Surgeons practice their own variations on a procedure. Residents experience shifting thresholds between variations that one surgeon holds firmly as principle and another takes more lightly as preference. Such variability has implications for surgical education, but the impact is not well understood. This is a critical problem to investigate as programs seek to define procedures for competency-based medical education (CBME) and improve learning through deliberate practice. Our study analyzes the emergence of procedural variation in an early-adopter CBME program through a situational analysis of tonsillectomy, a foundation level procedure in this otolaryngology, head and neck surgical program. An earlier phase of the study identified frequent variations (n = 12) on tonsillectomy among co-located surgeons who routinely perform this procedure (n = 6). In the phase reported here we interviewed these surgeons (n = 4) and residents at different stages of training (n = 3) about their experiences of these variations to map the relations of contributing social and material actors. Our results show that even a basic procedure resists standardization. This study contributes a sociomaterial grounded theory of surgical practice as an embodied response to conditions materialized by intra-relations of human and more-than-human actors. Shifting root metaphors about practice in surgical education from standardization to stabilization can help residents achieve stable-for-now embodiments of performance as their practice thresholds continue to emerge.

中文翻译：

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实践门槛的体现：外科教育从规范化到稳定化

外科医生在程序上练习他们自己的变化。住院医师经历了变化之间的阈值变化，一位外科医生坚定地认为是原则，而另一位外科医生则更轻松地作为偏好。这种可变性对外科教育有影响，但其影响尚不清楚。这是一个需要研究的关键问题，因为项目试图定义基于能力的医学教育 (CBME) 的程序，并通过刻意练习改进学习。我们的研究通过扁桃体切除术的情况分析，分析了早期采用 CBME 计划中程序变异的出现，扁桃体切除术是该耳鼻喉科、头颈外科手术的基础级手术。该研究的早期阶段确定了经常执行此手术的同地外科医生 (n = 6) 扁桃体切除术的频繁变化 (n = 12)。在此处报告的阶段中，我们采访了这些外科医生 (n = 4) 和处于不同培训阶段 (n = 3) 的居民，了解他们对这些变化的体验，以绘制贡献社会和物质参与者的关系。我们的结果表明，即使是基本程序也无法实现标准化。这项研究贡献了一种基于社会物质的外科实践理论，作为对人类和超人类行为者的内部关系所体现的条件的具体反应。将关于外科教育实践的根本隐喻从标准化转变为稳定化，可以帮助住院医师在实践阈值不断出现时实现目前稳定的表现。