Activity theory, agency and medical education reform

This post was stimulated by an interesting twitter exchange today, about using activity theory in research and, in particular, how issues of individual agency are addressed. I am interested in activity theory (and, in particular, Engestrom’s 3^rd generation activity theory ) having drawn upon it in my doctoral studies. In the first study, I analysed medical student learning on attachments, seeking to make sense of the ways in which they engaged with the learning cultures of the medical school and the workplace. In the second study, I set out to make sense of the emergence of ‘faculty development’ as a new set of practices within secondary care medicine. I was interested in the discourse around the so-called ‘professionalisation of medical education’ – for me an interesting phrase, given that medicine is one of the oldest professions with centuries old traditions of apprenticeship. 

In this study, I analysed 20 years of government policy and the grey literatures of professional bodies (eg GMC, PMETB) in three areas – the NHS, Postgraduate Medical Education and Undergraduate Medical Education. This led me to conclude that constant reform of the NHS had systematically dismantled medical apprenticeship, leaving doctors in a position where they were asked to adopt training practices that were antithetical to their own learning histories. In particular, I noted the growing disconnect (conceptually, practically) between ‘work’ and ‘learning’, no longer seen as mutually constitutive. The shift to formal curriculum in PGME, with ‘competences’ to be gained, tools to evidence their acquisition etc, signaled a profound culture shift, discussed, in part, in previous blog postings.

My analysis led me to argue that there had been a shift from time-served apprenticeship to time-measured training, creating a series of structurally accumulating tensions. For example, an increasingly risk averse culture (with consultant led services) sits uncomfortably with training practices which rely on the delegation of medical work to those in training grades. My analysis left me concluding that the medical profession found themselves in a contradictory positioning (an activity theory concept). Training practices of old were unsustainable in a reformed NHS, yet the solution put forward by the regulators, to ‘professionalise’ medical education, was unlikely to offer the creative, expansive solutions necessary to reconcile these tensions.  Compulsory, regulated, faculty development activity was offered up as the means to professionalise medical education, with the ‘curriculum’ being focused on rather instrumental trainer-trainee interactions e.g. the use of WPBA tools, how to give feedback, ‘managing the trainee-in-difficulty’ and so forth. The question for me, was how would deaneries respond to this positioning? Go with the grain (ensuring all trainers were ‘trained’) or seek more creative solutions that would genuinely help trainers find ways of sustaining high quality training practices in a reformed NHS. This is where, for me at least, the question of agency sets in.

My research led me to an analysis of one deaneries response and a series of in-depth interviews with a new ‘faculty development workforce’. I explored their sense making, talked to them about their faculty development practices, and the types of theoretical and biographical tools they drew upon in their work. In so doing I was able to trace a range of responses to the call to professionalise. For some there was a ‘conforming’ response, meeting the regulators requirement to ensure that all trainers were trained. Typical methods involved short, central workshops, across all specialties, covering key aspects of educational supervision practice. Others were a little more creative in their response (which I label as a ‘reforming’ response). They worked with doctors in a range of ways, always seeking to offer/elicit a medical context to their work, working with teams on site, offering up teaching observation type activity, so individual doctors had a chance to review existing educational practices and adapt them in light of new requirements. The third ‘transforming’ response involved a radical re-thinking of training practices. Here colleagues came together to explore what was working on the ground but also where the difficulties lay. They adopted and generated new forms of faculty development practices including team observations, faculty groups and  joint development activity between trainers and trainees to find solutions to the problems being encountered post reform.

So, how does this relate to the initial query i.e.  how the issue of agency is dealt with in activity theory? In activity theory the world is understood as partially conceptualized, the world acts on us but we also act upon the world. In finding themselves positioned to act in a particular way (to professionalise medical education through faculty development), the doctors and educators I spoke to chose to respond in a range of ways. They showed agency. This agency was influenced by the biographical and theoretical tools they had to draw upon, and the extent to which they were willing to go with, or against, the grain of reform.

Simulation, orthodoxy and doctrine...

Over the past year or so, I have been involved in a range of faculty development activity for medical and healthcare educators using simulation in Higher Education and NHS contexts. The emphasis of my work has been on enhancing the educational value of simulation, shifting the gaze from technical and clinical aspects. In doing this, I have found myself grappling with what I can only call simulation ‘orthodoxy’… my observations on the 'simulation doctrine' follow.

Simulation improves patient safety.

It seems to me that many of the claims about simulation are based on assumptions of transfer, from one context to another. For example, we note that simulation has improved safety in the aviation industry and assume it will do the same in medicine. We see that performance is enhanced in simulation and assume that this enhanced performance will readily transfer to the workplace. Yet we know that transfer is a problematic concept in education generally, and medical education specifically. Studies of transition to greater levels of medical responsibility, for example, show dips in performance in new jobs, because transfer from one context, setting or team to another is not a straightforward process.  How sure are we really that simulation achieves all that is claimed in its name?

Fidelity matters.

Beware the seductive appeal of new technologies...fidelity does not appear to be a significant determiner of the learning experienced. Can I suggest we start a dialogue about authenticity, which I suspect is more important? By authenticity, I mean the extent to which participants are able to engage in a simulation experience that feels meaningful, congruent and close to their lived experiences of working in clinical teams, in clinical contexts. Which brings me on to the next point…

Role-play is accepted as a proxy for actual performance

Too often in simulation we bring together a group of learners, all at the same stage in training, typically all within the same professional grouping, and give them parts to play. We ask a group of FY1s to ‘play’ the registrar, the nurse, the consultant and so on. In so doing, we ask them to play out their understandings of ways of being, thinking and acting…fine, if the goal is to work with their stereotypes! If simulation is to be meaningful, I think we need to stop thinking about role play, and move into role-rehearsal. We need to give opportunities to rehearse the types of work activity that are at the level of expectation (or just beyond) the learners point in development. We need to construct scenarios that seek authenticity in terms of roles, responsibilities and contexts. 

We are missing a real opportunity to bring ‘real’ teams into the simulated space, to run through scenarios they have already experienced, to consider different ways of being and acting in order to improve practice. Simulation is used in ways that are anticipatory of future action, why not use them to re-think the past? Which leads us to consider the types of learning experience we offer in simulation.

All simulated scenarios involve ‘surprises’ and ‘challenges’

From observation and discussion, it appears to me that the typical simulated scenario involves a moment (or several) of surprise, placing the learner in a position of uncertainty and challenge. Typically I witness a short briefing, a scenario that plays out to the agreed conclusion, with faculty observing and intervening only to lead the debrief. This is, of course, a perfectly legitimate use of simulation, if the intended learning outcome is to develop approaches to dealing with uncertainty /acute clinical situations. I fear this downplays much of the learning value of simulation.

• How would it be if we used simulation to explore a range of responses to more typical situations? 
• How would it be if we involved learners in choosing or shaping the scenario, so they could rehearse situations they are daunted by? 
• How would it be if in the briefing, we gave an account of what was going to be encountered, and talk through possible ways of responding before the scenario? 
• How would it be if faculty came alongside the learner, with an option on both sides to ‘freeze’ the scenario, to discuss possible options for action before moving on? 

Such variations would allow us to maximize the learning value of simulation.

Debrief and feedback are inter-changeable

In the past 6 months I have asked faculty to provide me with a simple definition of each of these terms and an account of the pedagogic strategies they use for each. The answers suggest that distinctions are unclear and that strategies merge into each other. The simulation literatures aren’t that helpful in this regards either! I do think they serve different purposes and require different actions as result. My working distinctions are as follows…

Feedback, is for me at least, a developmental conversation. This conversation (dialogue, not monologue) builds upon what is known (or shared) about performance, as a basis for moving forward. Whilst group feedback is possible (if the performance of the whole group is the focus), feedback is typically about the development of an individual. So, after a simulation session, this would mean finding time to talk to the individual about their performance and what they might do to develop their practice in light of that. With their consent, this might be ‘in the round’, so that peers might offer suggestions and benefit from listening in to tutor guidance. It is not ‘a given’ that an individual’s performance in the simulated scenario is open for discussion in the group (no more than it would be on a ward round, for example).

The term debrief has military origins – according to one on-line dictionary, to debrief means to question someone (typically a soldier or spy) about a completed mission or undertaking. The soldier provides a vivid account of what s/he has experienced (sight, sound, smell, sense). The purpose of the debrief, in this case, is for the unit to gain inside information, and, together, to consider next steps for action. 

Translating this into medical simulation, the debrief is a pedagogic strategy where  the lived experience of one team member is offered up to the whole group as a shared resources for learning. By inviting the learner to provide a narrative account, which includes affective responses to their experience of simulation, they are offering a gift to the group. Together they analyse ways of responding. Together they seek to make connections between the simulated experience and those experienced in vivo. Together they identify the learning arising from the scenario that they each can benefit from. This kind of debrief would be particularly powerful when bringing teams in to analyse existing practices and try out new ways of working to enhance patient care.

Simulation has the potential to be a powerful educational tool, if seen as that, a tool that supports learning of individuals (hence feedback) and development of teams and practice (hence debrief). It is time to take a critical stance to simulation and consider how it might make a meaningful, authentic contribution to developing patient care.

'Reflections' on reflection...

“In the varied topography of professional practice, there is a high, hard ground, overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the application of research-based theory and technique. In the swampy lowland, messy, confusing problems defy technical solution. The irony of this situation, is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, however great their technical interest may be, while in the swamp lie the problems of greatest human concern. The practitioner must chose. Shall he remain on the high ground where he can solve relatively unimportant problems according to prevailing standards of rigor, or shall he descend to the swamp of important problems and non-rigorous inquiry?” Schon, 1987, p.3.

I make no apologies for reproducing the first paragraph of Schon’s classic text, Educating the Reflective Practitioner in full – it is a paragraph that turned my world upside down! At the time I was undertaking an MA in Higher and Professional Education and working as a Senior Lecturer (in Speech Pathology and Therapeutics). I was trained (and was training) within the technocratic, scientific tradition captured in the pre-clinical/clinical divide of professional education. Schon’s glorious imagery of the high-ground (the ivory tower of academia for me at that point) and the messy swampy lowlands (of clinical practice) immediately resonated with my lived experience of both being a clinician and of preparing future-clinicians. The invitation to adopt a critical stance to the ‘apply theory to practice’ mantra of professional education was thrilling. Donald Schon became my ‘first love’ in the world of educational theory, and although he has subsequently been supplanted by my ‘grand affair’ with socio-cultural and activity-theorists, I will always have a soft spot for him. 

Which is perhaps why I feel the need to speak out about the injustices being committed in his name, through the wholescale adoption of (compulsory), written ‘reflections’ as part of the assessment practices of medical, dental and healthcare professionals. These instrumental practices seem so very far removed from Schon’s accounts of professional artistry and the ways in which expert practitioners negotiate the swampy lowlands, generating and testing out novel solutions to complex problems that do not respond to a by-the-book approach.

Schon’s accounts of reflection-in-action relate to the types of in-the-moment analysis and problem framing that happens when we encounter a unique case or situation, that, in his words ‘falls outside the categories of existing theory and technique’ and cannot 'be solved by applying on the rules in her store of professional knowledge’ p. 5.  The practitioner adjusts her problem framing, and formulates a response, which may involve aspects of improvisation, hypothesis formulation and testing and experimentation, which in my experience at least, may involve simultaneous internal narrative (what if, shall I, it might be, I could, I wonder if, lets go with) with external action.  Evidence-based practice, clinical guidelines and protocols sit rather uncomfortably with Schon’s account of the expert’s ‘professional artistry’.  Reflection-in-action feels a long way away from the rather predictable, ‘chose something that did not go so well this week, reflect on why that was the case and rationalize what you will do differently (and therefore better) next time’.

So, how might we reclaim and revive reflection-in-action in medical training, or rather more grandly, create a curriculum to foster professional artistry?

According to Schon, we need to find ways to ‘bring past experience to bear on a unique situation’. One way to do this, might be in the use of Case Based Discussion (or chart stimulated recall). Rather than fall into the trap of using CbD to check out whether practice was by the book (ie done the way you would have done it), the case becomes a trigger for a richer discussion, that allows exploration of other ways of thinking and responding to the situation in hand and situations in the future.  

The case of the 45 year old man presenting with ‘x’ and ‘y’ on findings is extended into other scenarios. 

• ‘What if it had been a 23 year old man, how might that have influenced thinking or action?’
•  ‘imagine that the finding ‘y’ had in fact been finding ‘z’, what might you have done then?’
•  ‘What would you have done if he didn’t respond in the way he had?’ and so on. 

Encouraging explicit links between this and other experiences is vital. 

• ‘To what extent did he present / not present typically?’, 
• ‘think of another case that has presented like this, but turned out to be something different…what was the pivotal piece of information /action that helped move things forward?'

Schon also encourages on-the-spot experimentation, clearly something that raises alarm bells in the clinical world. But how would it be if we used simulation rather more creatively here? Rather than create ‘surprise’ scenarios for ‘simulated teams’, why not provide opportunities for actual teams to come together, to re-run known situations, trying out and discussing a range of possible options for action? They might also rehearse new practices, anticipating those situations which don’t always go according to plan, using think aloud and debrief techniques so that ‘reflection’ becomes a shared endeavour, rather than a solitary pursuit in front of computer screen. Through rehearsing different approaches to a known situation, it is possible to find ways of thinking and working together that allow experimentation. This fits well with Schon’s encouragement to use virtual worlds, where ‘the pace of action can be varied at will’, allowing slow motion replays of both action and thinking.

Ultimately, reflection-in-action has to involve action – opportunities to engage in a rich and varied ‘practicum’ of the workplace. Recent calls to consider whether trainees have sufficient time to reflect are admirable, but only relevant if they have meaningful experiences to reflection in and upon.

Apprenticeship: a socio-cultural view

My starting point, when thinking about apprenticeship, is to turn to Lave and Wenger, who set out to ‘rescue the idea of apprenticeship’. Their social-anthropological study of diverse forms of apprenticeship opened up thinking about the nature of learning, challenging dominant (cognitive-behavioural conceptions of learning). It is their work that informs Sfard’s (1998) learning-as-participation metaphor, explored in an earlier blog. 

Lave and Wenger looked at learning as a social practice, analyzing apprenticeships out-with formal teaching and learning structures. As a result, they put forward an analytic viewpoint on learning, with two inter-related concepts, legitimate peripheral participation (LPP) in communities of practice.  The term CoP is widely (and loosely) evoked, but, for Lave and Wenger, it did not simply mean a team, rather a grouping of people, who shared a common purpose, working together (not in parallel) to sustain and develop practice, over time. Rather than use hierarchical distinctions (such as expert-novice, master-apprentice) they talked of newcomers (to a community) and old-timers, who preserve the work of the community. Newcomers are invited into the work of the established community through processes of legitimate peripheral participation, which socialize them into ways of thinking and practicing. The interesting point made, is that the engagement of a newcomer will always change established practice, and so the development of practice is a shared endeavor. Within a true community of practice, expertise is a distributed phenomenon; no single practitioner can undertake the work of the community alone. To over-simplify, apprenticeship might be seen as the learning arises from engagement in social practices, such as work, within a community of practice. Wenger later went on to explore the dimensions of any social theory of learning, arguing it encompasses elements of learning as meaning (sense-making), learning as practice (participation in a social practice (such as work), learning as belonging (to a community of practice) and learning as becoming (identity formation).

Lave and Wenger looked at informal apprenticeships, so their work is not directly applicable to medicine; their analytic standpoint is. The question for me therefore, is to what extent do (historical) forms of medical apprenticeship involve legitimate peripheral participation in a community of practice? (As an aside, I have written up research of medical student attachments as times spent in CoP in a forthcoming publication, which presents a range of interesting research on learning in clinical workplaces.) I would argue, from an analytic standpoint, that training to be a doctor has, historically, involved LPP in a CoP. The firms of old, with stable work teams were close to CoP, determining the nature, type and amount of work activity newcomers engaged in, as part of the shared care of patients.  Through processes of LPP (at different speeds, based on perceptions of readiness) newcomers therefore became integral to the work of the community.  Work is therefore the curriculum for training, with work activity being safety-netted by the CoP and other learning processes (sense-making, professional identity formation) being mediated by old-timers (firm leaders). 

CoP in the literature come across as being rather benign groupings, with issues of power differentials seldom explored. The critique of apprenticeship I tried to offer up in the earlier blog, suggested that these power differentials led to inequitable training practices. (Stephen Billet talks of workplace affordances, how these support learning and how they fail to be benignly distributed).

For a whole host of reasons, not explored here, I think this type of apprenticeship is unsustainable within current NHS/ medical working structures and practices. I think there has been a move away from a socio-cultural account of apprenticeship to something that is framed in cognitive-behavioural terms. Here, work-based learning is understood as having a work experience, that you subsequently reflect upon and, as a result, adapt your work practices to be more effective. Whilst I think socio-cultural accounts downplay the importance of cognition, ie how doctors put knowledge to work, they do provide a much richer, situated, collective account of learning arising through, from and for work reasons than the rather over-simplified metric of do-reflect-adapt which is put forward as being how medical learning happens. (I find Unwin and Fuller’s work on restrictive-expansive apprenticeships useful here, along with Evans, Guile and Harris’ work on ‘putting knowledge to work’ through processes of recontextualisation).

The current framing of medical training seems to isolate individuals and individual practice, disconnecting them from the work of the communities they are part of. This for me, is part of the diminishing of the cultural-heritage of apprenticeship.

Apprenticeship: a rose-tinted view?

Commenting on my last blog, Kirsty asked whether ‘we hold a rose tinted view of apprenticeship’? 

It is a question that struck a chord, having been asked something very similar in my doctoral viva; on both occasions I have tried to adopt a critical stance to the idea of apprenticeship. Part of that stance involves engagement with the implied rationale for the move towards structured, competency-based training systems in postgraduate medical education, under the heading of Modernising Medical Careers. This leads me to explore a series of propositions about medical apprenticeship. 

Apprenticeship was too risky.

A dominant discourse in both undergraduate and postgraduate medical education, is that of patient safety. The most recent (2009) edition of Tomorrow’s Doctors (TD), for example, highlights the responsibility of medical schools in ensuring that patients are not put at risk by being involved in medical education. Patient safety is the first domain of this new version of TD; it was barely mentioned in the first. I observe increasingly risk-averse training practices being adopted (such as simulation), and listen to doctors who are increasingly anxious about delegating medical work to medical students or others. Medical colleagues (of a certain age) talk about ‘being thrown in at the deep-end’ and share vivid stories of early near-misses. All this might lead you to think that apprenticeship systems of the past were inherently more risky than those we adopt now. Yet, I watched with interest the 1^st of August twitter feed yesterday, as comments from new and transitioning doctors echoed anxieties of the past. The inherent contradiction here is, of course, that risk-averse practices restrict learning opportunities, thereby increasing risks to patients. 

Was apprenticeship really inherently more risky?

 Apprenticeship is open to abuse of power.

Apprenticeship is often, unfairly in my view, coupled to accounts of teaching-by-humiliation, as if the two were integrally related. Strongly hierarchical systems amplify power differentials; senior doctors had considerable leverage over important decisions about progression to greater levels of medical responsibility in the past. These decisions are perhaps more transparent now; certainly the evidencing of decisions is more visible. The ‘lost tribes’ of Senior House Officers were put forward as part of the rationale for modernizing medical careers. Inequitable gender distributions across particular specialties, limited access to part-time training, under-representation of particular socio-economic groupings in medicine each suggest there have been inequitable training practices historically. An apparent silencing of the patient’s voice in medical education, (with patients seen as an exemplar of rather than an expert in their own condition) is another reason to rethink training practices of old. Prof Alan Bleakley talks, with passion, about the need to democratize medical education.

I wonder the extent to which new medical education and training practices move the profession towards this goal?

Apprenticeship is financially unsustainable.

Over the past three decades we have witness significant form throughout the public sector, based on financial imperatives. The three e’s of new managerialism, ‘economy, efficiency and effectiveness’ have driven much of this reform, shaping the ways in which healthcare is organized and delivered. Apprenticeship into the medical profession is a lengthy, resource demanding process, involving significant investment of time and energies. 

"The apprenticeship model, long the bedrock of our training in the past remains important but now needs to be set within efficiently managed, quality assured training Programmes compatible with the Working Time Directive." Modernising Medical Careers: the Next Steps (2004) 

Should new managerialist principles replace sound educational thinking when designing medical curriculum?

Apprenticeship fails on learning grounds?

In adopting a critical stance, it is clear, to me at least, that apprenticeship is costly in terms of human and financial resource. I recognize that apprenticeship practices were distorted by the playing-out of power differentials, leading to inequitable training practices. I fail to be convinced, that apprenticeship systems were inherently more risky than those we adopt now. Indeed, I grow increasingly concerned about the amount of hands-on experience gained and the increasingly narrow range of work activity undertaken by medical students and doctors in training. But did apprenticeship fail on learning grounds? I am not sure it did and I have found few accounts critiquing apprenticeship in the learning literatures. Medicine has a rich cultural inheritance in apprenticeship. A reformed NHS may make it increasingly difficult to sustain, but there is merit, in my mind at least, in taking time to re-think and develop a new form of medical apprenticeship. 

Rose-tinted? Perhaps!