A Case Study of Physicians at Work at the University Hospital of Northern Norway

Introduction A common argument today is that many organizations have become so complex that their knowledge is fragmented, difficult to locate and share, and therefore redundant, inconsistent or not used at all (consider for instance Zack, 1999). There are also arguments about increased market competition, which make it necessary for organizations to focus on knowledge as an important resource. According to these arguments, knowledge creation, representation and diffusion are key mechanisms in ensuring modern companies' and organizations' competitive advantages (Blackler, 1995; Davenport and Prusak, 1998). Aligned with a relatively high share of the knowledge management literature, this knowledge is associated with so-called knowledge-intensive firms and their knowledge workers (read for instance Alvesson, 1995). In this way knowledge is considered a property of the firm or a specific entity (Blackler, 1995) that typically is stored in large databases as externalized and codified know-how. At a later stage, it is assumed that this knowledge will be readily reused in various contexts associated with the firm. Considering the knowledge concept as outlined above is both narrow and too optimistic. Several studies have reported the shortcomings of such a perspective and pinpointed that it is essential to take an alternative or broader approach (consider Knorr-Cetina (1999), Atkinson (1995) and Hunter (1991), to which this work also adheres). From this point of view, it is insufficient to focus on knowledge as a thing; the focus must rather be how people create knowledge and how knowledge is made sufficiently trusted in order to be used across contexts. Atkinson (1995:45), for instance, places emphasis on medical knowledge production as work. This work is achieved not only through the content of collegial talk, but also through the form of that talk. Thus the knowledge creation and translation process is not only based on journals and textbooks (Atkinson, 1995:90-91) but also includes talks between colleagues such as clinical lectures; ward rounds; morbidity reviews; and a surgeon's comments to juniors and students. The study reported in this paper focuses on physicians' work in four different contexts at the University Hospital of Northern Norway (UNN) when they produce discharge letters. At UNN the discharge letters are an important part of the hospital's electronic patient record, accordingly placing this study at the core of the hospital's most critical information system. In contrast with the traditional view on knowledge work (Alvesson, 1995) clinical work, and especially as practiced at large hospitals like UNN, is highly specialized. It is characterized by state-of-the-art knowledge, high levels of education and organizational complexity. As knowledge originates from a myriad of different contexts and information sources, a large part of knowledge work in hospitals involves summing up and thus reusing previous information (Berg, 1998:298). It underscores the importance of historical knowledge as a foundation for present action and for future knowledge creation along the patient trajectory. The term "trajectory" refers not only to the physiological unfolding of a patient's disease but to the total organization of work done over that course, plus the impact on those involved with that work and its organization (Strauss et al. 1985:8). The work done on patient trajectories is highly specialized and distributed (Strauss et al. 1985:26; Blume, 1991:17; Atkinson, 1995:7; Reiser, 1984:303). This points out that work in hospitals is extremely interdependent and accordingly emphasizes the role of trust as expectations about another's trustworthiness become relevant when the completion of one's own activities depend on the prior action or co-operation of another person (Lane, 1998:3). Moving beyond simplistic dichotomies, such as tacit/ explicit knowledge representations, I dwell on the practices for rendering knowledge (regardless of representation) credible, relevant and trustworthy. …