MEDICAL WORK IN TRANSITION: Towards collaborative and transformative expertise

This chapter is dedicated to the memory of my sister Anne Piira (1947—2018).


Forces and demands from multiple directions mould medical work and expertise. A foundational change is going on in the overall object ot medicine: the growth of chronic illnesses that bundle together into complex forms ot multi-morbidity (DeVol et al. 2007; Bodenheimer, Chen and Bennett, 2009; Afshar et al. 2015; Milani and Lavie 2015; Moffat and Mercer 2015; Pefoyo et al. 2015). Whereas this would seem to require longer time perspectives as well as broader collaborative and interdisciplinary approaches from practitioners and their organisations, two other forces are often experienced as pulling in quite different, if not conflicting, directions. The rules of medicine are increasingly penetrated by market-oriented business calculations and managerialism that tend to favour rapid turnover and relatively short-term profits (Pollock 2004; Giaimo 2009; Hunter 2013; Beck and Melo 2014; Gilbert, Clarke and Leaver 2014). And the instruments of medicine are increasingly framed in terms of rationalisation and standardisation, again notions that tend to favour relatively linear and pre-packaged processes and procedures rather than horizontally co-constructed care trajectories and long-term impact (Timmermans and Berg 2010; Martin et al. 2017). Thus, we may tentatively identify systemic contradictions between the major force of change in the object on the one hand and the dominant tendencies in the rules and instruments on the other. These contradictions are marked with double-headed arrows in Figure 3.1. The components ot community and division of labour in Figure 3.1 are left open, with question marks indicating widespread uncertainty in the search for optimal organisation of health care sendees.

In this chapter, 1 will argue that this contradictor)’ state ot affairs calls tor deliberate and persistent efforts to redefine medical expertise so that practitioners, their organisations and society at large may begin to see and pursue expansive ways out ot the seemingly uncontrollable situation. My argument is not aimed at proposing specific policies and models of health care. My aim is to chart a zone of proximal development for building the kind of medical expertise that will allow the creation and implementation of robust emancipatory solutions, not as policy dictates from above but as evolving practices generated and appropriated from below.

/ Forces and contradictions of change in medical work and expertise

Figure 3. / Forces and contradictions of change in medical work and expertise

To construct a zone ot proximal development for medical work and expertise, we need to depict a field of identifiable historical types of this activity. In Figure 3.2, the vertical dimension represents movement from individual expertise towards collective expertise; the horizontal dimension represents movement from learning for stability towards learning for change. The historical starting point in the lower-left quadrant is professional craft medicine conducted by an individual expert and strongly bound to the expectation of stability. The two dominant forms of medical work today (in the upper-left and lower-right quadrants, respectively) are hierarchically organised medicine and market-driven medicine.

Various relatively weakly conceptualised forms of collaborative community are emerging in the upper-right quadrant, as if through the cracks that open up between and within the two dominant types (Engestrom et al. 2010). Movement from one type to another is not linear or automatic. There are clashes, retreats and detours, and all tour types continue to influence medical practice today. Yet 1 argue that the emerging collaborative and transformative expertise is a real historical possibility and an avenue towards expansive resolution of the contradictions summarised in Figure 3.1.

Moving towards collaborative and transformative expertise can be facilitated by means of appropriate conceptual instruments. Such instruments should pave the way tor theoretical understanding and practical construction of new forms of expert work. They may be seen as spearheads into the zone of proximal development ot medical expertise. I suggest three such spearheads: (1) object-oriented and contradiction-driven activity systems as locus of expertise, (2) knotworking as emerging forms of collaborative expertise and (3) expansive learning as emerging modes of transformative expertise. In the next sections ot this chapter, I will examine each ot these spearheads in turn.

The zone of proximal development of medical expertise (Engestrom 2018

Figure 3.2 The zone of proximal development of medical expertise (Engestrom 2018: 256)

Much of the empirical and interventionist research I have conducted in different arenas of medical practice over some 30 years is brought together in my book Expertise in Transition: Expansive Learning in Medical Work (Engestrom 2018). Taking a step forward from that body of research, in this chapter I will illuminate the three spearheads by briefly reviewing recent activity-theoretical studies published by others, pertinent to each of the spearheads in turn. I will further concretise the spearheads by discussing findings obtained by my own research group in a series ot studies on home care in the city of Helsinki. Although home care is not at the core of traditional medicine, 1 will show that it is relevant tor the emergence of new forms of collaborative and transformative expertise. New patterns ot activity often take shape in the margins of a complex field of activities, such as health care.

Expertise as object-oriented activity systems

In activity theory, a collective, artefact-mediated and object-oriented activity system, seen in its network relations to other activity systems, is taken as the prime unit of analysis. Goal- directed individual and group actions and action clusters, as well as automatic operations, are relatively independent but subordinate units of analysis, eventually understandable only when interpreted against the background of entire activity systems. Activity systems realise and reproduce themselves by generating actions and operations. Figure 3.1 above is built on a general model of the structure of an activity system (Engestrom 2015: 63).

The object ot activity is always under construction, interpreted and moulded by the actors involved in the activity. Object-oriented actions are, explicitly or implicitly, characterised by ambiguity, surprise, interpretation, sense making and potential tor change. There are multiple mediations in an activity system. Instruments mediate the subject and the object, or the actor and the environment, including material tools as well as signs, symbols and representations of various kinds. The less visible social mediators of activity—rules, community and division of labour—are depicted at the bottom of the model. Between the components of the system, there are continuous transitions and transformations. The activity system incessantly reconstructs itself.

Contradictions are the prime source of change and development in activity systems. Contradictions are not the same as problems or conflicts. Contradictions are historically accumulating structural tensions within and between activity systems. An activity system is constantly working through tensions and contradictions within and between its elements. Contradictions cannot be directly observed. They must be interred from historical analysis and from empirical analysis of their mundane manifestations, such as dilemmas, conflicts and double binds (Engestrom and Sannino 2011). Thus, the identification of contradictions in activity systems is always a working hypothesis, to be tested and elaborated on. Expertise resides in object-oriented collective activity systems mediated by cultural instruments and cannot be meaningfully reduced to individual competency. Expertise is inherently heterogeneous and increasingly dependent on crossing boundaries, generating hybrids and forming alliances across contexts and domains.

In medical work, a natural starting point for an activity-theoretical analysis of expertise is to examine the interplay of the activity system of the physician and the activity system of the patient. The constellation becomes more complex when we analyse the interplay between the activity systems of a primary care health centre, a hospital and a patient, tor example. An activity-theoretical framework tor the study of expertise implies a shift in emphasis from what goes on inside the head of the subject to what goes on in the object. Therefore, the study of expertise should re-focus on the objects of expert work. A trajectory of care that transcends institutional and professional boundaries is a promising way to conceptualise and operationalise the object of medical work.

Several studies of medical activity systems, their objects and their contradictions have been published in the past 10 years or so. De Feijter et al. (2011) analysed the experiences of final-year undergraduate medical students concerning patient safety. They found that the simultaneous occurrence of two activities, namely learning to be a doctor and delivering safe patient care, generated contradictions that could be approached as potential learning opportunities. Focusing on contradictions in the object ot the activity, Greig, Entwistle and Beech (2012) published an ethnographic study of primary health care teams responding to a policy aim of reducing inappropriate hospital admissions of older people by the “best practice” of rapid response teams. Teodorczuk et al. (2015: 757) analysed what they called “practice gaps” in hospital care of dementia and delirium. They found that “the primary object ot activity in relation to managing successfully the contused older patient is improving the care ot the confused patient through learning about the patient,” and identified a number ot systemic contradictions behind the practice gaps.

In recent years my own research group has conducted a series ot longitudinal intervention studies on the home care ot elderly clients with multiple illnesses in the city of Flelsinki (Nummijoki and Engestrom 2010; Engestrom, Nummijoki and Sannino 2012; Engestrom, Kajamaa and Nummijoki 2015; Nummijoki, Engestrom and Sannino 2018). We focused our work on the implementation of the Mobility Agreement, a new practice and artefact aimed at facilitating the physical mobility of elderly clients by means of regular exercises embedded in everyday chores at home. On the basis of our studies, we modelled the activity systems of the client and the caregiver, as well as their mobility-related contradictions, as depicted in Figure 3.3.

The tension between the need for safety and the craving tor autonomy, or more concretely between a tear of falling and a desire for movement, is a persistent primary contradiction in the life activities ot frail, elderly home care clients. Correspondingly, the primary contradiction in the activity of home care workers appears as tensions between the desire to stick to the prescribed standard tasks ot hygiene, nutrition and medication and the desire to respond to the client’s needs in a more proactive way, activating the client by working with rather than doing chores for him or her. These primary contradictions are depicted within the objects of the respective activity systems in Figure 3.3. Put together, they can be translated into the persistent institutional contradiction between the immediate cost efficiency and long-term effectiveness of home care. In Figure 3.3, the Mobility Agreement appears as a new instrument that aggravates the latent primary contradictions, generating secondary contradictions between the new instrument and old rules and division of labour in the two interacting activity systems. These secondary contradictions are marked with lightning-shaped, double-headed arrows in Figure 3.3.

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