Formats of responsibility: elective surgery in the era of evidence‐based medicine

Abstract

This article illustrates what pragmatic sociology refers to as investments in form, by examining the formats created and used by a group of surgeons to determine when elective surgery for pelvic floor disorders could be responsibly undertaken. Drawing upon ethnographic observations of surgical consultations at an academic medical centre in Canada, we show how two specific formats - that the patient is sufficiently bothered and the patient accepts the risks of surgery - allow for justifiable action in conditions of uncertainty and contingency and in light of the demands of dominant imperatives in medicine and health care, especially evidence-based medicine (EBM). We argue that an analytic of justification is necessary for understanding when and how surgery is offered and elected for, and for considering how surgical consultations might be improved.

Paragons, Mavericks and Innovators—A typology of orthopaedic surgeons' professional identities. A comparative case study of evidence‐based practice

“…You know, it's immediacy, you need to have an immediate decision' (Consultant Surgeon, A). The exercise of real-time judgement and the need to respond to case and external contingencies echoes previous work, (Ducey & Nikoo, 2018;Pope, 2002), but identity work influenced how this was reconciled in practice.…”

“…Evidence in the form of protocols and guidelines is changed and re‐appropriated and social relationships, contingent practice and organizational positioning have all been shown to contribute to surgical variation (Berg, 1997 ; Fox, 1992 ; Mannion & Exworthy, 2017 ; May, 2006 , 2007 ; Silverman, 1987 ; Svensson et al, 2009 ). Variation has been explained as a consequence of the microlevel action of individuals and the ways that knowledge or evidence become privileged (Delamothe, 1993 ; Ducey & Nikoo, 2018 ; Grove et al, 2020 ; Mannion & Exworthy, 2017 ; Mykhalovskiy, 2003 ). McDonald et al ( 2006 ) in particular highlighted how the identities that individuals create and negotiate, and the social norms which correspond to those identities in practice, support resistance to EBP.…”

The clinical effect and safety of new preoperative fasting time guidelines for elective surgery: a systematic review and meta-analysis

“…However, fasting from food and water for too long before surgery will produce a series of adverse reactions that affect the safety and effectiveness of the surgery (the most common occurrences are hunger, thirst, abnormal metabolic function, and digestive tract reactions). It can also increase the chance of reflux after anesthesia, which not only reduces the comfort of the patient during the perioperative period, but can even lead to the postponement or cancellation of the operation (28). The ASA and ERAS revised the preoperative fasting guidelines to shorten the preoperative fasting and no drinking time.…”

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

“…We have previously shown how a moral‐epistemological orientation towards repairing anatomy meant many surgeons were favourably disposed to transvaginal mesh procedures (Ducey et al., 2020). In a separate ethnographic study of one pelvic floor clinic, carried out in 2013, as the use of transvaginal mesh was beginning to be curtailed, we examined how pelvic floor surgeons develop and work with a set of rationales that allow them to justify undertaking elective surgery (Ducey & Nikoo, 2018). The analysis in this article, however, proceeds from surgeons’ in‐depth accounts of their experience operating with transvaginal mesh and considers this experience as a distinct element in understanding how these device‐procedures came to be so widely used.…”