Moving Beyond Static, Individualistic Approaches to Agency: Theories of Agency for Medical Education Researchers: AMEE Guide No. 177.

Abstract

Agency - the capacity to produce an effect - is a foundational aspect of medical education. Agency is usually conceptualized at the level of the individual, with each learner charged with taking responsibility to pull themselves up by their bootstraps. This conceptualization is problematic. First, collaboration is a central component of patient care, which does not align well with an individualistic approach. Second, a growing body of literature documents how minoritized and marginalized trainees experience inequitable restrictions on their agency. Third, a myriad of structures across medicine restricts individual agency. In this guide, we present four conceptualizations of agency beyond the individual that medical researchers can incorporate to modernize and broaden their understanding of agency: (a) temporal: how individuals wrestle with their own agency across time; (b) relational: how agency is co-created dialogically with other individuals and structures; (c) cultural: how culture and cultural resources shape possibilities for agency; and (d) structural: how restrictive structures - like racism and ableism that unjustly curtail individual agency - are created, maintained, and resisted. For each dimension, we first describe it by drawing from and summarizing the work of theorists across disciplines. Next, we highlight an article from medical education that makes particularly good use of this dimension, discussing some of its relevant findings. Finally, we offer a set of questions that researchers in medical education can ask to highlight the dimension of agency in their work, and we suggest potential directions for future inquiry. We conclude by offering an example of how a researcher might understand a resident's educational experiences through each of the four proposed dimensions and further explicating the complexity of agency in medical education.