Abstract
Clinical guidelines, as vehicles for evidence-based practice (EBP) attempt to standardize health-care practice, reduce variation and increase quality. However, their use for surgery has been contested, and often resisted. This article examines professional responses to EBP in hip replacement surgery using data from case study observations and interviews in three English orthopaedic departments. A professional identity perspective is adopted to explain how standardization through EBP, represents an empirical phenomenon around which surgeons enact their identities as Paragons, Mavericks or Innovators, to enhance legitimacy and stratify themselves in their response to EBP. Attention is drawn to variation between Paragon surgeons working in university (teaching) hospitals and Maverick and Innovator types located in general hospitals, and the ways this interacts with adoption of EBP. The typology shows how practice variation is related to surgeons' tendencies to align to characteristic types, with distinct social processes, power and prestige, and which are in turn influenced by organizational context. The dynamics of EBP and professional identity continues to limit attempts to standardize surgical practice. The typology contributes to the understanding of failures to follow EBP, as associated with the identities individuals create and negotiate, and with identity narratives used to legitimize differing responses to EBP.