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.