Reading :: Expertise in Transition

Expertise in Transition: Expansive Learning in Medical Work
By Yrjo Engestrom

This 2018 book, like 2016's Studies in Expansive Learning, serves as a capstone for aspects of Engestrom's prodigious work. Whereas Studies in Expansive Learning summarized his career findings related to the theory of expansive learning, Expertise in Transition summarizes his career findings about the nature, development, and improvement of expertise, a theme stretching back to his 1992 research bulletin Interactive Expertise. Specifically, it focuses on medical expertise.

As Engestrom says in the preface, "our predominant notions of expertise are foundationally insufficient in the face of the present challenges of an interconnected and unpredictable world," and in response, "this book builds a perspective of transition toward collaborative and transformative expertise" (p.vii). This argument is based on the one from Interactive Expertise, in which Engestrom argued that traditional cognitive foundations of expertise are dualistic, with algorithmic and enculturational poles (Ch. 1 in Interactive Expertise, covered also on p.4 in this book). He goes on to note two dimensions of expertise (learning for stability vs change, and collective vs individual locus of expertise), which he maps into a four-field diagram (p.10) to demonstrate a lacuna in the quadrant of learning for stability && collective locus of expertise. That's the quadrant that Engestrom fills with this book, using activity theory (p.13). He argues that

• Expertise is located in mediated activity systems and "cannot be meaningfully reduced to individual competency";
• "Expertise is inherently heterogeneous"; "there is no universally valid, homogeneous, self-sufficient expertise"; and 
• "Expertise is increasingly faced with the challenge of radical transformations that require culturally novel solutions and learning about what is not yet there" (p.14).

Related to the third point, he argues that in situations that require emergent learning, "There is no competent teacher, or there are many competing ones" (p.18). As he did back in Interactive Expertise, Engestrom points to Gregory Bateson's "Learning III," characterized as dialectical and understood within Engestrom's expansive learning cycle (pp.18-19). To address emergent learning, we need an interventionist developmental methodology (pp.20-21) in which "research aims at developmental re-mediation of activities" (p.22). He proposes a "methodology of formative interventions" (p.23), such as his own Change Laboratory (p.24). 

In this book, Engestrom specifically focuses on medical expertise. Like Annemarie Mol in her study of medical expertise, Engestrom notes that "a chronically ill patient typically becomes an object for a number of physicians, each viewing the patient from the perspective of his or her own specialty" (p.25), and "the multiplying nature of chronic illness further complicates the issue" by yielding different diagnoses and prescriptions (p.25). (Unlike Mol, however, Engestrom sees these as perspectives on a unitary object.) This question of the object is discussed further in Ch.2, where Engestrom illustrates the question in an empirical study, demonstrating that physicians hold different dominant models of the object associated with different theories of the illness (p.41). The object, he concludes, "is not only constructed by the subjects, it also constructs itself" (p.54). I note that here, he characterizes Latour in Science in Action as being purely constructivist, and relates this view to "critical sociological studies of medicine" in which "the professional dominance of doctors is commonly pictured as constructing patients and illnesses as if they were passive material" (p.54)—a characterization that seems at odds with Latour in that book and subsequent ones. 

In Chapter 3, Engestrom discusses levels of activity and contradictions. 

Chapter 4 goes into the spatial and temporal expansion of the object, focusing on the case of a Change Lab intervention. In addition to activity system triangles, Engestrom develops other representations (care maps, calendars; see p.78). These three types of representations are mediational means that provide dual stimulation for the participants in the Change Lab. I want to note this point because critics of CHAT have often focused on the activity system triangle as an oversimplified and limited representation of activity. Yes, it's simplified, just as a paper prototype is a simplified version of a tool to be fully developed later. These representations are not meant to be purely descriptive, analytical devices; they are starting points for codesign and co-intervention. 

In Chapter 5, Engestrom brings in the notion of knotworking, which happens in "work that requires active construction of constantly changing combinations of people and artifacts over lengthy trajectories of time and widely distributed in space" (p.85). Knotworking involves fluid combinations of individuals that have roles but do not work together continually, such as judges and attorneys (the combinations change for each trial). "These combinations of people, tasks, and tools are unique and of relatively short duration. Yet, in their basic pattern, they are continuously repeated" (p.86). Such combinations, he says, are not well described by terms such as team or network, both of which (he argues) assume stable configurations (p.86). In contrast, knotworking is unstable, pulsating, with no center of coordination or control (p.87). In his example of knotworking, the case of a mental patient, "the knot functioned as a self-conscious agent" whose duration was too short to develop infrastructure (p.91). He concludes the chapter by discussing another case, the development of a care agreement. 

In Chapter 6, Engestrom examines knotworking as expansive decision-making. Drawing on Klein's work in naturalistic decision-making, Engestrom argues that activity theory can contribute to NDM by providing a framework that addresses socio-spatial, temporal, moral-ideological, and systemic-developmental dimensions of decision-making.

The book has more chapters, but I'll stop there. In sum, Engestrom has drawn across his theorization and case studies of the last three decades to provide a coherent accounting of expertise from an activity-theoretical perspective. In doing so, he has demonstrated and illustrated the extraordinary potential for activity theory to understand and intervene in domains of complex expertise. If you're interested in expertise, activity theory, or both, you really ought to read this book.