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Cited by 137Interprofessional Education and CollaborationInnovative Education and Learning PracticesEducation, Healthcare and Sociology Research

Using activity theory to transform medical work and learning

Open access
Engeström, Yrjö, Pyörälä, Eeva·2021·Medical Teacher
DOI 10.1080/0142159x.2020.1795105
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Abstract

This article introduces key concepts of activity theory and expansive learning. Expansive learning builds on the foundational ideas of the cultural-historical activity theory (CHAT). It is a research approach designed for studying the complexities and contradictions in authentic workplace environments. Change Laboratory is a formative intervention method developed for studying workplaces in transition and for stimulating collaborative efforts to design improved patterns of activity. We present concrete examples of formative interventions in healthcare, where good patient care was compromised by the fragmentation of care and disturbances in collaboration between the healthcare experts. This implies that physicians are challenged to develop collaborative and transformative expertise. We present three spearheads into a zone of proximal development, representing opportunities for change of medical expertise: (1) reconceptualizing expertise as object-oriented and contradiction-driven activity systems, (2) pursuing expertise as negotiated knotworking, and (3) building expertise as expansive learning. While medical expertise needs to expand, medical education must also look for ways to evolve and meet the challenges of the surrounding society. We call for adopting an interventionist approach for developing medical education and intensifying collaboration with the practitioners in healthcare units, their patients, and target communities.

AI snapshot

Written from the paper’s full text.

TL;DR

This conceptual article presents cultural-historical activity theory and expansive learning as frameworks for understanding and transforming medical work and education. It argues that medical expertise should move toward collaborative, transformative practice, using formative interventions such as Change Laboratory to address fragmented care.

Key findings

  • The article identifies three directions for developing medical expertise: treating expertise as activity systems oriented to objects and driven by contradictions; pursuing expertise as negotiated knotworking; and building expertise through expansive learning.
  • Fragmentation of care is explained through contradictions within and between activity systems. In a Helsinki case, specialist and primary care systems had different objects, separate instruments, and solo responsibility, while market-oriented cost-efficiency pressures reinforced short-term priorities.
  • A Finnish Change Laboratory study conducted nine sessions and jointly analyzed ten patient cases. Participants developed a care agreement signed by key parties including the patient, along with care map and care calendar tools.
  • Expansive learning cycles can occur at three scales: foundational inter-system change over several years, focused local transformation over several months, and mini-cycles within single sessions or short episodes. Typical Change Laboratory interventions run six to ten sessions.

Methods

  • Conceptual and theoretical article introducing cultural-historical activity theory and expansive learning, illustrated with prior formative intervention examples in healthcare.
  • Uses the Change Laboratory method: researchers collect authentic workplace material such as interviews, observations, and video recordings; select critical incidents for mirror material; and guide participants through questioning, analysis, modeling, testing, implementing, reflecting, and consolidating.
  • Example data come from a Finnish study on negotiated primary-specialist care in Helsinki: nine Change Laboratory sessions and ten patient cases analyzed with patients and practitioners.

Limitations

  • The paper states no limitations.
  • Evident from the text: it is an introductory conceptual piece relying on selected illustrative interventions rather than a systematic empirical evaluation or meta-analysis.
  • Evident from the text: the detailed case material is drawn mainly from Finnish healthcare settings, though the article notes Change Laboratory work in Denmark, Brazil, and the UK; generalizability is not formally assessed.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1080/0142159x.2020.1795105

Cites

41 of 41 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

13 of 45 cited sources checked · 7 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Fragmentation of patient care is a major challenge for healthcare practice.

    “Fragmentation of patient care is a major challenge for healthcare practice.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Walker and Druss 2017 source

      The Discussion says improving health for people with multimorbidity requires coordination between services and that limited use of collaborative care for substance use disorders can result in fragmented care. It does not characterize fragmentation of patient care generally as a major challenge across healthcare practice. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
  • Premisecitation

    Change Laboratory interventions have been carried out and reported in various medical settings in Finland, Denmark, Brazil, and the United Kingdom.

    “Change Laboratory interventions have been carried out and reported in various medical settings in Finland (Engeström 2018), Denmark (Skipper et al. 2016), Brazil (Vilela et al. 2020;Grilo Diniz et al. 2020, in press) and the United Kingdom (Reid et al. 2015;Morris et al. 2020, in press).”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites Engeström 2018 source
    • cites Skipper et al. 2016 source
    • cites Vilela et al. 2020 source
  • Premisecitation

    Contradictions stimulate everyday innovation and local change.

    “On the other hand, they also stimulate everyday innovation and local change (Martin et al. 2017).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Martin et al. 2017 source
  • Premisecitation

    Healthcare systems are largely designed to treat single symptoms and diseases rather than complicated long-term disorders and co-occurrence of chronic conditions, mental disorders, and poverty.

    “Healthcare systems are largely designed to treat patients' single symptoms and diseases rather than complicated long-term disorders and the co-occurrence of chronic conditions, mental disorders and poverty (Walker and Druss 2017).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Walker and Druss 2017 source

      The Discussion says that traditional views of multimorbidity often omit mental illness and socioeconomic factors, and that care for some co-occurring conditions can be fragmented. It does not establish that healthcare systems are largely designed to treat single symptoms or diseases rather than complex long-term conditions. Page numbers are not available in our copy. (LLM, conf=0.83)

      Experimental — accuracy not yet measured
  • Premisecitation

    In healthcare, permanent teams are increasingly replaced by fluid combinations of expertise (knots) corresponding to the problem at hand.

    “In healthcare, permanent teams are increasingly replaced by fluid combinations of expertise,”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites Engeström 2008 source
    • cites Bleakley 2014 source
    • cites Hurlock-Chorostecki et al. 2015 source

      The Background describes healthcare knotworking as short-lived collaboration among changing participants, and the Discussion describes an NP working within a team of changing professionals. Neither section says that permanent teams are increasingly being replaced; the paper supports the fluid-collaboration aspect, not the claimed trend. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
  • Classified as probably not a substantial claim. 41
  • May combine two claims. 15

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Patients with multimorbidity (two or more chronic conditions) are expanding and use a significant portion of healthcare resources.

    “Patients with multimorbidity, i.e. suffering from two or more chronic conditions, is expanding and utilizing a significant portion of health care resources (Barnet et al. 2012;Braithwaite 2018).”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites Barnet et al. 2012

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Braithwaite 2018 source

      The ‘Why change is hard’ section describes patients with diverse needs but does not discuss multimorbidity prevalence or resource use. Searches for ‘multimorbidity,’ ‘two or more chronic conditions,’ and healthcare resource use found no passage in our copy addressing those claims. (LLM, conf=0.72)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Competency-based education frameworks require medical training to develop systems-based practice, advocacy, and collaboration.

    “Competency-based education frameworks require that medical training develop future physicians' systems-based practice, advocacy, and collaboration (Orsino and Ng 2019).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Orsino and Ng 2019 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The smallest scale of mini-cycles of expansive learning consists of single intervention sessions or similar restricted episodes.

    “The smallest scale of mini-cycles of expansive learning consist of single intervention sessions or similar restricted episodes (e.g., Nummijoki et al. 2018).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Nummijoki et al. 2018 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Change Laboratory was developed in the 1990s for studying organizations and workplaces facing major transformations.

    “A formative intervention method called Change Laboratory was developed in the 1990s for studying organisations and workplaces facing major transformations (Engeström et al. 1996;Engeström and Sannino 2010;Virkkunen and Newnham 2012;Sannino and Engeström 2017).”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites Engeström et al. 1996
    • cites Engeström and Sannino 2010 source
    • cites Virkkunen and Newnham 2012

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim.

    Premisecitation

    Expansive learning proceeds through learning actions that form cycles of expansive learning.

    “Expansive learning proceeds by means of learning actions that form cycles of expansive learning (Figure 5).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites Engeström and Sannino 2010 source

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationcitation

    This type of approach is particularly well suited for exploring the challenges healthcare is facing.

    “This type of approach is particularly well suited for exploring the challenges healthcare is facing (Barnet et al. 2012;Braithwaite 2018;Engeström 2018;Bleakley 2020, in press).”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites Barnet et al. 2012

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Braithwaite 2018 source
    • cites Engeström 2018 source

  • Classified as probably not a substantial claim.

    Premisecitation

    Studies on multimorbidity and fragmentation of care call for medical education to provide continuity, coordination, and collaboration across healthcare units and with patients.

    “Studies on multimorbidity and fragmentation of care call for medical education to adopt an approach that provides patients with continuity, coordination and collaboration across healthcare units and with patients under their care (Barnet et al. 2012;Braithwaite 2018;Engeström 2018).”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites Barnet et al. 2012

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Braithwaite 2018 source

      In “Towards a nuanced appreciation of change?” (Table 1; page unavailable), Braithwaite calls for stronger communication and relationships across interacting networks of people. The section also centres improvement on networks of clinicians and patients. Our copy does not link these points to studies of multimorbidity or fragmented care, or call for medical education to provide continuity and coordination across healthcare units. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
    • cites Engeström 2018 source

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationcitation

    A new prototype and paradigm of medical education will emerge, namely a transformation coalition between target communities, healthcare organizations, medical schools, students, healthcare professionals, patients, and other stakeholders.

    “A new prototype and paradigm of medical education will emerge, namely a transformation coalition between target communities, healthcare organizations, medical schools, students, healthcare professionals, patients and other stakeholders (Coburn and Penuel 2016;Sannino 2020).”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites Coburn and Penuel 2016 source
    • cites Sannino 2020 source

      In the Figure 6 section (page unavailable), Sannino describes a developing coalition of diverse actors working across sectors and organizational levels toward change. The paper applies that idea to homelessness, not to medical education; it does not predict a new medical-education paradigm or identify the listed participants as its coalition. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingown data

    In the healthcare examples, fragmentation of care and disturbances in collaboration compromised good patient care.

    “We present concrete examples of formative interventions in healthcare, where good patient care was compromised by the fragmentation of care and disturbances in collaboration between the healthcare experts.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    In Excerpt 2, the chief physician had to remind other practitioners that the patient's signature was needed in the care agreement.

    “In Excerpt 2, the chief physician had to remind the other practitioners that also the patient's signature was needed in the care agreement.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The care agreement was signed by key parties, including the patient.

    “The care agreement was signed by the key parties, including the patient.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Fragmentation emerged when specialist caregivers concentrated exclusively on symptoms and care belonging to their own restricted areas, there was neither common language nor understanding between caregivers, and no efficient mechanism guaranteed coordination, cooperation, and communication between parties.

    “Fragmentation emerged when (a) the different specialist caregivers concentrated exclusively on the symptoms and care that”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    In multiple cycles of expansive learning, practitioners and patients generated a new instrument called the care agreement, initiated by a physician who noticed fragmentation in the care of a patient with multiple chronic illnesses.

    “In multiple cycles of expansive learning, practitioners and patients generated a new instrument called the care agreement initiated by a physician who noticed fragmentation in the care of a patient with multiple chronic illnesses (Kerosuo and Engeström 2003).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Kerosuo and Engeström 2003 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingreasoning

    The care agreement summarized diagnoses and key concerns of different subjects and outlined their plans of care.

    “The care agreement summarized the diagnoses and key concerns of the different subjects and outlined their plans of care.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The draft was sent to other healthcare practitioners involved in the patient's care and negotiated among the parties.

    “The draft was then sent to other healthcare practitioners involved in the patient's care and negotiated among the parties.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The first draft of the care agreement was negotiated between the initiating physician and the patient.

    “The first draft of the agreement was negotiated between the initiating physician and the patient.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Physicians are challenged to develop collaborative and transformative expertise.

    “This implies that physicians are challenged to develop collaborative and transformative expertise.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisenone given

    Three opportunities for changing medical expertise are reconceptualizing expertise as object-oriented contradiction-driven activity systems, pursuing expertise as negotiated knotworking, and building expertise as expansive learning.

    “We present three spearheads into a zone of proximal development, representing opportunities for change of medical expertise: (1) reconceptualizing expertise as object-oriented and contradiction-driven activity systems, (2) pursuing expertise as negotiated knotworking, and (3) building expertise as expansive learning.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    Contradictions challenge the medical social system to understand and manage complexity, identify dynamics, and utilize them in emancipatory transformations.

    “Thus, they challenge the medical social system to understand and manage complexity, to identify the dynamics of contradictions, and to utilize them in emancipatory transformations.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    A theoretical and methodological approach designed to investigate transformation, disturbances, and controversy is needed.

    “Therefore, we need a theoretical and methodological approach designed to investigate transformation, disturbances and controversy.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationnone given

    Engaging in negotiated knotworking is a demanding step in creating new tools for negotiated care and collaboration in healthcare.

    “Engaging in negotiated knotworking is a demanding step in the creation of new tools for negotiated care and collaboration in healthcare.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Knotworking requires a shared language and object between participating actors.

    “This requires a shared language and object between the participating actors.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    One foundational idea of CHAT is the distinction between short-lived goal-directed actions and durable collective activities.

    “One of the foundational ideas of cultural-historical activity theory is the distinction between short-lived, goal-directed actions and durable and collective activities (Leont'ev 1978).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Leont'ev 1978

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim.

    Premisecitation

    The theory of expansive learning focuses on learning new patterns of activity that are not yet there and are learned as they are designed.

    “The theory of expansive learning focuses on learning of new patterns of activity that are not yet there; they are learned as they are designed (Engeström 2015;2016).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Engeström 2015

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Engeström 2016

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim.

    Premisecitation

    A knot refers to a rapidly pulsating and partially improvised orchestration of collaborative performance between loosely connected actors and activity systems.

    “The notion of a knot refers to a rapidly pulsating and partially improvized orchestration of collaborative performance between otherwise loosely connected actors and activity systems (Engeström et al. 1999).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Engeström et al. 1999

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    Collaborative and transformative expertise implies that medical practitioners are involved in ongoing systemic change efforts.

    “Collaborative and transformative expertise implies that medical practitioners are involved in ongoing systemic change efforts.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Expansive learning provides a conceptual framework for analyzing complexities and contradictions of health care systems and methods for formative interventions where participants in different healthcare units and patients work together to find new creative solutions.

    “Expansive learning provides a conceptual framework for analyzing the complexities and contradictions of systems of health care and methods for formative interventions where the participants in different healthcare units and patients work together to find new, creative solutions to the tensions and obstacles they face.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    Change Laboratory is aimed at triggering and supporting expansive learning.

    “Change Laboratory is aimed at triggering and supporting expansive learning.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    In activity theory, transformations are understood as zones of proximal development, not linear moves toward pre-fixed end points.

    “In activity theory, transformations are not seen as linear moves toward pre-fixed end points. They are understood as zones of proximal development.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Vygotsky 1978

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Engeström 2015

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    An intermediate level consists of a focused local transformation with a Change Laboratory intervention, requiring several months.

    “An intermediate level consists of a focused local transformation with the help of a Change Laboratory intervention, requiring several months (e.g., Engeström et al. 2013).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Engeström et al. 2013 source

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    Cycles of expansive learning sometimes occur without deliberate intervention, but this is rare.

    “Cycles of expansive learning sometimes occur without deliberate intervention, but this is rare.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    The specific instrumentality of knotworking in healthcare relates to clients or patients as equal parties in negotiations and flexible agreements.

    “The specific instrumentality of knotworking in healthcare is related to clients or patients as being equal parties in the negotiations and flexible agreements.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    Fragmentation of patient care and medical education, along with increasing long-term conditions and comorbidities, require a radical expansion of the object of medicine: longer time perspectives, broader collaborative and interdisciplinary approaches, and transformative agency from practitioners and organizations.

    “Fragmentation of patient care and medical education as well as the increasing number of patients with long term conditions and comorbidities require a radical expansion of the object of medicine: longer time perspectives, broader collaborative and interdisciplinary approaches, and transformative agency from medical practitioners and their organizations.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Market-oriented business calculations and managerialism make the needed expansion of the object of medicine very difficult.

    “These forces make the needed expansion of the object of medicine very difficult.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Healthcare systems are increasingly penetrated by market-oriented business calculations and managerialism that favour rapid turnover and short-term profits.
    • Rests on an assumption: Instruments of medicine are becoming framed in terms of rationalization, standardization, and commoditization, favouring linear top-down processes over horizontally co-constructed care trajectories and long-term societal impact.

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    Cultural-historical activity theory takes historically formed systemic contradictions as the starting point of analysis.

    “Cultural-historical activity theory (CHAT) takes historically formed systemic contradictions as the starting point of the analysis.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisenone given

    Knots operate by tying and retying separate threads of activity and expertise, involving rapid improvisation and long-term planning and follow-up.

    “Knots operate by tying and retying together otherwise separate threads of activity and expertise, involving both rapid improvisation and a long-term perspective of planning and following up.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Premisereasoning

    In healthcare, the general object is health and illness, while each specific patient with a specific complaint is a situated manifestation of the object.

    “In healthcare, the general object is health and illness, whereas each specific patient with a specific complaint is a situated manifestation of the object.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisenone given

    Knotworking is a model for overcoming fragmentation of the object.

    “Knotworking is a model for overcoming fragmentation of the object.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Subjects of expansive learning engage in a multi-voiced process in which they struggle, negotiate, and hybridize between alternative perspectives and collectively form concepts in the wild.

    “The subjects of expansive learning are involved in a multi-voiced learning process in which they struggle, negotiate and hybridize between the alternative perspectives and collectively form concepts”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Engeström and Sannino 2012 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given

    A Change Laboratory may focus on a local unit or bring together multiple activity systems to resolve larger-scale contradictions and tensions.

    “A Change Laboratory may focus on a local unit, such as a clinic, or bring together multiple activity systems to resolve larger-scale contradictions and tensions.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    Collaborative and transformative expertise can only be accomplished through collaboration among healthcare practitioners and coalition-building between healthcare units, patients, target communities, and other societal actors.

    “This can only be accomplished by means of collaboration among healthcare practitioners and coalition-building between healthcare units, their patients and target communities, and other societal actors.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    In the transition toward collaborative and transformative expertise, medical education becomes co-responsible for shaping future medical practice.

    “In the landscape of transition toward collaborative and transformative expertise, medical education becomes co-responsible for shaping future medical practice.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    The methodology of formative interventions, especially Change Laboratory, may serve as an important resource for building and analyzing such transformation coalitions.

    “The methodology of formative interventions, especially the Change Laboratory method, may serve as an important resource for building and analyzing such transformation coalitions (Sannino et al. 2016).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Sannino et al. 2016 source

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Achieving this requires intensifying collaboration and communication between interconnected activity systems of healthcare, client communities, and medical education.

    “This can only be achieved by intensifying collaboration and communication between the interconnected activity systems of healthcare, its client communities, and medical education.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    All medical practitioners in workplaces become medical educators.

    “Correspondingly, all medical practitioners in workplaces become medical educators.”
    Quote in the paperNot a substantial claim
45 of 45

  • The paper relies on this without support.

    Most medical studies focus on disease-centred specialist perspectives at the expense of comprehensive patient care and collaboration between primary and specialist care.

    “Still, most medical studies focus on disease-centred specialist perspectives at the expense of comprehensive patient care and collaboration between primary healthcare and specialist care.”

  • The paper relies on this without support.

    Healthcare systems are increasingly penetrated by market-oriented business calculations and managerialism that favour rapid turnover and short-term profits.

    “Concurrently, systems of healthcare are increasingly penetrated by market-oriented business calculations and managerialism that favour rapid turnover and short-term profits.”

  • The paper relies on this without support.

    Instruments of medicine are becoming framed in terms of rationalization, standardization, and commoditization, favouring linear top-down processes over horizontally co-constructed care trajectories and long-term societal impact.

    “The instruments of medicine are becoming framed in terms of rationalization, standardization and commoditization, notions that favour linear and pre-packaged top-down processes and procedures rather than horizontally co-constructed care trajectories and long-term societal impact.”

  • The paper relies on this without support.

    Medical practice can only evolve in response to the needs of the broader communities within which it operates.

    “Medical practice can only evolve in response to the needs of the broader communities within which it operates.”

  • The paper relies on this without support.

    Contradictions generate disturbances and conflicts in everyday medical work.

    “Contradictions generate disturbances and conflicts in everyday medical work.”

  • The paper relies on this without support.

    In complex social institutions such as healthcare, there are historically accumulated systemic contradictions within and between nodes of each activity system, and among interconnected activity systems.

    “In complex social institutions such as healthcare, there are historically accumulated systemic contradictions within and between the nodes of each activity system, and among interconnected activity systems.”
6 of 6

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The shift to digital teaching methods requires a collective effort and transformative expertise among teacher trainees.

    “The shift to digital teaching methods requires a collective effort and transformative expertise among teacher trainees (Engeström & Pyörälä, 2021).”

    From Transforming Online Teacher Training Through Expansive Learning: A Case Study Applying Cultural-Historical Activity Theory and the Change Laboratory Method (2025) · cites this paper as Engeström & Pyörälä, 2021

    The ‘Lessons for medical education’ section links medical education to a transition toward collaborative and transformative expertise, and the discussion near Figure 2 describes collective change efforts among healthcare practitioners. The paper does not apply that argument to a shift to digital teaching methods or specifically to teacher trainees. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • The implementation of UST highlighted the importance of facing challenges and expanding understanding and comfort zones.

    “The implementation of UST highlighting the importance of facing challenges and expanding understanding and comfort zones (Engeström & Pyörälä, 2021).”

    From Transforming Online Teacher Training Through Expansive Learning: A Case Study Applying Cultural-Historical Activity Theory and the Change Laboratory Method (2025) · cites this paper as Engeström & Pyörälä, 2021

    The sections “Expertise as expansive learning” and “Lessons for medical education” describe learning through struggle and finding new solutions to healthcare challenges (page numbers unavailable). But the paper does not discuss UST implementation or say that it expanded participants’ comfort zones, so it supports only the general idea of learning through challenges. (LLM, conf=0.80)

    Experimental — accuracy not yet measured

  • The Change Laboratory is a formative intervention method designed to facilitate collaborative learning and development.

    “These processes often occur within the context of a Change Laboratory (CL), a formative intervention method designed to facilitate collaborative learning and development (Engeström & Pyörälä, 2021;Engeström et al., 2005).”

    From Transforming Online Teacher Training Through Expansive Learning: A Case Study Applying Cultural-Historical Activity Theory and the Change Laboratory Method (2025) · cites this paper as Engeström & Pyörälä, 2021

  • CHAT responds to complexity and views practice and learning as inseparable, therefore it is a useful methodological framework to study practice-based learning such as general practice.

    “inseparable therefore is a useful methodological framework to study practice-based learning such as general practice (Engeström & Pyörälä, 2021).”

    From SimLab: an intervention to promote expansive learning and organisational change in team-based emergency care simulation (2025) · cites this paper as Engeström & Pyörälä, 2021

  • There have been several examples of CL interventions in medical education and healthcare.

    “There have been several examples of CL interventions in medical education (Reid et al., 2015;Dornan et al., 2021;Engeström & Pyörälä, 2021) and healthcare (Skipper, 2016;Vilela et al., 2020;Morris et al., 2021;Kerosuo et al., 2010).”

    From SimLab: an intervention to promote expansive learning and organisational change in team-based emergency care simulation (2025) · cites this paper as Engeström & Pyörälä, 2021

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. Engeström Y, 1996, Lifelong Learn Eur, 1, 10
  2. Varpio L, 2020, Med Teach

Cited by

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Related

Authors
Engeström, Y., & Pyörälä, E.
Affiliations
University of Helsinki (FI)
Corresponding author
Engeström, Yrjö
ORCID
Venue
Medical Teacher
Publisher
Informa UK Limited
Published
2020-07-25
Volume
43
Issue
1
Pages
7-13
ISSN
  • 0142-159X (ISSN-L)
  • 1466-187X
DOI
10.1080/0142159x.2020.1795105
OpenAlex
W3045364861
Cited by
137
References
39
Citations by year
2026: 13 · 2025: 27 · 2024: 34 · 2023: 19 · 2022: 25 · 2021: 10 · 2020: 6
FWCI
15.75
Type
journal article
Language
en
Open access
Licence
other-oa
Locations
  • Medical Teacher (publishedVersion)
  • PubMed (publishedVersion)
  • Työväentutkimus Vuosikirja (submittedVersion, other-oa)
Topics
  • Health Sciences › Health Professions › General Health Professions › Interprofessional Education and Collaboration
  • Social Sciences › Human Factors and Ergonomics › Innovative Education and Learning Practices
  • Social Sciences › Psychology › Social Psychology › Education, Healthcare and Sociology Research
Keywords
activity theory, expansive learning, cultural-historical activity theory, Change Laboratory, formative intervention, medical expertise, medical education, care fragmentation
MeSH terms
Delivery of Health Care, Education, Medical, Humans, Learning, Workplace

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