining sequence

Ascertaining sequences occur most frequent, not only within the assessment category but of all categories. I have found 32 ascertaining sequences. Both O as S/A are ascertaining during the surgery. Who is gazing at who differs per sequence. In the following example A ascertains and gazes at O, who is still busy drilling into the femur bone. Since the language that is used plays an important role I added a transcript of this sequence below. I have transcribed the sequence using the

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16 Transcript 1 ascertain example

1 O: Volgens mij kan ie nog wat dieper namelijk According me can it (part) bit deeper (part) I think this can go a little deeper

2 Z: Nog een keer, (part) a turn, Again,

3 A: Nou we moeten even goed op diepte komen (0.2) Even goed medialiseren Well we must (Part) good on depth coming. (0.2) (part) good medialyse. Well we have to reach a certain depth (0.2) We need to medialyse. 4 O: Ik denk dat dit

I think that this I think that this

5 A: [Dit scheelt al wat volgens mij hè,

[This differs (part) bit according me (part)] [This is already a bit better isn’t it,] 6 O: Ja dit heeft die gedaan (.) Okee (.) Dit is prima

Yes this has that done (.) Okay (.) Dit is fine Yes this worked (.) Okay (.) This is fine

In the first line O tells A what he is doing, Z responds (line 2) to what O is saying (line 1). While we might expect a reaction from O, A starts to answer (line 3) the question asked by Z (line 2). O starts to verbally starts to ascertain (line 4). A responds (line 5) to the utterance of O (line 4) and starts to gaze at O. The gaze itself is helping A to understand any form of response that O might provide. It helps reaching intersubjectivity on what O uttered. Levinson (2013) discovered that “nonverbal action sequences may help us understand the verbal ones” (p. 125). Since O is occupied, he might nod his head, for instance. There is no nonverbal reaction coming from O and A has to continue his task. Within this short sequence we can see that A was able to gaze at O because he was disengaged from the operating area. O is drilling and at the very moment A has no manual task to perform. As soon as O stops drilling we see A turning his gaze towards the operating area and starts to use the suction tool. Directly after A reacts to O his comment (line 5), O acknowledges A (line 6).

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17 Example 4.1

In example 4.1 we can see how the sequence starts. O is drilling into the femur bone to make room for the artificial hip. They have already changed the size of the drill a couple of times, each time the head of the drill is replaced with a bigger one. O says he thinks he should drill a little deeper into the bone (line 1). Z (the person who hands over the tools) replies with: “again?” in line 2. Then A replies: “We will have to reach a certain depth” (line 3).

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In example 4.2 we see the second part of the sequence. O is trying to say something but he is getting cut off by A. O said: “I think that this” (line 4) then A cuts him off. He states: “This is already better, isn’t it”(line 5). With his remark he refers to the new head of the drill and that this head is making a good hole in the femur bone. O acknowledges this in his last utterance within this sequence. He says: “Yes, this has worked, okay, this is fine” (line 6).

Suggestion sequence

In the operating room suggestions are being made frequently. On 12 occasions a suggestion made by one of the surgeons led to gazing at one another. All suggestions were made by either A or S, O made no suggestions, which seems to be quite logical since O is the leading surgeon. Because O is the leading surgeon he chooses how to approach the task at hand. A or S are assisting O and are therefore more prone to make suggestions. In only one occasion the gazing of A/S led to a mutual gaze. However, it must be said that in two other occasions both surgeons were gazing at each other, but not at the same time. To give an illustration of an assessment in the form of a suggestion, it would look like this: “I would do it this way”. In this example S is making a suggestion to O, see the transcript below. When S is making her suggestion, she gazes at O. S is holding O accountable for his actions, the gaze is aiding S in making the behavior of O accountable.

Transcript 2 suggestion example

1 O: We zouden natuurlijk dit <onhoorbaar> kunnen incideren want het staat wel heel erg onder spanning hè (1.5) Vind je niet,

We could of course this <inaudible> do cut because it stands (part) a lot under tension (part) (1.5) find you not,

We could <inaudible> cut because the tension here is pretty high (1.5) Don’t you agree,

2 S: [Ik zou eerst kijken hoe je uitkomt kan je altijd nog doen [I would first look how you outcome can you always still do] [I would first check how far you can get this way you can always do so

3 O: [Ja]

[Yes] [Yes]

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19 Example 4.3

In example 4.3 we can see the start of the suggestion sequence. Both surgeons are engaged in performing surgery. O says that they could make the incision bigger because the tension around the area they are working on is very high (line 1).

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20 Example 4.4

In example 4.4 we see that S is making a suggestion (line 2) as a response to what O uttered in the previous example. While doing so she closely examines the operating area. She says: I would first check how far you can get this way, you can always do so (make a bigger incision) later. After “I would” uttered by S. O already reacts halfway through her suggestion with “yes” (line 3). Example 4.5

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At the end of uttering the suggestion S disengages from the surgery and starts to gaze at O. Notice that her gaze will continue after she completed her sentence. In this example the gaze of S helps in creating intersubjectivity, the gaze of S helps S in understanding if O understood what she said in line 2. Since O already responded with “yes” (line 3) no other response follows and the sequence ends.

Decision sequence

Although decisions are being made by the surgeons constantly, in only 10 occasions making a

decision led to one of the surgeons gazing at the other. In this example we will see O and A discussing the patient’s hip. When O asks the opinion (line 3) of A he starts to gaze at A. A starts to give her opinion (lines 6, 8-9) and starts to gaze at O as well. This action sequence could be best described by the grounding theory (Clark & Schaefer, 1989). O is making a new contribution by stating he needs to do a recut (line 1). Z interrupts him (line 2) but O finishes his sentence (line 3). He waits for an assertion of acceptance or a request for clarification. To create a common ground, A starts to feel in the wound to make an assessment of her own. After some time she acknowledges what O said (lines 6, 8-9), thereby giving O an assertion of acceptance. Grounding comes in phases. The presentation phase and the acceptance phase. With the first utterance O makes, he creates the presentation phase. The acceptation phase is about the showing evidence of understanding the utterance. As she does by replying that she also feels it (line 6).

Surgeons work following a principle depicted in Figure 1 (p. 4).The principle consists of four stages. In this example the surgeons will have come up with a decision. They will need to judge if a recut is necessary and if so, how they are going to perform the recut (by drilling or using a saw). O wants to hear A’s judgement on the situation (line 3). After hearing that A assesses the situation the same as O (lines 6, 8-9), the decision follows. They will perform a recut. What follows next is the motor action of the recut, the actual performance. With each motor action, new environments are created, leading to a new moment of judgement. As the new environment is being judged, a common ground is being created. And within the moment where O presented an utterance in the form of an assessment, A showed evidence of understanding the utterance and provided O with an assessment of her own. I have added a transcript to make sure we have a clear overview of what is being said by whom.

Transcript 3 decision example

1 O: Ja we doen nu even een recutje maar die boor ss Yas we do now (part) a recut but that drill ss Yes, we will do a recut but the drill ss

2 Z: [Was dat,

[What’s that, [What’s that. 3 O: Die zaag is zo vervelend want voel maar hier zit

That saw is so annoying because feel (part) here sits That saw is annoying because feel this

4 A: [Ja

[Yes [Yes

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5 O: Ja

Yes Yes

6 A: Ja voelt <onhoorbaar> inderdaad ja het is (0.2) meer dan een vinger voor mij Yes feels <inaudible> indeed yes it is (0.2) meer than one finger for me Yes, it feels <inaudible> indeed (0.2) to me it is more than one finger

7 O: Ja Yes Yes 8 A: Dus naja. So yes. So yes.

9 A: Anderhalf centimeter is het zeker hoor daar One and a half centimeter is it sure <part> there A centimeter and a half it is for sure

10 O: Dusse dan krijgen we ook wat meer ruimte So then receive we also bit more space So this will also create more space 11 A: Ja

Yes Yes

Example 4.6

In example 4.6, O and A are working on the patient’s hip. O is feeling with his fingers in the hip bone. A second later he is looking at the screen in the back of the room. It shows an x-ray of the hip. He

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starts to utter the phrase: “Yes, we will do a recut but the drill ss” (line 1). While O is still making an assessment Z interrupts by asking a question (line 2). O stops talking, looks at Z, and continues to finish his sentence: “that saw is annoying because feel this” (line 3). The last part of his sentence contains an invitation, we regard this as a first-pair part.

Example 4.7

After the question from O, A utters “yes?” (line 4) and O confirms with “yes” (line 5). A starts feeling in the wound. It takes her a little more than three seconds to come up with an assessment of her own. On 33.34 minutes she starts to produce a second-pair part. She utters: “Yes, it feels <inaudible> indeed (0.2) it is more than a finger for me” (line 6). As soon as she starts to produce the second-pair part, O starts gazing upon A. A few milliseconds later A starts to gaze at O. The gaze of A at O lasts 1.6 seconds, the gaze of O lasts longer. He gazes at A for 2.5 seconds. The gazes of both surgeons lasts shorter than the second-pair part that A produces (line 6). O acknowledges the second-part with a “yes” (line 7). A continues with: “So, it is at least 1.5 centimeters for sure” (line 9). While uttering the continuation of the second-pair part, she gazes once more at O. Her gaze remains unanswered as O is looking back and forth at the hip and the monitor in the back. O concludes by saying: “So this will also create more space.”

Question-answer sequence

While the surgeons are performing the surgery a lot of questions are being asked. Interestingly, gazing only occurs when A or S is asking a question. When A/S is asking a question he or she does not always immediately gaze at O. In some examples A/S does not start to gaze at O until he is answering the question. Questions come in various shapes therefore I chose to analyze two very different examples. In both examples A/S is trying to create a mutual on the understanding by asking a question. The function of gazing helps to reach intersubjectivity on the topic at hand. The first

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example shows a sequence which contains a question about the next procedure. The second example shows a sequence which contains a repair initiation (Schegloff 1977).

Example 5.1

In example 5.1 we see that A is asking a question to O. He wants to know how O will start the following procedure. With this question A wants to create a mutual understanding on how to perform the next procedure, the intersubjectivity seems lost (Schegloff, 1992), which needs a restoration of intersubjectivity (Seuren, Huiskes & Koole, 2016). Both surgeons are still engaged in surgery and are looking at the operating area. It might seem that A is already gazing at O from the top left video, but this is not the case. The bottom video shows us that O is bending over the hip, while A is also gazing at the hip.

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25 Example 5.2

In example 5.2 we see that O is starting to answer the question from A while both surgeons remain engaged in the process of working on the hip. Therefore their gaze remains to be focused on the hip. O is cleaning the area around the femur bone while A is keeping away the tissue around the femur bone.

Example 5.3

At this very moment O starts to disengage from the operating area. He pulls out the suction tool and lays it on a cloth next to himself. A notices that O has disengaged from the operating area. A is still keeping the wound open. Since holding the wound open is a fairly simple task which doesn’t need full focus when the other surgeon is working on the patient’s hip, he looks up and starts to gaze at O. The gazing aids in reaching intersubjectivity on the task at hand. Shortly after O finished his answer A

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responds with: “Gewoon eh” meaning “Just like eh”. Jefferson (1983) discovered that when the current speaker utters “eh” the listener often takes his or her turn as to becoming the speaker. In this example we see the same thing happening. The person handing over the tools starts to join in on the conversation by taking over the role of the speaker from A. She utters a formulation which states that he (O) wants to have half sized (tools) when the time is ready. O acknowledges this by uttering “Ja” (yes). In the next example I will discuss a question-answer sequence which contains a repair initiation.

Example 5.4

In example 5.4 we see that O is asking a question to S. He wants to know S her opinion about the incision he made. On the moment of asking there is a lot of talk going on around the patient. S seems to listen to the conversation going when O is starting to ask his question. It takes almost 1.5 seconds before O utters: “Oh ja” (Oh Yes), he notices there is already a conversation going on and S is a member of that conversation. After something inaudible is uttered by one of the bystanders she points at something (it is unclear to what she pointing) and then initiates a repair (Schegloff, 1977) by asking what O was saying.

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27 Example 5.5

In example 5.5 we see that S producing a repair by stating: “wat zeg je?” (what did you say?) and halfway through the sentence she starts to gaze at O. As we can see she continues to gaze halfway through O his answer. The gaze is aiding in getting a understanding of what O wants. There is a need of intersubjectivity, a need for mutual understanding. She listens and gazes at O to reach that intersubjectivity, that mutual understanding. When O starts to point at the hip while he is repeating what he was trying to say before, S her gaze turns from O towards the hip. The mutual understanding is created when he repeated his question.

Conclusion & Discussion

With this thesis I set out to describe the functions of gazing in the operating room. When studying the data I discovered that the gazing behavior of surgeons is very different from the gazing behavior other interactional settings. When we interact at work or at home, we tend to gaze at each other frequently. Goodwin (1981) claimed that listeners gaze toward speakers more than speakers do toward listeners. Surgeons, however, hardly gaze at one another. Most of their interaction occurs whilst remaining focused on the patient’s body. It is important to remember that performing surgery is not a form of interaction, it is a joint activity which needs interaction in order to make the joint activity a success. I therefore focused on whether the functions of gazing of surgeons are different from that of any other setting.

While analyzing the data I made a categorization based on the utterances of the surgeons. This led to 16 different categories. By making categories it became observable how often the surgeons would gaze when certain utterances were produced or when unexpected moves were made. The categories made it clear that gazing occurs most frequent when an assessment was made, an explanation was given, a question was asked, a social chat was formed or when someone would

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move in an unexpected way. From each category I chose to analyze a prototypical example. I added a recruitment example as well, since recruitments play a huge part in our everyday interaction.

The Recruitment example could be explained by the joint activity theory (Clark, 1996). Clark states in his book that: “Most activities don’t come scripted like a marriage ceremony. They emerge in time as two or more people try extemporaneously to accomplish certain ends.” (p. 31). Within the joint activity of performing surgery another joint activity can be embedded, for instance the aiding of A in disentangling the tubes. These roles help to shape the setting of the joint activity. The norm for the behavior of people is partly defined by the roles they have. O initiates a joint activity by an embodied display of trouble. He wants A to join in on the activity of disentangling the tubes. The actions by O recruit A, even though in the first instance they are accountable as an action taken by O to resolve the trouble himself. Yet, he attracts the gaze of A, who notices his embodied display of trouble and starts to help him. The theories of accountability can also aid in analyzing this example. A gazes at O in order to make the situation recognizable and understandable. A is holding O

accountable for his actions. With A gazing at O, A understands O is in need of help.

The Movement example could be explained by the theories of accountability as mentioned earlier in this conclusion. In this Movement example A chooses to put her hand on the hand of O. We could describe this behavior as marked behavior (Heritage, 1984). According to Heritage, such marked conduct “is a positive signal for us to initiate a search for an explanation that is appropriate to the circumstances”. The behavior of A is marked, it is somewhat inappropriate to the setting in which the action of A unfolds. O is trying to understand the action of A by gazing upon A.

The explanation sequence was very interesting to analyze. Explanations come in various forms; sometimes an explanation is given in retrospect, and sometimes an explanation is given on how to approach the task at hand. Explanations are closely related to the gazing behavior that occurs when the surgeons are having a social chat. That is because explanations were only given when both surgeons were disengaged from performing surgery. Explanations differ from social chats because the subject of the conversation is about performing surgery. In these sequences gazing occurred more frequent and often led to a mutual gaze.

The three assessment examples showed a need for reaching intersubjectivity. The

Ascertaining example starts with O ascertaining. A reacts to the ascertaining of O and starts to gaze at O in order to understand any form of response that O might provide. In the Suggestion example O is working on the hip. While he is working on the hip he states that the area that they are working on seems to be under a lot of tension. S makes a suggestion on how to approach the area that is under tension and gazes at O. S is holding O accountable for his actions regarding her suggestion and how he is going to approach the area that is under a lot of tension. The Decision example is another example in which there is a need for intersubjectivity. This example could be described best by the grounding theory (Clark & Schaefer, 1989). Since the surgeons are in a joint activity and are working together there is a need for having a common ground. O is making a new contribution by stating he needs to do a recut. O is waiting for an assertion of acceptance or a request for clarification. To create a common ground, A starts to feel in the wound to make an assessment of her own. After some time she acknowledges what O said, thereby giving O an assertion of acceptance. By doing so, intersubjectivity on how to approach the task at hand is reached.

The question-answer sequences showed two examples of gazing while a question was being asked. One question was asked in order to understand how to approach the task at hand. A wanted to create a mutual understanding on how to perform the next procedure because the

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(Seuren, Huiskes & Koole, 2016). The other example focused on a repair initiation. Both examples showed a need for intersubjectivity. In both example gazing aided in reaching intersubjectivity.

In all examples accountability plays an important role. Intersubjectivity is needed to understand the other surgeon and make the joint activity a success. These findings show that the gazing behavior of surgeons who are performing surgery is different from the gazing behavior in a social setting. Surgeons only gaze when it is absolutely necessary. Surgeons disengage from performing surgery in order make gazing possible without putting the patient’s body at risk. This study cannot make any claims about the necessity of gazing while performing surgery. To make such claims data is needed in which surgeries do no go as planned or are not successful. All the surgeries that have been analyzed in this study were performed without any problems.

The function of gazing in the operating room is the same as in any other setting. Gazing aids in reaching a mutual understanding. However, the way surgeons reach intersubjectivity is quite interesting. In some occasions, for example the Movement example, intersubjectivity needs to be recalibrated. One surgeon moves in an unexpected way, the other surgeon would gaze in order to understand the unexpected movement. The gaze aids in recalibrating the intersubjectivity. In other occasions, for example the assessment sequences, intersubjectivity is reached by interacting verbally. In these examples gazing also aids in reaching a mutual understanding, but mutual understanding is mainly created by talking to another.

I have tried to analyze the timing of the gaze in relation to the timing of the utterance; however, there were too few examples analyzed to make any claims about the timing of the gazing. Further research could focus on the timing of gazing in regard to the timing of an utterance. Aside from the fact that gazing did not occur frequently, I would like to note that the duration of the gazes were short. Shorter than when the surgeons were having a social chat. This could be explained by the fact that they were working on the patient’s hip and that they would remain mainly focused on the patient’s hip.

I believe that gazing at each other is crucial in order to make the joint activity work. In our everyday lives we can have a misunderstanding without any major consequences. For surgeons, however, this is very different; they are responsible for a patient’s health. A misunderstanding could have devastating consequences. Further research could also focus on misunderstandings between surgeons in order to get a better grasp of how intersubjectivity is reached and when it is crucial to disengage from the surgery in order to reach a mutual understanding. The role of gazing in reaching a mutual understanding should not be left out of this research, as this study shows that gazing at each other aids in reaching a mutual understanding. I would like to add that this study might be a good reminder for surgeons to reflect on their gazing behavior while performing surgery. It could create new personal insights into when it is important to disengage from performing surgery, gaze, and create intersubjectivity on the task at hand in order to make the surgery a success.

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Master’s Thesis: Gazing in the operating room