Going against the grain: An exploration of agency in medical learning

• Published in: Medical education Vol. 55; no. 8; pp. 942 - 950
• Main Authors: Watling, Christopher, Ginsburg, Shiphra, LaDonna, Kori, Lingard, Lorelei, Field, Emily
• Format: Journal Article
• Language: English
• Published: England Wiley Subscription Services, Inc 01-08-2021
• Subjects: Medical education
• ISSN: 0308-0110; 1365-2923
• DOI: 10.1111/medu.14532

Background
Learner‐centred medical education relies on learner agency. While attractive in principle, the actual exercise of agency is a complicated process, potentially constrained by social norms and cultural expectations. In this study, we explored what it means to be an agentic learner in medicine, and how individuals experience and harness agency in their learning.
Methods
Using a constructivist grounded theory approach, we interviewed 19 physicians or physicians‐in‐training who identified as ‘learning mavericks’; this strategy facilitated recruiting participants with a strong sense of themselves as agentic learners. We asked them about atypical learning choices they had made, about support and resistance they encountered and about how they managed to carve a distinct path for themselves. Data collection and analysis were concurrent and iterative, grounded in the constant comparative approach.
Results
We identified one overarching concept: agency is work. The work of exercising agency was compounded by a system of professional training that was perceived to promote conformity and to resist individual learner agency. Individuals’ capacity to exercise agency appeared to be bolstered by social capital, self‐knowledge and mentorship.
Discussion and Conclusions
Our work extends and elaborates the understanding of learner agency in medicine, highlighting the exercise of agency as a sometimes counter‐cultural act that requires learners to resist considerable pressure to conform to social and professional expectations. Agency may come more easily to strong learners who have established their ability to succeed within the system's expectations. Enhancing learner agency thus requires careful attention to learner support. Mentorship that both helps learners to identify appropriate learning paths and shields them from the pull of social expectations may be especially fruitful.
This study demonstrates that exercising agency in a way that enables learner‐centred education is difficult work that gets amplified by perceptions of an inflexible educational culture and a pressure to conform.