By Es Will & Nick Marks

Introduction

Is the place of individual effort in clinical specialty development illuminated by consideration of the past? The model of scientific progress pursued through investment in deliberately designed projects is an ideal, rehearsing a belief in the linear possibilities of human discovery. In a modern context, the fund-raising for pre-defined projects readily fits with the marketing of a specialty and its associated research programmes. The reality, in the stories of history, offers a mixture of incidental, serendipitous, developments and the unlikely combination of different technologies, as much as any focussed effort.¹ The intellectual processes brought to bear in research are not uniform, but how should  that be described?² Thankfully,  the more incidental  properties of the past can be explored without needing to engage with the burdens of literature review or the Grand Theories of Scientific Discovery.³

In fact, the absence of a conscious direction of intellectual energies has been found to be highly productive. The interwar Dutch Historian, Johann Huizinga, as the widely accepted originator of Cultural History, saw mankind as ‘Homo Ludens’, the species that plays.⁴ It is from that perception that the question of the profit of certain types of adult play (aka tinkering) can be examined in Renal Medicine and its elements isolated, in contrast to the deliberate fostering of research productivity.

Imaginative play

Of course, imaginative play with little focus or topic is possible but typically there is some context to rumination or freely contemplated practical activity. We can distinguish, say, ‘mulling’ and ‘pottering’ from ‘tinkering’ by virtue in the latter of an object of some practical interest for modification, adjustment or repair. Such activities are probably timeless and reconceived in each generation. The persistence of hobby-type TV programmes suggests a widespread and persistent interest in practical personal diversion, through Gardener’s World, Repair Shop etc. The CEO of Amazon has identified ‘wandering’ in business, to conjure up value-added processes, which has an obvious relationship to this discussion.^5,6

Commercial application immediately splits the activity, whatever we call it, into amateur versus funded circumstances. However, informality should not be taken as signalling an inevitably lesser level of seriousness, even if it is less committed or essential to an outcome. It seems that professional silversmiths, for example, have a high expectation of a need to improvise technically in the course of discharging a commission.

Tinkering presages a refinement of product

It seems that the two spheres are related, since commercial development has frequently capitalised on amateur efforts to uncover the needs and wants of potential customers. The major tinkering efforts around the early motor car in the USA, prior to the first World War, defined the desirable characteristics of domestic vehicles in their transition from nineteenth century carriages to streamlined touring models.⁷ Another example would be the long period of informal, social, exposure to the BBC computer, as exploring widely the features, capacities and utilities of computerisation. The maturation of renal clinical computing, through a sort of tinkering with enabling software, is manifest in the agendas of the BRCG in the 1980s, as another UK example. The CCL (Clinical Computing Ltd.) software was ideal for the independent, multicentre exploration and validation of clinical and renal unit applications.⁸

 Haemodialysis provenance

Tinkering was at the heart of the historical development of dialysis and demonstrated a similar trajectory. Haemodialysis was developed in the mid-twentieth century in several international centres by individuals who were attracted to the possibilities.⁹ The technology was not initially collaborative or  coherent. It is useful to think of the early investigations as a form of technical tinkering, involving mechanisms, materials and clinical feasibilities. In the UK that has been represented through Stanley Shaldon in London and Frank Parsons  in Leeds, in particular.¹⁰ The timing is of interest, since the post War period of the 1950s in the UK was arguably a heyday for tinkering with gadgets and the repair of domestic items, in an era that was spoken of as economically austere. Parsons tinkered not only in the hospital but also at home.¹¹ Apropos of which, the 1950s suburban garden shed was a special, semi-reserved haven, especially for the male imagination and diversion. In the form of hobbies, that was endorsed enthusiastically by one of the first ecologists.¹²  The informal description of ‘old boys’ toys’ is apposite, and confirms a dimension of adult play?

The essentials of tinkering

There are several properties that characterise what can be thought of as orthodox tinkering. One is the focus on an improvable object or task, whether at home or on the job. The object notionally ‘calls’ for attention, which generates a relationship to it and/or the problem that it represents. Such emotional attachments are exposed in the feeling of presenting it to others, whether they are expert or not. Tinkering is notionally piecemeal  and improvisatory. The time taken to tinker is critical, whether released at work or prised from a social /family agenda. It is a sort of gift to the self, a treat? A deep personal effort makes it free of malice, reflected in the forgiving admonition of meddlesome children as just ‘tinkers’. The preoccupation eliminates other anxieties and is relaxing. While personal, the opportunity to share the pleasure of such experience creates social bonds with similarly diverted others (exploited in modern times by the ‘Men’s Sheds’ movement).^13,14 The personal engagement carries a certain naivety and exposure that feels a touchstone of honesty and even light humour in its unseriousness. The idiosyncrasy is unadorned with vainglory and tied typically to an only too real task, which avoids the abstractions of principle and extension towards anything radical. Essentially, the benefit of tinkering can be felt as relatively effortless, derived from a rewarding, intuitive, personal curiosity. It is an example of the Principle of Least Effort, where the profit typically exceeds the voluntary input.¹⁵

European semantics

Just as Huizinga felt that ‘fun’ was difficult to translate from the English, a similar linguistic variation is discoverable for tinkering.⁴ The French ‘Bricolage’ is used popularly as DIY, although it is extended as handiwork/craft on occasion. ‘Tripoter’ is an alternative. The German ‘Basteln’ and ‘Tüftellabor’ come closer. In the Italian, ‘armeggiare’, while distinct, alludes perhaps to tools. That lack of correspondence leads to the unselfconscious adoption of the English Tinkering term in Italian publications. The  Dutch coin ‘knutselen’, which is reverting towards the element of craft. The dependence on a national conventional usage and the ambivalence of Art versus Craft is noteworthy.

A role for tinkering

It should not be surprising that tinkering is productive as a form of ‘blue sky’ thinking, the more common term for whimsy? What can be thought of as the academic, intellectual establishment is built on past, restricted, insights and effortful study, so that some intuitive means to release alternative avenues of development are inevitable. The fashion for ‘disruption ‘ in business expresses that sentiment. There is often a negative reaction to novelty from established social and commercial entities, but that has a part-defensible logic;  the need to demonstrate real progress rather than mere wishful thinking. In practice, stable applications often only emerge as experience is accumulated. The now recognised role of bisphosphonates in osteoporosis is one example, coming late out of research in Paget’s Disease, or the subsequent dominance of maintenance haemodialysis over the original use for reversible acute renal failure (severe AKI).

It is apparent that the commercial development of haemodialysis was built gradually on informal contributions, analogous to the changes in the early US motor industry. In the same way, the informal origins were overtaken by increasingly specialised components and technical sophistication. In house renal unit technical support was made increasingly difficult  to the point of impossibility, which outflanked ultimately the local development of satellite haemodialysis to accommodate increasing patient demand. The consequences, the near monopoly of commercial dialysis in the USA, for example, have been even more profound than for the modern car industry, as seen on the road!

Other applications of the concept

The improvising hand of man is absent when the process, rather than the activity, of tinkering has been considered academically. Nature can be seen as tinkering, without any insight, as a core mechanism of Biological Evolution, which has been applied in ecological change management.^16-18 In education, an explicit  system based on tinkering has been formulated to encourage curiosity and confidence in children (Pedagogy) and development in engineering/informatics.^19,20

The very process of considering different applications is a form of tinkering, so that it is self-referential!²¹ 

In human healthcare practice, the word has been used rather loosely for the tailoring of aids in disablement; ‘to care is to tinker and to doctor’. ‘In care practices all things are (and have to be) tinkered with persistently’.²² A doyen of nephrology, Stewart Cameron, wrote extensively about the technological enablement of clinical diagnosis, management and research, which will have depended at some junctures on the appreciation of possibilities through puzzling and intellectual play.^23,24

It seems likely that a tinkering mindset is one of the universals of human intellectual activity, which can be actively fostered. It is then unsurprising that medical abstractions, say the uncertainties of clinical diagnosis and treatment, make it a highly desirable attribute in the trial and error of everyday medical practice. That need is almost certainly reflected, without explicit recognition, in medical student and research selection processes.

Conclusion

There seems good reason from historical and descriptive evidence to isolate tinkering as a characteristic intellectual and practical behaviour, enacting certain processes of investigation. The universality of the tinkering mindset raises the question of whether future AI systems will be found to be playing or whether it is a feature of only human mental activity. The examples from historical cultures provoke the recognition of universal human capacities and their role in an appreciation of the past. Renal medicine has an obvious and continuing debt to the tinkering mindset. Unfortunately, given the near infinite range of contemporary electronic diversions and a prevailing social impatience with anything ill-defined, modern life is not well placed, without prompts, to promote  the ‘time to tinker’, and reap its rewards.

A short version of this article may be found on the Hektoen International website.²⁵

Authors: Es Will & Nick Marks

 References

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25. https://hekint.org/2025/04/07/tinkering-towards-technology-examples-from-the-evolution-of-renal-medicine-in-the-uk/

 

 

 

 

 

 

Last Updated on September 6, 2025 by John Feehally