The embodiment of practice thresholds: from standardization to stabilization in surgical education

The (commercialised) experience of operating: Embodied preferences, ambiguous variations and explaining widespread patient harm

“…To a significant degree, they relied on their situated, personal experience with transvaginal mesh procedures to determine when and how they were acceptable to use. ‘Procedural variation is not just a matter of reason, it is an embodied performance of problem‐solving conditioned by an assemblage of spatial, temporal, material and social actors’ (Ott et al., 2020, p. 149). At the same time, the meaning of these variations remained ambiguous and contested, as became evident when we talked to surgeons about whether their choices were relevant to others, and when we observed surgeons at medical meetings in various modes of sharing their experience and preferences.…”

“…GS challenged his colleagues’ use of prolapse kits, after using two versions himself, but referred to his own experience and observations as merely ‘smoke’. OR called her choice, as surgeons often do, the right one ‘in my hands’ (see also Ott et al., 2020), implying it was not a necessary choice in other hands. CS felt strongly that transvaginal implantation of mesh was an inferior practice rooted in some surgeons’ insufficient repertoires, but rebuffed any suggestion that she might be able to explain cases of patient harm, on the grounds that she couldn’t ‘know’ what others were doing in their practice.…”

“…The case of transvaginal mesh illustrates the politics of how and when embodied experience, in this case of operating, comes to have meaning (Spackman, 2020). There was considerable scope for operative experience in the use of transvaginal mesh to be contested, because of the variations and nuance the physical and personal work of operating entails (Ott et al., 2020). Furthermore, the commercialisation of transvaginal mesh procedures arguably made collective understanding more elusive and enabled ambiguous variations to be folded into everyday practice on a broad scale.…”

“…Because preferences about how to operate are derived to a significant degree from hands‐on experience that can be passed along only via informal routes and direct exposure (Pope et al., 2003), they are often tacit in nature (Goodwin, 2009; Greenhalgh et al., 2008; Maslen, 2015)—difficult to make explicit or codify as rules, but also difficult to recognise as such. Knowledge acquired through operating poses particular challenges to being assessed, standardised and communicated (Ergina et al., 2009; Ott et al., 2020). Such embodied and tacit skills are nevertheless necessary for good medical care in many settings (Carmel, 2013; Gardner & Williams, 2015; Harris, 2016; Prentice, 2007; Underman, 2020) and have been arguably devalued, especially in relation to what is supposedly known through evidence produced by clinical trials (Kelly et al., 2019; Maslen, 2016; Nettleton et al., 2008).…”

“…The practice of operating is shaped by contingencies related to the case, the surgeon and external forces (Pope, 2002). Variable material tools and technologies and spaces may be used (Heath et al, 2018;Ott et al, 2020;Schubert, 2011) and surgery must be coordinated in interaction with others in the operating room (Hindmarsh & Pilnick, 2007) in distinct organisational and system contexts. Surgeons' practice preferences are shaped by the specific people with whom they train and work (Brattheim et al, 2011), and often organised into distinct repertoires, styles and identities (Grove et al, 2021(Grove et al, , 2022Schlich, 2015).…”