Objectives: The thesis seeks to provide an analysis of surgical work and decision making, to identify the basis of the widely observed variation in surgical practice and to indicate what surgeons see as the source(s) of that variation. Against this background, it examines the strengths and limitations of the approach promoted by the evidence-based medicine movement to surgical work. Methods: A qualitative study of surgical practice by urological and gynaecological surgeons in England and the USA involved in the treatment of female urinary stress incontinence. Depth interviews with 29 English surgeons and five American surgeons. Interviews were recorded and transcribed. Observation of 23 operations and additional ethnographic data collection at the hospitals and clinics where these surgeons worked. The observational data consist of near verbatim notes. All these data were analysed using the constant comparative approach described by Glaser and Strauss (1967). A variant of the split-half technique was used to test emerging themes. Results: Surgical practice is contingent: it is dependent on a range of variables, and, it is serendipitous. Three categories of contingency are identified (case, surgeon and external contingency). It is argued that surgical practice entails the complex interplay of these conditional factors and chance happenings. In order to learn to deal with contingency, surgeons learn or acquire practice skills through first hand experience. The thesis explores the role of the surgical apprenticeship and models of learning used by surgeons. Conclusion: The nature of surgical practice presents some fundamental challenges to EBM. The contingent and experiential features of surgical work raise serious doubts about the applicability of EBM to surgery.

Based on dialogical theory and empirical exploration of surgical operations in a Swedish hospital, this text contributes to the study of critical work practice. In empirical detail, ethnographic investigation and video analysis show that ‘everyday interactivity’, i.e. technical development beyond the control of individual participants, is a ubiquitous phenomenon of surgical work. This research interest can be contrasted to models of human-machine interaction, which describe how a given technology affords or impedes an intended outcome. Conclusions are that there may be fundamentally different ways of describing the regular course of surgery. From so-called ‘designer-oriented‘ perspectives, creative or unexpected results would be seen as emergent signs of design failure. According to dialogical theory, unfolding and multifunctional technical outcomes are necessary in working life. The latter is everything but trivial for research and development. As concrete products of collective practice, workplace technology cannot support individual ‘user experiences’ or workflows. Instead, we may recognise already present, parallel, and ongoing design changes. Thus, the thesis problematise the meaning of teamwork and technology in everyday practice. / Utifrån dialogisk teori, interaktionsanalyser och etnografiska undersökningar av kirurgiska operationer inom olika kirurgiska specialiteter, problematiserar avhandlingen betydelsen av vardagliga och kritiska verksamheter. I empirisk detalj av några fallstudier, tagna ur ett omfattande material av inspelningar och etnografiska data om arbetsplatsen, visar avhandlingens videoanalys att “vardaglig interkreativitet”, det vill säga teknisk utveckling inom och mellan arbetslag, är ett ständigt närvarande fenomen i kirurgisk praktik. Detta ska ses i förhållande till gängse beskrivningar av kritiska verksamheter, vilka i huvudsak handlar om hur givna instruktioner och verktyg stödjer, eller inte stödjer, planerade delmål. Slutsatsen är att det är möjligt att ge helt olika empiriskt grundade beskrivningar av kirurgi. Utifrån så kallade “designerorienterade” ansatser förklaras varje oväntad teknisk användning som tecken på underliggande designproblem. Enligt dialogisk teori framstår istället teknisk pluralism och förändring som nödvändiga delar av verksamheten. Det senare är allt annat än självklart inom området verksamhetsutveckling. Med föränderliga tekniker och tekniska system som grund, blir det inte längre prioriterat att undersöka eller stödja situerade “användarupplevelser”. Istället bör redan befintliga interkreativa design processer och konkreta samkonstruktioner lyftas fram som tekniska förutsättningar för forskning och utveckling. Avhandlingen problematiserar således både hur teamarbete kan förstås och hur teknologi gestaltas i vardagen.