Authors: Fawziah Alsalmi MD; Lorne Costello MD, MSc;  Kristine Prince DNP, APRN;
Editor: Sara M. Krzyzaniak, MD

A Case

Ms. Smith, an 87 year old with a past medical history of untreated hypertension, called the ambulance when she developed significant chest pain. On arrival, she informed Shannon, one of the paramedics, that the severe, tearing pain began suddenly about one hour prior and radiated into her left arm and back. As per her medical directive, Shannon began transporting the patient and consulted with an emergency physician, Dr. Lee, via a telemedicine link. 

During transport, the telemedicine platform had connection issues and kept cutting in and out, much to the frustration of Shannon and Dr. Lee. As a result, Shannon was unable to relay much of the patient’s history or her vital signs, so Dr. Lee asked that she just send the ECG. He planned to review it to determine appropriate triage prior to the patient’s arrival. His review of the ECG showed ST elevation in the inferior leads (II, III, and aVF), and he interpreted this as consistent with an inferior ST-elevation myocardial infarction. The concerned emergency physician informed the paramedics to bypass the emergency department and transport her directly to the cardiac catheterization suite for primary coronary intervention. He requested that the paramedics give aspirin and sublingual nitroglycerin. As Shannon started to express her concern about the patient’s atypical sounding chest pain, Dr. Lee was called overhead to attend to another sick patient. He apologized and ended the telemedicine call. 

On arrival at the cardiac catheterization suite, the patient had received the requested medications. The patient was now short of breath and hypotensive. As the paramedics handed over the patient to the interventional cardiology team, Dr. Sam, the cardiologist, performed a bedside echocardiogram. The bedside echo demonstrated hypokinesis of the inferior wall with moderate aortic regurgitation and a large pericardial effusion. Dr. Sam raised the concern for an aortic dissection, which is what Shannon had been concerned about all along.

Shannon and her partner transported the patient down to the emergency department while Dr. Sam called for an emergent cardiac surgery consult. As the paramedics bring the patient into the emergency department, Shannon hears a familiar voice; standing before her is the now shocked emergency physician, Dr. Lee. 

Background

The core tenant of sociomateriality is the effect technology has on human interaction, personal and professional lives, and sociality. This framework concurrently describes effects of people on the design of, use of, and dependence on technology in the modern world. Commonly cited examples in the literature include internet search engines and smartphones. Sociomaterial is a concept that has been circulating in the fields of sociology and economics since the 1950s. There has been a relatively slow evolution of the topic up until 2007, a key point-in-time for sociomaterialism and advances in related research and application. In 2007, Orlikowski built upon her work from 1995 and sparked a renewed interest in sociomaterial through the development of sociomaterialism and the concept of entanglement.³ As previously discussed, constitutive entanglement is the intertwining of social and material as a singular concept.³ Subsequently, several authors have debated the soundness of Orlikowski’s constitutive entanglement and theorists have created several branching theories under sociomaterialism including artefact, apparatus, affordance, constrain, object, entity, and actor-network-theory.^5,6

Modern takes on this Theory

Despite its 2007 resurgence, sociomateriality has had few modern advances apart from the aforementioned viewpoints, notions, and debates.⁸ Regardless, its value is increasingly recognized in the impact of technology in the modern world and is now be utilized in many fields of study after years of being used primarily in organization and information systems literature. The constitutive entanglement described by Orlikowski is evident more than ever with humanity’s dependence on technology in nearly all aspects of everyday life. There are myriad benefits to the advances of technology in the modern world including but not limited to worldwide connection, rapid communication and dissemination, ease of access to information, improved productivity and efficiency of industries, and increased lifespan. However, there is a darker side to technology including vulnerability, risk of breaches of sensitive personal information, diminished need for human rote memory and knowledge, and human job loss as processes become automated. More significant concerns include pandemics due to synthetic biology, climate change with geoengineering, production of weapons of mass destruction via distributed manufacturing, and unpredictable artificial intelligence systems.⁹ While the benefits of technology outweigh the risks, individuals and organizations must be cognizant of these risks to mitigate adverse outcomes. Sociomaterialism is the conceptual framework surrounding these issues. 

With the rapidly changing face of technology and its impact on humanity, sociomaterialism and sociomateriality are among the most commonly discussed and debated conceptual framework and theory applications in many fields of study and organizations. Applications of sociomaterialism are also evident within the COVID-19 pandemic with mitigation measures, rapid transition from face-to-face interaction to digital platforms, use of technology in continuing patient care without in-person interaction, as well as significant educational responses in light of COVID-19.¹⁰ 

Other Examples of Where this Theory Might Apply

With technology’s far-reaching impact in many aspects of the modern world, the classroom and clinical settings are prime locations for application of sociomaterialism as technology intersects these arenas. Within the classroom, sociomaterialism is rooted within use of advanced technology (e.g. computers, smartboards and projectors), online teaching practices or mobile learning, simulations, use of social media to disseminate information or provide educational opportunities, open educational resources via the Internet, and access to unlimited digital resources that benefit both the educator and learner.^11-14

Within the clinical setting, there is a plethora of medical literature applying sociomaterialism and sociomateriality to both medical education and practice. Examples of application include multidisciplinary approaches to patient care, medical technology, distributed medical education (e.g. distance education, web conferencing, video conferencing, online educational platforms and online communities), use of social media to disseminate evidence-based practices and free open access medical education (FOAM), electronic medical records, use of smartphones and tablets, simulation-based learning, and digital resources.^4,15-19

Limitations of this Theory

Limitations to sociomaterialism depend on the field of study or area to which the conceptual framework is being applied. However, common limitations noted in the literature include the lack of addressing of problems in social inequality, strong versus weak versions of sociomaterialism, confusing language of the framework itself, and ruminating design. 

• Social Inequality: sociomaterialism and sociomateriality assumes equal access to technology among all individuals and organizations. This limitation is highlighted in work using sociomaterialism within the fields of education and literacy. This limitation is also seen in healthcare applications, for example the use of a computerized algorithm that assumes equal access to care 
• Strong versus weak versions: weak sociomaterialism denotes separateness of social and material while strong sociomaterialism does not.⁵ 
• Language and descriptors can be very difficult to understand.⁵  This, combined with multiple definitions and overlapping theories, lends to significant confusion. 
• Ruminating design: authors repeatedly debate the soundness of the foundation rather than focusing on the establishment of the framework and its application to individuals, relationships, and organizations.

Returning to the case…

After Ms. Smith is quickly stabilized in the emergency department and transferred to the operating room, Shannon asks Dr. Lee if they can discuss the case since she feels uneasy about what has happened. Dr. Lee agrees and they go to a quiet room.

Shannon expressed that she feels guilty for not speaking up sooner and is frustrated that there were technology issues that prevented clear communication. Furthermore, she felt that she was dismissed by Dr. Lee who rushed her off the phone. Dr. Lee stated that he also felt guilty for missing the correct diagnosis, leading to a delay in care. He apologized to Shannon for dismissing her earlier – reiterating that there was a sick patient and he was faced with competing urgent issues that needed attention. They agreed on the importance of better communication in this and decide to file a safety report with their respective leadership teams to help mitigate the risk of a similar incident in the future. Within their meeting, Shannon and Dr. Lee unknowingly identified key issues applicable to sociomaterialism. The lack of functional technology prevented both parties from doing their job correctly and led to frustration. Shannon was unable to communicate her concerns and Dr. Lee, with minimal information, switched to another material (ECG) to decide how he would act next. Furthermore, this technology glitch changed the way that both the physician and paramedic interacted. Similarly, the environments that they both were in also influenced their behaviours and interaction. For example, Dr. Lee was paged overhead to attend to another sick patient, despite being within eyesight of the patient’s room and available to immediately help. 

Beyond this conversation, there are other factors at play in this constitutive entanglement. So, there you have it, a practical example of the complexities that involve material and social in everyday learning and practice. Sociomaterialism supports that medical practice is a collective sociomaterial enactment and not a question solely of an individual’s skills. It decenters the human as the focus to allow for a deeper exploration of the complex, messy and non-linear relationships between materials and social practices.²⁰

References

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