We the system: A call for a perspective shift towards systems agency in trainees

In their paper ‘Constraints and affordances for UK doctors-in-training to exercise agency: a dialogical analysis’, Mattick et al call for urgent work to enhance agency for doctors-in-training.¹ Agency can be understood as trainees' ability to act independently within the system and make decisions about their educational trajectory, professional development and patient care.² As a trainee impacted by COVID-19, the challenges of learning to navigate agency were exacerbated by a system under strain. While this study was conducted at the height of the pandemic, the health workforce crisis continues to threaten workplace affordances of agency.³ Trainees must navigate a landscape where educational and care delivery processes are increasingly centralised, and top-down crisis responses challenge agentic behaviour.³

Mattick et al call for ‘urgent work […] to provide medical trainees with greater agency and favourable workplaces’.¹ The authors highlight learners feeling ‘disengaged [and] resigned’ and their ‘perceived powerlessness to influence a wider agenda’.¹ Addressing trainees' perceived lack of agency to change the system is crucial. Maximising systems agency will mitigate disengagement and leverage changes that trainees are uniquely positioned to make. We see this paper not only as a call for greater workplace affordances but also as a call for a perspective shift on learner agency. Establishing greater workplace affordances for agency without empowering learners to recognise their position as active agents within the system will leave a critical aspect of agency unaddressed.⁴

Reframing trainee perspective on systems agency requires answering two questions. First, we must consider ‘agency for what’—whether agency is directed towards personal trajectories or advancing health outcomes. Learner agency is often conceptualised as directed towards learners' own professional development, which can be in tension with system needs.⁵ Cultural historical activity theory (CHAT), which positions agency as negotiated between various elements of an activity system including the learner, workplace, institution and context, provides a helpful lens to understand tensions between the objectives of agency.^{2, 6, 7} Mattick et al suggest that learners' perceived lack of agency can arise from a shift away from the patient as the object of the activity towards systems-level issues.¹ If learners also perceive agency primarily as the ability to influence their personal trajectory, learners may therefore perceive the shift from individual to systems issues as a lack of agency. Agency may be better interpreted as directed at activities spanning clinical care, research and learning, bridging the gap between the individual and the system.⁸

A shift towards agency as expressed through clinical care, research and learning expands opportunity for trainees to find agency within a ‘faceless nameless entity’.¹ Mattick et al call for ways for trainees to ‘influence the wider policy agenda’ to combat perceived powerlessness when systems-level issues overshadow individual patient care.¹ They suggest ‘amplify[ing] existing positive affordances of agency; for example, when doctors-in-training collaborate positively with peers, and suggest process improvement’.¹ Addressing systems-levels challenges through research or quality improvement at a micro or meso systems level is a means for learners to exercise systems agency under constraining circumstances.^{4, 9} Vipler et al discuss how recognising system failings and advocating for change allows trainees to ‘move from passive acceptance of their situation’ to ‘an active agent in constructing a different, more just reality’.⁴ The importance of developing systems agency is reflected in physician competency frameworks, including CanMEDS, which identifies ‘advocating for system-level change in a socially accountable manner’ as an essential competency for trainees.¹⁰

Next, we must consider to what extent agency can be afforded, and to what extent learners must create it—‘agency from whom?’ Through CHAT, learners can be seen as an ‘agent within an activity system’, where agency is co-constructed and negotiated within the sociocultural context, communities of practice and hierarchies.^{2, 6, 7} Within this view, learners are not ‘mere and hapless hostages’ within the wider healthcare system.^{2, 5} Learners are active participants in their local system and can create agency through the clinical care, research and learning activities that fall within their role.⁸ Learners are already uniquely situated to act as ‘change agents’ through holding both a near-outsider perspective and an insider position within the system.

We agree with Mattick et al's recommendation to ‘smooth the peaks and troughs of clinical responsibility’.¹ Working within their zone of proximal development allows learners to co-construct greater agency through meaningful contributions to care and teaching.⁹ Workplace systems that stretch to accommodate learners' scope of practice support the embedding of agency in workplace care and learning activities.

This brings us to the idea of an ‘agency literate’ learner. Agency literacy implies a shift towards learners' recognition of their position as embedded within the system rather than powerless against it.^{4, 5} Agency literate learners are prepared to negotiate opportunities for agency through clinical care, research and learning. They recognise and can leverage their privileged position within the system to drive change. Agency literacy primes trainees to take advantage of organisational affordances for agency, including the changes called for by the authors.¹ Fostering agency literacy will prepare trainees to operate within complex systems as independent practitioners, as systems pressures will threaten agency throughout their careers.

We recognise that a shift towards recognising and enacting systems agency is no easy task. As stated by Watling et al, ‘agency is work’.⁵ Cultivating agency literacy requires motivation, mentorship, support, social capital and belonging.⁵ A paradigm shift in how trainees perceive agency must be accompanied by support from practice communities and workplaces. For example, Mattick et al suggest that supervisors could ‘facilitate this by noticing, suggesting and endorsing’ agentic activities.¹ We agree with the authors' call to explore how critical consciousness could offer insights into enabling trainees to act as change agents and suggest exploring how else agency literacy can be developed and maintained.¹ An agency literate approach may help learners move from resignation to realisation of their role as active change agents in care, learning and research. As it stands, in the face of unabating systems-level pressures that threaten agency, a shift in perspective from ‘me versus the system’ to ‘we the system’ is warranted.

Arden Azim: Conceptualization; resources; visualization; writing—original draft; writing—review and editing. Matt Sibbald: Conceptualization; supervision; writing—review and editing.