Absences or Misalignments?
Through this analysis of strategic plans, we see potential absences in the rhetoric of medical schools as compared to their AHSC counterparts. As outlined in our analysis, medical schools are embracing a technologically enhanced future. We do not mean to imply otherwise. Medical schools specifically outline the possibilities to enhance educational practices through various technologies, learning management systems, and the power of data analytics. There are mentions of adjusting curriculum and competency profiles to anticipate a future where clinical decision making is augmented by AI. In some cases, medical schools are explicit about digital futures and associated implications for health professions education. However, the strategic plans of medical schools largely under-specify the kind of transformations anticipated for Canadian healthcare. It is possible that the futures being anticipated by medical schools and academic health science centres may differ by degree, rather than by substance. However, it is also possible that these imagined futures might become a site of struggle, with competing visions for the role of health professions and health professional knowledge in these digital futures. Early studies of professions and professional knowledge have under-estimated the influential role of clinical workplaces and employing organizations on professional knowledge, power, and identity (Evetts, 2013). Learning from past transformations of healthcare work, it seems wise to attend to these broader dynamics, particularly as academic medicine becomes influenced by new forms of knowledge, expertise, and power associated with data science, AI, and associated industry interests acting within health service organizations.
Socio-technical Imaginaries and Creating Futures
While the medical schools might be under-specifying potential transformations of Canadian healthcare, the AHSCs are projecting a robust vision of healthcare systems and organizations transformed by digital health technologies. Included under this umbrella of digital health technologies are health information systems, virtual care technologies, remote monitoring technologies, and the potential for all forms of decision making to be augmented by machine learning capabilities. Organizations that have a longer history with concepts, tools, and strategies associated with precision medicine (e.g. cancer care centres) are the most specific about these possible futures and their current manifestations. However, the vision of digitally enabled solutions to healthcare’s most pressing problems also permeated the strategic plans of rural centres and community hospitals. In light of increasing digitization of healthcare, academic health science centres are strategically turning their attention inwards towards internal data collection, curation, and analysis capacities. Directing attention inwards may have implications for the knowledge regime of evidence based medicine, historically operationalized as practitioners and organizations looking outwards towards established bodies of literature (Rowland et al., 2022). Furthermore, the growing investment in various forms of technology involves shifting networks of expertise in these sites, inviting interdisciplinary teams to include data scientists and engineers. These strategic plans also seem to signal a further dissolution between the boundaries of providing care and generating research within academic health science centres. Whereas the teaching hospitals of the past required the submission of “patienthood” and patient experience to the teaching mandate (Rowland et al., 2019), current iterations may treat every patient encounter as an opportunity to generate data. This reordering of relationships with patients also has implications for care and learning practices.
Our analysis of strategic plans largely aligns with other studies of digital transformations of healthcare organizations, exploring how health service organizations are being reimagined and reconfigured through the promises of digital health (Gardner, 2022; Hoeyer, 2019). For example, Hoeyer’s (2023) extensive ethnographic study of Denmark’s healthcare data infrastructures traces tensions that emerge when data is being produced, analyzed, and used in simultaneous attempts to produce knowledge, health, governance, and wealth. Each of these aims of data work are governed by different sets of values. Furthermore, the ways these values are pursued by different actors in the system have implications for the ways rights, risks, and responsibilities are distributed (and redistributed) across care work (McLoughlin et al., 2017). In this way, the transformation towards digital health is more than a translation of existing practices or the use of digital repositories to store clinical knowledge. Instead, these tools participate in the moral ordering of clinical work (McLoughlin et al., 2017), having implications for the ways care is provided, the clinical learning environment is organized, and what it means to be a competent professional. The result is a collection of paradoxes, where multiple but contradictory visions of current circumstances and future possibilities are held to be true. Considered in the context of the exiting science and technology literature, our current study suggests the possibility for emerging tensions between the robust sociotechnical imaginaries being pursued by AHSC, the more generalist aspirations being pursued by medical schools, and the possible tensions clinicians might experience as their day-to-day work is transformed in these clinical sites.
Implications for Academic Medicine
Looking through the lens of sociotechnical imaginaries, we see these strategic plans as framing desirable futures, directing attention towards specific ways of understanding problems of healthcare, and mobilizing the resources to knit together social and technical systems in ways that bring these imaginaries into fruition. However, academic health science centres are complex spaces, pursuing multiple mandates of patient care, research, and health professions education. In the face of such organizational complexity, there are bound to be tensions as these sociotechnical imaginaries are wrestled into material realities. Many of those tensions and their attempted resolutions will have direct implications for the expectations of health professional graduates, the nature of clinical learning environments, and relationships with patients. Some authors claim that the current moment in time reflects a transformation even larger than the shift to evidence-based practice (James et al., 2021), even potentially challenging evidence-based medicine as the dominant knowledge regime (Kenny et al., 2021). Understanding how the linked ecologies (Abbott, 2005) of educational institutions, professional associations, and health service organizations are orienting towards a digital future should be a matter of interest for leaders in academic medicine.
In addition to considering implications for competency development and associated curricula, future research can draw upon robust social science traditions exploring the meanings, implications, and unintended consequences of these kinds of transformations. Working in collaboration with social scientists, leaders in academic medicine can draw upon the social science of quantification (Porter, 1996) and information infrastructures (Berg, 2001), sociology of professions (Abbott, 1988; Freidson, 1988; Larson, 1977/2013), and science and technology studies (e.g. Latour, 2007) to better understand the reconfigurations of these sociotechnical systems (Carboni et al., 2022) and their possible implications for academic medicine. There is also an opportunity to relate to broader technopolitics of this moment in time, as society writ large becomes increasingly datafied and digitized, potentially reframing our most fundamental human relationships (Spar, 2020). Much as a sociology of evidence-based practice has revealed the ways in which evidence-based medicine began as a particular kind of sociotechnical imaginary and evolved into a global web of institutions, experts, technologies, devices, and policies that define what healthcare is and what kinds of help we do (or do not) receive as patients (Broom & Adams, 2012), a sociology of digital health and the adjacent promises for digitally-enabled personalized medicine can help us see sociotechnical dynamics as they are evolving in the moment (Kenny et al., 2021). In the process, we may choose to question how digital work is being imagined, how it is being distributed, and to what uses it is being designed. The purpose here is not to dismantle these aspirational digital futures, but to contextualize, balance, and potentially emphasize voices that might become marginalized in these imagined futures. Arguably, the desired aim of academic medicine is not just become data-driven, but to become data wise (Hoeyer, 2023), an aspiration that is socially, politically, technically, and epistemologically complex.
Limitations
We recognize the limits of analyzing strategic plans as particular kinds of texts. An absence in a plan does not necessarily equate to an absence in activity. Furthermore, practices of creating strategic plans are culturally and historically situated. Absences in the produced texts might reflect a style of writing and reporting, rather than an absence of organizational consideration. That being said, these strategic plans are in the public domain and serve as a declaration of organizational focus (Vaara, 2015). They also serve as a proxy for moral ordering, declaring what an organization indicates it should direct attention towards (Tsoukas, 2018). Given their role in directing organizational attention and identity, the analysis of strategic plans contributes to our understanding the field of academic medicine. We further recognize the limits of our case study. To maintain feasibility of the study and to ensure the trustworthiness of our document selection process, we focused primarily on one province in Canada. To elaborate our understanding, we expanded to included strategic medical school plans publicly available in English. Rather than claiming that our results are generalizable to other contexts, our aim is to use the results of our study to display our theoretical concepts in ways that help others to appraise their own contexts with new insights (Merriam, 1988). Given the resonance of our findings with the various promises being made in the UK (Gardner, 2022; McLoughlin et al., 2017), Denmark (Hoeyer, 2023), and Australia (McLoughlin et al., 2017), we believe our analysis is tapping into broader promissory discourses about the role of technology in healthcare.