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Situated learning theorizes the process by which learners integrate into

communities of practice. However, it tells us little about the objects and mechanism of that process or what happens when it fails. Sociomaterial theories can offer this

perspective. Integration into a community of practice is a complex nonlinear process shaped by multiple social discourses. But, conventionally speaking, medical education loses sight of the social and material objects that shape the process in favor of focusing solely on cognitive structures. Thresholds abound with sociomateriality: the movements of hands, the sighting of planes, the shakes of the head, the grasping of tools, the pushing of human tissues. Considering thresholds using a sociomaterial perspective may help to bridge theoretical gap between the intent of situated learning and its uptake in medical education. Sociomaterial approaches “understand human knowledge and learning in the system to be embedded in material action and interaction (or intra-action), rather than focusing strictly on internalized concepts, meanings and feelings of any one

participant”.42(p. 6) _{The bones in the spine of the sociomaterial approach—cultural-}

historical activity theory, actor-network theory, and complexity theory—each possess areas of inquiry that can reframe procedural variation not simply as a clinical problem to be solved or Thresholds as an individual experience but rather as social processes

reflective of a larger system, one where forces constantly intertwine and decisions are made based on shared constructions. For example, looking closely at how surgeons and residents tacitly negotiate control dynamics by silently picking up certain tools or exposing new planes can inform medical education’s understanding of how discourses can act silently but forcefully in the social process of workplace-based learning. Paying

attention to cultural ‘materials’ like discourse through sociomaterial work allows learning theories in medical education to more directly attend to the complexity and ambiguity of learning so embedded in materials.

Complexity theory casts the individual as incompletely autonomous. Like situated learning, complexity theory considers knowledge not as an object to be acquired but as a form of interaction.43 But unlike situated learning, in complexity theory the individual and the environment “are engaged dialectially in a mutually specifying choreography where, all at once, each specifies the other”.43(p. 118) _{Each element of the system—be it a non-}

human material, a discourse like evidence-based surgery, or an individual person—exerts rippled effects over the rest of the system. In this study, residents carried variations from operating room to operating room (from fiefdom to fiefdom). The Thresholds they experienced with previous surgeons shaped their experience of thresholds with surgeons later in the education process. Residents spoke of variations and socially constructed interpretations of how to interact with the surgeons and the materials over which surgeons had institutional control. Understanding the rippling consequences of simple actions— like the frustrations over the unavailability of a specific tool, for example—can help medical education conceptualize how the systems of operating rooms sometimes silently resist a learner’s attempts to actively engage with a surgeon’s Threshold.

A second theoretical force in sociomaterial approaches, actor-network theory, destabilizes what it means to be a cognitively independent individual. Rather than thinking about persons, as in situated learning, actor-network theory “focuses on the minute negotiations that go on at points of connection. Things—not just humans, but the parts that make up humans and non-humans—persuade, coerce, seduce, resist, and compromise each other as they come together”.42(p. 10) _{Rather than perceiving a surgeon’s}

threshold of principle and preference as a static object, actor-network theory teaches us how “clinical diagnosis does not depend on sharp thresholds: its division between health and disease is more fluid”.44(p. 259) _{In moments like these, actor-network theory}

problematizes the notions of individuality that so fundamentally undergirds surgical culture. Where much of surgical research sees individual humans taking control and acting purposefully to acquire a stable self, and the stable Threshold such a self would imply, actor-network theory sees one actor in the midst of others—human and nonhuman,

social and cultural, material and ethereal—each acting as forces in their own right. Boundary objects are objects brought from one discursive setting to another that actors use to create movement between their respective discursive communities. Procedural variations are an excellent example of such objects. And looking closely at those objects—those actors—can help to identify networked actions like thresholding that previously existed as a black box…something that seemed both important and fraught enough to be ignored.

Finally, cultural-historical activity theory (CHAT) holds that learners exert influences over the educational system. Where the teacher, for instance, acts to teach, the learner acts to shape the way teaching is performed; conversely, situated learning is perceived primarily as unidirectional change, of an individual learning become a part of a community. Activity, in CHAT, constitutes the most basic unit of analysis of human learning.42 It is in activity that tensions and contradictions arise between the

understanding of the student and the understanding of the teacher. These tensions lead to questions and learning; therefore, rather than being concerned about what knowledge a student has acquired, cultural-historical activity theory traces materials, interactions, and histories to divine insights about the ‘potential development’ of a learner rather than focusing solely on what has been determined by a single snapshot in time.45(p. 86) _Bringing

the CHAT perspective to the analysis of Thresholds may help medical education to better understand how a resident with the desire to learn can find themselves barred from key insights. If learning is situated in the friction between teacher and learner, then posing Thresholds as a way of understanding that activity can reframe those frictions as part of an ongoing process rather than a failure to acquire sufficient abstract knowledge.

Situated learning remains a key theoretical tool in medical education research. Bringing a sociomaterial lens to the study of Thresholds helps to identify some of the ways that medical education’s use of situated learning theory can be refined by attending to the social complexity of control over key learning resources. The mechanisms of such social process are many. They are smaller and more widely dispersed than conventionally recognized. By considering the sociomaterial, we open up medical education’s theoretical approach to defining what matters in a situation. Medical education has comfortably taken up situated learning theory but has been slower to take up sociomaterial approaches.

Sociomaterial approaches teach us that learning to become an expert is more complex than accruing a sufficient volume of rote physical practice. Discourses like evidence, gender, and risk that shape power relations and control over key resources—like

operative opportunities—constitute the sociomaterial approach’s most powerful tools in capturing the complexity of the learning process. Yet it isn’t as if medical education researchers were not aware that hierarchical control over key resources was relevant to surgery. Bosk, for instance, showed in 1979 how quasi-normative errors are used to make decisions around resident competence.38 Yet, as Bosk retrospectively admits two decades later, even his analysis failed to question the mechanisms of control over materials with sufficient rigor:

“I undermined my own intent in developing the concept of quasi-normative error. My intent, as I understood it at the time, was to show that the world of surgery was a highly authoritarian one and that that authority had a defect—it was occasionally eccentric, arbitrary, and capricious. Yet by not showing the degree to which [the residents] were baited, I lodge[d] the defect not in authority itself, but in the underlings who are too dim to discern its workings”.38(p. 228) This legacy of ignoring hierarchy’s more capricious consequences has lasted well in surgical education research. Today, field study after field study46-49 decrees that

residents—whose “hands are underdeveloped”47(p. 542)—struggle to learn the maneuvers because of the dexterity required. Research in this vein chooses not to ask if dissonances in the teaching residents receive play any role in their struggle. Instead, even this

socioculturally-conscious ethnographic, anthropological, and critical theory-based research46-49 chalks up the challenges of postgraduate surgical education to the difficulty of the task itself and rarely to the traditionally reinforced boundaries of surgical culture. Education research has turned to sociomaterial theories to answer the kind of questions about hierarchy, control, and material resources in teaching and learning that the theory of Thresholds invokes.42 Rigorous theorising of the relationship between procedural control dynamics and thresholding beyond the current individual skill development approach may require further investigation of the sociomateriality of this situated learning phenomenon in the future.