Fokus i denna avhandling utgör läkares och civilingenjörers kunskaps- och identifikationsprocesser under utbildning och arbete – vilka studeras som utsnitt ur levnadsbanor. Syftet är att beskriva och tolka relationen mellan högre utbildning och arbete, dels utifrån föreställningar i forskning och policy, dels utifrån människors subjektivitet, vardagserfarenheter och liv. Studien baseras på textanalys och intervjuer med läkare och IT-ingenjörer under de första åren i arbetslivet och yrket. Kännetecknande är att processer följs över tid genom en longitudinell design. Den teoretiska ramen struktureras runt tre länkade teman: Kunskap och dynamiker i det samtida samhället; Högre utbildning och arbete; Människors formbarhet. Reflexiv tolkning utgör metodologisk ansats. Begreppen flexibilitet, stabilitet och ambivalens används dialektiskt vid analys av empiriska data. Avhandlingen visar att människors subjektivitet och vardagserfarenheter samspelar med generella föreställningar och sammanhangens reella förhållanden. Utbildnings- och yrkesval kan förstås som uttryck för såväl reflexiva livsprojekt som subjektiva dynamiker. Att formas till civilingenjör och läkare ter sig på vitt skilda sätt. Ingenjörerna formas till generalister och ”spelar med säkra kort” medan läkarna bygger en karaktär och ”spelar med sig själva som insats”. I arbetet använder civilingenjörerna titeln som en flexibel strategi – identifikation är främst bunden till plats, funktion och arbetstid. Läkarnas identifikation med yrket utgör ett konstant tillstånd – läkare är något de alltid är, också på fritiden – yrket är starkt bundet till person. Resultaten indikerar att både ingenjörs- och läkaryrket kännetecknas av livslånga kvalificeringsprocesser. De visar sig stark exkluderande över tid. Relationen mellan högre utbildning och arbetet diskuteras vidare i avhandlingen genom människors levnadsbanor och i termer av såväl formbara som hållbara liv. / The focus of this thesis is the formation of knowledge and professional identification through physicians’ and engineers’ education and work – life-trajectories are the frame of interpretation. The aim is to describe and interpret the relationship between higher education and work, partly by studying ideas in research and educational policy, partly by people’s subjectivity, experiences and everyday life. This study is based on text analysis and interviews with physicians and engineers. The characteristic of this study is that processes are described and interpreted through a longitudinal design. The theoretical framework is built up by three interrelated themes: knowledge and dynamics in contemporary society; higher education and work; the reflexivity of the individuals. An overarching interpretive approach is applied, and the concepts of flexibility, stability and ambivalence are used dialectically in the analysis of empirical data. The study indicates interplay between subjectivity, everyday life experiences and conditions in different practices. The informants’ educational and career choice can be understood as expressions of reflexive life-projects or as subjective dynamics. Becoming an engineer or physician stand out as substantially different processes. The engineers in information technology are becoming generalists and are “playing the game with a safe hand”, while the physicians becoming characters and are “playing the game with oneself as stake”. At work the engineers are using their title as a flexible strategy – identification is confined to place of work, occupation and working hours. The physicians’ identification with their profession is a fixed state of mind – they are always physicians, even in their leisure time – the profession is associated with their personality. The results indicate that both engineers and physicians careers can be characterised by life-long qualification. It appears as a strongly excluding factor. The relationship between higher education and work is discussed as life-trajectories and in terms of formable and sustainable life.

The focus of this thesis is on describing and analysing recently graduated physicians’ and engineers’ experiences of the relationship between the professional education programs and the respective professional practices. The aim is to explore the professionals’ reasons for their educational and career choices, what they learn in professional education, the demands they encounter in the workplace, and the perceived needs and opportunities for learning and further development in their professional practices. This study is based on a comparative design and the empirical data have been collected in interviews with physicians and master’s level engineers in information technology. The theoretical framework is structured around three parts, consisting of theories of professionalisation, theories concerned with the functions of higher education, and theories concerned with the concepts of knowledge, competence and qualifications. There is a close relationship between the process of professionalisation, the authority of the professions, the legitimacy of professional knowledge, and the higher education institutions. The results indicate that theory and practice are intimately integrated in the physicians’ professional education, whereas the engineers’ experiences of the educational program are characterised by little overlap between theory and practice. Furthermore, the physicians emphasise the importance of theoretical specialist knowledge and socio-communicative competence while the engineers instead stress the importance of generalist competence. The educational knowledge base is relatively static for both physicians and engineers. However, whereas there is a correspondence between the educational and the professional knowledge base in the case of the physicians they are only a loosely coupled in the case of the engineers. This can be attributed to the changing nature of the engineers’ professional knowledge base, which is characterised by constant change. The physicians regard their professional education as a rational preparation for the world of work. Although education does provide a general foundation for further professional development and learning, the engineers associate their professional education more with a symbolic ritual. For physicians, the formal credentials are a legal requirement to practise the profession. Education is regarded as constituting an important credential also for the engineers as it increases individual employability. The physicians tend to emphasise the use value of the educational program, while the engineers instead stress the exchange value of their educational program.

Denna essä syftar till att belysa och problematisera rådande ekonomiska och management-baserade styrningsformer och dess effekter inom hälso- och sjukvårdssystemet genom att undersöka hur läkekonsten och allmänläkares praktiska kunskap påverkas i en marknadsstyrd vård. Utgångspunkten är en gestaltning av en allmänläkares arbetsdag på en vårdcentral i Stockholm. Med avstamp i en hermeneutisk och politisk filosofisk tanketradition utforskar essän frågor kring patientens narrativ, läkares utmattning, samvete och empati, reflektion och motstånd, arbete och alienation samt konflikten mellan olika rationaliteter och kunskapsparadigm. Essän visar hur den nyliberala rationaliteten och nuvarande naturvetenskapliga och biotekniska paradigmen förstärker varandra och en reduktionistisk och ekonomisk människosyn. Essän förespråkar förändring genom en mer balanserad kunskapssyn och medicinsk praktik med en mobilisering av kollektiv och individuell fronesis hos läkare för att upphöja värdet av det mellanmänskliga mötet, den praktiska kunskapen och läkekonsten. / This essay aims to highlight and problematize current economic and management-based forms of governance and its effects in the healthcare system by exploring how the art of medicine and general practitioners' practical knowledge are influenced in market-based health care. The starting point is a narrative of a general practitioner's working day at a healthcare centre in Stockholm. The theoretical framework is mainly within the fields of philosophical hermeneutics and political philosophy. The essay explores questions about the patient's narrative, physician burnout, conscience and empathy, reflection and resistance, work and alienation, and the conflict between different rationalities and knowledge paradigms. The essay shows how neoliberal rationality and current paradigms of natural sciences and biotechnology reinforce each other and a reductionist and economic view of human being. The essay advocates change through a more balanced understanding of knowledge and medical practice with a mobilization of collective and individual phronesis in physicians in order to elevate the value of the interpersonal meeting, the practical knowledge and the art of medicine.

Bakgrund: Teknologi och behandlingsmöjligheter inom intensivvården är under ständig utveckling. Den växande möjligheten till livsuppehållande behandling är inte alltid gynnsam för alla patienter. Det är en utmaning att identifiera tidpunkten då behandlingen blivit medicinsk meningslös och därmed ska avslutas. Beslutsfattandet försvåras eftersom patienterna ofta inte kan tala för sig själva. Processen att komma fram till ett beslut kräver ett samarbete mellan läkare och sjuksköterskor för att tillgodose patientens bästa och anhörigas behov. Att ge alla inblandade en röst har visat sig vara en utmaning och kan leda till konflikt. Syfte: Att belysa intensivvårdssjuksköterskans upplevelse av samarbetet med läkare inför beslutsfattande kring avslutande av livsuppehållande behandling. Metod: En systematisk litteraturöversikt med kvalitativ ansats och induktivt förhållningssätt. Resultat: Sjuksköterskor upplever att deras involverade i beslutsfattandet är viktigt och åtar sig ett antal handlingar för att bidra till samarbetet, samtidigt som de känner sig exkluderade och att deras arbete är undervärderat. Beslutsfattandet upplevs komplext där tid, anhöriga och olika professionella perspektiv påverkar samarbetet. Hur samarbetet är utformad och vilka beslut som tas i enskilda situationer upplevs variera relaterat till hur den individuella beslutsfattaren är som människa och vilka erfarenheter de involverade har. Slutsats: Samarbetet mellan sjuksköterska och läkare vid beslutsfattande om avslut av livsuppehållande behandling är viktigt för att utforma vården efter den individuella patienten. Beslutsfattandet är komplicerat, där etiska och moraliska principer behöver tillgodoses. Genom att få bättre förståelse och reflektera över den professionella rollen kan samarbetet underlättas. Att ta beslut om människors livsöden förblir tungt, men rätt förutsättningar gynnar såväl yrkesprofessionella som patienter.

Läkarens arbetsmiljö har satts alltmer i fokus de senaste åren. Karasek och Theorells krav-kontroll-stöd modell beskriver hur kraven i arbetet, kontrollen eller inflytande som arbetstagare har över sitt arbete och det sociala stödet som ges på arbetsplatsen kan vara avgörande för upplevelser av den psykosociala arbetsmiljön. Syftet med studien var att kartlägga hur ST-läkare i allmänmedicin upplever sin psykosociala arbetsmiljö utifrån krav-kontroll-stödmodellen. En webbenkät skickades till 310 ST-läkare i allmänmedicin i områdena Göteborg och Södra Bohuslän i februari och mars 2022. Totalt svarade 104 läkare på enkäten som ger svarsfrekvens på 33,5%. Allmänt upplever deltagarna höga krav och högt socialt stöd. De skattar sin hälsa bra trots hög stressnivå och att många upplever konflikt mellan arbete och privatliv. Majoriteten är tillfredsställd och engagerad i sitt arbete. De som upplever höga krav har signifikant sämre hälsa och upplever mer konflikt mellan arbete och privatliv. Deltagare som har mycket kontroll och bra socialt stöd är mer engagerade och tillfredsställda med sitt arbete. Det finns inget samband mellan kön och den psykosociala arbetsmiljön men deltagare som arbetar på privata vårdcentraler är mer engagerade och upplever mindre konflikt mellan arbete och privatliv än deras kollegor på offentliga arbetsplatser. Resultat är förenligt med tidigare studier kring läkarens arbetsmiljö. Dessa har också rapporterat höga krav, hög stressnivå och bristande inflytande över arbetet men även de konsekvenser som obalans mellan krav, kontroll och socialt stöd kan ha. Resultatet av denna studie ger insikt i ST-läkarens arbetsmiljö och skapar möjligheter för att arbeta vidare med gruppens arbetsmiljö och förhållningssätt till arbetet. / Over the last years there has been an increasing focus on the physician´s work environment. Karasek & Theorell´s demand-control-support model describes how the work demands, control or influence that employees have over their work and the social support provided in the workplace can be decisive for experiences of the psychosocial work environment. The purpose of the study was to explore how GPs in training in certain areas in Sweden experience their psychosocial work environment. A web-survey was sent to 310 GPs in training in Gothenburg and the southern part of Bohuslän in Sweden in February and March 2022. A total of 104 doctors responded to the survey, which gives a response rate of 33,5%. In general, the participants experience high demands and high social support. They estimate their health to be good despite high levels of stress and that many experience conflicts between work and private life. The majority are satisfied and committed to their work. Those who experience high demands have significantly poorer health and experience more conflict between work and private life. Participants who have a lot of control and good social support are more committed and satisfied with their work. The study found no relationship between gender and experiences of the psychosocial work environment but participants who work in privately run health centers are more committed and experience less conflict between work and private life than their colleagues in publicly run health centers. The results from this study are consistent with previous studies on physician´s work environment. These have also reported high demands, high levels of stress and a lack of influence over work. These have also reported the consequences that an imbalance between demands, control and social support can have. The results of this study provide insight into the work environment of GPs in training and create opportunities to continue working with physician´s work environment and how they approach their work.

Healthcare is generally characterized by deep traditions, old working methods, and clear hierarchies. A central part of medical wards is the so-called “round”. During the round, physicians and nurses visit the patients and decide on further action. The round is a central process at wards and affect the rest of the working day, both for physicians and nurses. In this study, the round process was observed at Ward 4 at Norrtälje Hospital. The staff at Ward 4 experienced high-stress levels and this was related to an ineffective round according to a prestudy conducted by Clinical Innovation Fellowships. The project aimed at producing a new optimized round routine that would reduce the high-stress levels. The study was conducted through observations, dialogue with staff, interviews, surveys, comparative observations at other wards at Norrtälje Hospital and other hospitals as well as theoretical studies. The main difficulties discovered in our study with the round process at Norrtälje Hospital were that (i) information was communicated dual, (ii) the round process was too time-consuming, (iii) late decision-making, (iv) inefficient role for nurses and the (v) priority of work. The study resulted in a recommendation of a new round routine in which we have taken the staff’s interests into account as well as literature and research within the field of how developing healthcare processes. Our target was to increase communication and collaboration between physicians and nurses and furthermore exploiting human resources in the best possible way. Our main recommendation was to introduce a seated pre-round prior to commencing the daily round routine and to introduce a reconciliation meeting afterwards. / Sjukvård är generellt sett präglat av inrotade traditioner, gamla arbetsmetoder och tydliga hierarkier. En central del på medicinska avdelningar är den så kallade ronden. Under ronden besöker läkare och sköterskor patienterna och beslutar om vidare åtgärder. Arbetet under ronden påverkar sedan resten av arbetsdagen, både för läkare och sköterskor, eftersom den är en väldigt central del av arbetsdagen på en medicinavdelning. I denna studien så undersöktes rondprocessen på avdelning 4 på Norrtälje Sjukhus. Bakgrunden till detta var att personalen präglats av höga stressnivåer och att det varit ett resultat av en ineffektiv rond. Detta framkom från en förstudie utförd av Clinical Innovation Fellowships. Vår studie syftade i att producera en ny effektivare rondrutin som i sin tur skulle minska stressen hos personalen. Detta genomfördes med hjälp av observationer, dialog med personal, intervjuer, enkätundersökningar, jämförande observationer på andra avdelningar och andra sjukhus, och teoristudier. Dom största problemen som upptäcktes i vår studie var att (i) information kommuniceras dubbelt, (ii) ronden tog för lång tid, (iii) att beslut inte fattas tillräckligt fort, (iv) sköterskans roll under ronden och (v) prioritering av patienter. Studien resulterade i ett förslag till en ny rondrutin som strävar efter att öka kommunikation och samarbete mellan läkare och sköterskor, och samtidigt utnyttja personalresurser på ett optimalt sätt. Vår främsta rekommendation var att införa en sittrond före gåronden och avsluta med ett avstämningsmöte.

Introduction: Vulnerable European Union citizens (vulnerable EU citizens) are those who come to Sweden from EU member states. In Sweden the term “vulnerable EU citizens” is associated with the word “beggars”, which in turn is associated with Roma people. By November 2015 the number of vulnerable EU citizens in Sweden was estimated to be 4 700. The majority of these were from Romania. Roma as citizens of an EU member state have the right to reside in EU countries in accordance with the EU’s freedom of movement rights concept for up to but no longer than three months. However, to obtain the right for residence after three months, proof of financial resources and health insurance are required. Lacking these resources, vulnerable EU citizens have subsequently lost their right for residence and therefore became undocumented. They often find themselves in the same situation as undocumented migrants from outside the EU, having poor health outcomes and limited access to health care. In my study I aim to explore access to health care for vulnerable EU citizens in Umeå, a city in eastern Sweden. Methods: A qualitative design methodology has been applied in this thesis. Those contacted for this study were; Doctors of the World, Health on Equal Terms, Staff for planning and control Västerbotten Region, University Hospital of Umeå and representatives of vulnerable EU citizens’ community from Romania in Umeå. Seven in-depth interviews were collected with professionals and volunteers from these organisation/institutions and members of vulnerable EU citizens’ community. Questions were asked about their experience and knowledge regarding access to health care for vulnerable EU citizens. Data was analyzed using qualitative content analysis. Results: Three main categories and one final theme were developed during data analysis. The first category “Difficult to access health care for vulnerable EU citizens in Sweden without European Health Insurance” elaborates the dependence of vulnerable EU citizens’ access to health care on having health insurance, specifically European Health Insurance and National Health Insurance. It also describes what kind of access to health care vulnerable EU citizens have in Sweden. The second category “Decision about how much access to health care provide for vulnerable EU citizens lies on medical personnel” discusses the situation of health care personnel when they treat vulnerable EU citizens in hospitals. The third category “Organisations, Doctors of the World and Health on Equal Terms, mediate connection between vulnerable EU citizens and hospitals, so they can have their right to health fulfilled” elaborates about the role the organisation plays when vulnerable EU citizens are in need of health care. After grouping categories and looking at the data from more interpretive, abstracted higher level, the final theme was created “Lack of attention from the national and international levels to the situation of vulnerable EU citizens’ access to health care”. Conclusion: This study highlights the difficulty for vulnerable EU citizens to access health care in Umeå if they do not have European Health Insurance. Being treated as undocumented migrants is the only way they have access to emergency services. Health care personnel feel insecure when treating vulnerable EU citizens, because there are no clear guidelines when vulnerable EU citizens can be treated as undocumented migrants as well as what is included in the clause “the care that cannot wait”. Because of this situation, vulnerable EU citizens sometimes are not able to receive the medical help they need. Organisations, Doctors of the World and Health on Equal Terms, help to mediate the connection between vulnerable EU citizens and hospitals which helps them to access the health care and fulfille their right to health. Lack of attention from the national as well as international governments to this situation is found to be important factor influencing vulneralbe EU citizens’ access to health care

The main purpose of this thesis is to study and analyze how concepts of childhood and adolescence were constructed in scientific medicine during the period 1870 to 1930. The focus in the first part of the thesis is to study the sick girl as a stereotype in 1870–1900. In the late nineteenth-century, the poor health of girls was a popular topic in Swedish medical discourse. It was a well-established opinion that a substantial number of Swedish girls suffered from various diseases and ailments. Mass- and coeducation was under debate and physicians became interested in the impact of schools and schooling on children’s health. It is here shown that children, and in particularly adolescents, were de-fined as gendered creatures. The doctors emphasized the universal nature of adolescence and conceptualized pu-berty as a traumatic and risky stage of life and they also tended to focus on middle-class girls. Pubescent girls were seen as most vulnerable to external stress such as mental strain and physical demands. Physicians claimed that ill health inevitably followed when girls were educated in the same way as boys. However, boys and their health were discussed too. The most common ailments for both girls and boys were overstudy, anemia, headaches and disor-dered digestion. It was also shown in various studies, that poorer children were substantially inferior in weight as well as in height. Chlorosis was a common theme in late nineteenth-century medical discourse. Although it appeared mainly as a girls’ disease in medical books and in most sanitary journals, health studies for example, showed that chlorosis could also be a boys’ disease. However, sick boys were rarely spoken of. Medical opinions on overstudy, chlorosis and dress reform could be interpreted as a concern for unhealthy girls as future mothers of the nation. It is not my intention to advertise doctors as vicious oppressors, as opponents of female emancipation. In fact, the doctors often pointed out social factors and unequal circumstances of childhood and adolescence for girls and boys. In early twentieth-century, the scientific opinion of girls changed. Even though gendered notions of children and youths persisted all through the period studied, more and more some doctors, Karolina Widerström, for example, began to question them. The new girl was not weak and ill, but rather healthy and active. However, a dividing line between those who claimed the weakness of girls and those who emphasized the new, healthy girl became more evident after 1900. In this thesis, this disparity is discussed in terms of popular medical discourse and scientific medi-cal discourse. In the latter, girls were still described as more sensitive and more frail than boys and as unfit for higher education and strenuous schoolwork. Thus, the new girl – vivid, healthy and equal to the boy – was above all a con-struction in popular medicine. The uniform medical discourse on girls from the late nineteenth-century thus dissolved. A number of changes in the medical discourse on sickness and health of girls and boys during in this period occurred. First, concepts of sickness and health were modified over time and fewer schoolchildren were considered sick. Fi-nally, in the beginning of the period studied, girls were sicker than boys were, but in the end, in the 1930s, there was no obvious gender difference. Both sexes seemed equally sick (or healthy).

Denna essä syftar till att ur filosofiska och idéhistoriska perspektiv belysa utmaningar och möjligheter med artificiell intelligens (AI) och digitalisering inom hälso- och sjukvården, med fokus på läkekonst, kropp, hälsa och ovisshet. Essän undersöker hur automatisering och digitala vårdformer omformar läkekonstens grund, nämligen mötet mellan patienten och läkaren. Genom en fenomenologisk kritik av AI och teknikens väsen, belyses skillnaden mellan människan och maskinen och hur den levda erfarenheten är situerad, förkroppsligad, fylld av mening och delad med andra. Essän utforskar hur situationsunik kunskap som praktisk klokhet, fronesis, samt ett reflekterande förnuft, intellectus,kan hantera den ovisshet som är inbäddad i det allmänmedicinska mötet. Essän belyser även hur digitalisering och AI passar väl med pågående marknadsanpassning av sjukvården, där homo economicus och homo digitalis båda omformar kropp och hälsa till mätbara resurser och data. Avslutningsvis lyfts etiska dilemman kring AI och digitalisering, samt vikten av praktisk och existentiell kunskap som förutsättningar för utvecklandet och designen av en teknik som syftar främja det mänskligt goda. / This essay aims to illuminate challenges and opportunities with artificial intelligence (AI) and digitalization in health care, focusing on the art of medicine, body, health and uncertainty. The theoretical framework is mainly within the fields of phenomenology and philosophical hermeneutics. The essay explores how automatization and digital health care are transforming the essence of medicine: the patient – physician encounter. By a phenomenological critique of AI and the essence of technology, the essay highlights the difference between machines and humans and how lived experience is situated, embodied, filled with meaning and shared with others. The essay explores how situational knowledge such as practical wisdom, phronesis, and reflective understanding, intellectus, can deal with the uncertainty that is embedded in the medical encounter in primary health care. The essay also highlights how digitalization and AI fit well with current market adaptation of health care, where homo economicus and homo digitalis both transform body and health into measurable resources and data. Finally, ethical dilemmas of AI and digitalization are highlighted, as well as the importance of practical and existential knowledge as preconditions for the development and design of a technology that aims to promote the human good.

Syfte: Syftet med detta arbete var att analysera vilka faktorer som bidrar till utbrändhet hos de som arbetar inom hälsovården. Metod: Följande arbete bestod av en litteraturstudie. Analys: Flera vetenskapliga tvärsnittsartiklar från olika länder användes med målet att undersöka vilka arbetsmiljöfaktorer ofta förekommer och orsakar utmatning hos läkare, sjuksköterskor och undersköterskor. Resultat: Under arbetets gång under resultatet redogjordes det att utbrändhet orsakas av många faktorer såsom stressiga arbetsdagar, ung ålder, brist på arbetserfarenhet, familjestatus, antal barn, tätt samarbete med många patienter, liten kontakt med arbetskamrater, höga krav och otacksamhet från patienter, problem med ekonomi, brist på vila och individens hälsoproblem. Med hjälp av Maslach Burnout Inventory och Copenhagen Burnout Inventory som användes i artiklar var utmattningssyndrom tydligt definierad, och dess faktorer noggrant analyserade. Diskussion: I diskussionsdelen var två olika Burnout Inventory - enkäter beskrivna med stöd av artiklar. Dessutom diskuterades egenskaper hos en enkät vilket stöddes av Bryman (2008), och förutom det genomfördes genomgång av artiklar, använda i analysdelen, för att säkerställa deras trovärdighet. / Purpose: The purpose of this work was to analyze the factors that contribute to burnout in those who works in health care. Method: The following work consists of literature study. Analysis: Several scientific cross-sectional articles from different countries were used with the aim of investigating which work environment factors often occur and cause the burnout among physicians, nurses and assisted nurses. Result: During the result, it was reported the burnout is caused by many factors such as stressful working days, young age, lack of work experience, family status, number of children, close cooperation with many patients, little contact med colleagues, high demands and ingratitude from the patients, problems with finances, lack of rest and individual´s health problems. Using the Maslach Burnout Inventory and Copenhagen Burnout Inventory used in articles, fatigue syndrome was clearly defined, and its factors carefully analyzed. Discussion: In the discussion two different Burnout Inventory – surveys were described with the support of articles. In addition, the characteristics of a survey were discussed, with was supported by Bryman (2008); and articles, used in the analysis, were presented to ensure their credibility.